“Let's Call a Spade a Spade. My Barrier is Being a Black Student”: Challenges for Black Undergraduate Nursing Students in a Western Canadian Province

Abstract

Background

We need more understanding of experiences that hinder or promote equity, diversity, and inclusion of Black students in undergraduate nursing programs to better inform their retention and success.

Purpose

To explore documented experiences of Black undergraduate nursing students, review barriers affecting their retention and success, and suggest evidence-based strategies to mitigate barriers that influence their well-being.

Methods

We used a focused qualitative ethnography for recruiting Black former and current students (N = 18) in a Western Canadian province's undergraduate nursing programs via purposive and snowball sampling. Most participants were female, 34 years or younger, with over 50% currently in a nursing program. Five participants later attended a focus group to further validate the findings from the individual interviews. Descriptive statistics were used to describe participant characteristics; we applied a collaborative constant comparison and thematic analysis approach to their narratives.

Results

Challenges influencing Black students’ retention and success fell into four main interrelated subthemes: disengaging and hostile learning environments, systemic institutional and program barriers, navigation of personal struggles in disempowering learning environments, and recommendations to improve the delivery of nursing programs. Participants also recommended ways to improve diversity and mitigate these barriers, such as nursing programs offering anti-oppression courses, platforms for safe/healthy dialogue, and more culturally sensitive learning-centered programs and responsive supports.

Conclusions

The study findings underscore the need for research to better define nursing program conditions that nurture safe, learning-centred environments for Black students. A rethink of non-discriminatory, healthy learning–teaching engagements of Black students and the mitigation of anti-Black racism can best position institutions to promote equity, diversity, and inclusion of Black students.

Background and purpose

The scientific literature and anecdotal data indicate Black nurses are underrepresented in the Canadian nursing workforce (Hamzavi, 2021; Jefferies et al., 2019; Jefferies et al., 2022; Oudshoorn, 2020; Premji & Etowa, 2014), particularly in leadership and faculty positions (Bell, 2021; Hamzavi, 2021). Black nurses account for only 2.3% of Registered Nurses (RNs) in Canada (Premji & Etowa, 2014), well short of the 4.3% national representation of Black people (Statistics Canada, 2022). Better diversity in the nursing workplace could improve the provision of culturally responsive and quality services (Jefferies, 2020; Jefferies et al., 2019; Vukic et al., 2016) and address health care inequities (Jefferies et al., 2019; Registered Nurses’ Association of Ontario [RNAO], 2022; Sergeant et al., 2022) among racialized groups in Canada, including the Black population. Indeed, Black Canadians have worse health outcomes than non-Black Canadians who do not identify as Indigenous (El-Mowafi et al., 2021). The health inequities they experience are compounded by underrepresentation of Black people in health care professions (Jefferies et al., 2019; Sergeant et al., 2022). A review of 40 studies indicates patient disposition for a positive health care experience and adoption of essential preventive care improves when they see their race represented among health care providers (Shen et al., 2018), i.e., diversity can improve health care outcomes (Alsan et al., 2019). Relative growth in the representation of Black nurses (Jefferies, 2020) also improves health care access by racialized populations as clients “can relate to, believe in, and trust” providers (Vukic et al., 2016, p. 50).

Recruiting and retaining Black students and ensuring their successful path into the nursing profession can improve health care provider workplace diversity. In particular, reducing Black nurses’ inequity (Canadian Nurses Association [CNA], 2009; Tomblin Murphy et al., 2012) could enhance culturally responsive care that is critical to meet the diverse health needs (Jefferies et al., 2019; Vukic et al., 2016) of the Black population in Canada, which quadrupled in the prairies in the last two decades (Statistics Canada, 2019).

Inadequate literature to inform the experiences of Black nursing students

However, literature on the experiences of Black nursing students is sparse, with most emanating from the USA; the few Canadian studies feature small sample sizes (Besa et al., 2022; Luhanga et al., 2020; Sedgwick et al., 2014). In addition, participants who failed or dropped out of nursing programs are often not included, which limits understanding of supports or barriers to success. Moreover, despite the increasing enrolment of Black students in Canadian universities (Abawi, 2018; Blackett et al., 2022), their enrolment in and graduation from undergraduate nursing programs remain low (Jefferies, 2020; Jefferies et al., 2022). Without race-based outcome data, this low representation (CBC News, 2017; Jefferies et al., 2022; Oudshoorn, 2020) and the concerns of Black students may continue to go unnoticed or be “dismissed as anecdotal,” with interventions “not prioritized” (Bell, 2021, p. 2). As James et al. (2017) concur, “data [are needed to validate] anti-Black racism [experiences; if not,] concerns may never be taken seriously by school administrators and educators” (p. 2). Thus, an in-depth understanding of Black students’ experiences in undergraduate nursing programs is needed to explore challenges impeding Black representation in the Canadian nursing workforce (CBC News, 2017; CNA, 2009; Oudshoorn, 2020).

The fast-growing Black population also offers significant opportunities to address gaps in Black nursing equity and diversity and include their voices in Canadian academia (CNA, 2009). Unfortunately, Black and other racialized students are not only underrepresented in Canadian university and college of nursing programs (Besa et al., 2022; Jefferies, 2020; Jefferies et al., 2022; Luhanga et al., 2020; Monteiro, 2018; RNAO, 2022) and elsewhere (e.g., the USA) (Ezeonwu, 2019; Iheduru-Anderson et al., 2021), they also experience challenges or barriers that affect their academic success (Besa et al., 2022; Luhanga et al., 2020; Monteiro, 2018; Sedgwick et al., 2014). These encompass racial discrimination (Bell, 2021; Besa et al., 2022; Iheduru-Anderson et al., 2020; Luhanga et al., 2020; Monteiro, 2018), language and cultural depreciation, social isolation, feeling misunderstood, and lacking role models (Bell, 2021; Jefferies, 2020; RNAO, 2022).

Systematic racism and bias concerns

Canadian studies highlight systemic racism and intentional discrimination that create barriers for racialized nurses (Beagan et al., 2023; Brathwaite et al., 2022). Systemic racism “consists of patterns of behaviour, policies or practices that … create or perpetuate a position of relative disadvantage for racialized persons” within societal and institutional systems (Government of Canada, 2019, p. 24) and, sadly, exists in both academic and health care institutions in Canada (Brathwaite et al., 2022; Dryden & Nnorom, 2021; James et al., 2017; Jefferies, 2020). A clear consequence is the underrepresentation of racialized populations in healthcare leadership as effective role models (Bouabdillah et al., 2021; Brathwaite et al., 2022; Etowa & Hyman, 2021; Jefferies et al., 2022; Hamzavi, 2021; Premji & Etowa, 2014).

Discrimination comes in many forms, including “treating someone unfairly by either imposing a burden on them, or denying them a privilege, benefit or opportunity enjoyed by others, because of their race, citizenship, family status, disability, gender or other personal characteristics” (Ontario Human Rights Commission, 2013, p. 57). Examples of microaggression include: micro-insults (unconscious actions meant to be rude, demeaning, or damaging to individuals or specific groups; micro-assaults (conscious, non-verbal attacks meant to hurt, discriminate, or oppress a marginalized group); and micro-invalidations (subtle communication aimed at nullifying the thoughts and feelings of racialized people (Ackerman-Barger & Jacobs, 2020; Doctor, 2018; Smith, 2022). Repeated microaggression can impact the overall health and well-being of Black and other racialized people.

Several studies show Black students’ experiences of microaggressions or discrimination lead to self-doubt, fear, and diminished self-esteem, which can interfere with their academic performance and cause some to give up or withdraw before completing their program (Ackerman-Barger & Jacobs, 2020; Iheduru-Anderson et al., 2021; Pusey-Reid & Blackman-Richards, 2022). When non-Black nursing faculty enact microaggressions, Black students are less likely to seek academic supports or use resources on campus, further impeding their academic success (Bourdon et al., 2020; Montgomery et al., 2021) and/or ability to voice learning-centered concerns.

Other studies present Black students’ narratives of being subjected to racial bias by faculty, clinical instructors, peers, nursing staff, and patients; this includes being undervalued, overly scrutinized, ignored, or excluded by White students and faculty (Gona et al., 2019; Hill & Albert, 2021; Iheduru-Anderson et al., 2020). For example, Luhanga et al. (2020) found Black students in an undergraduate nursing program experienced being belittled, intimidated, or excluded. Other barriers to academic success for Black students include: perceived racial discrimination (e.g., Bell, 2021; Besa et al., 2022; Ezeonwu, 2019; Iheduru-Anderson et al., 2020; Luhanga et al., 2020; Monteiro, 2018); financial and work issues (Beagan et al., 2023; Montgomery et al., 2021); difficulties creating an ideal work-family-school balance (Ezeonwu, 2019; Koenigsman, 2017); lack of support and cultural barriers (Beagan et al., 2023; Besa et al., 2022; Iheduru-Anderson, 2020; Monteiro, 2018); heavy language accents and overall communication bias (Ezeonwu, 2019; Iheduru-Anderson, 2020; Iheduru-Anderson & Wahi, 2018); exclusion (Ackerman-Barger et al., 2020; Ezeonwu, 2019; Iheduru-Anderson et al., 2020; Luhanga et al., 2020); and silencing (Ackerman-Barger & Hummel, 2015; Iheduru-Anderson et al., 2020).

Discriminatory practices and limited support from White faculty and peers are likely to leave Black students feeling isolated, excluded, and misunderstood (Bell, 2021; Jefferies, 2020; RNAO, 2022; White et al., 2020), which, in turn, can influence their engagement, retention, and/or success. Underrepresented racialized students have few role models or mentors with whom they can identify among faculty, students, and staff (Besa et al., 2022; Brathwaite et al., 2022; Monteiro, 2018; Montgomery et al., 2021). Black, Indigenous, and people of colour (BIPOC) study participants have stated how they would benefit from mentorship by faculty of colour (Hamzavi, 2021; Monteiro, 2018). Evidence also suggests the availability of Black faculty members as well as peer and social support aid in the retention and success of Black students in nursing programs (Besa et al., 2022; Brathwaite et al., 2022; Payton et al., 2013).

The complexities and challenges Black nursing students experience inform how they navigate their educational pathway to success. Alienation can be compounded by experiences of anti-Black systemic racial discrimination and social isolation (Besa et al., 2022; Luhanga et al., 2020). These inequities are tied to lack of diversity, with inclusivity barriers jointly inciting the high attrition of Black nursing students (Jefferies, 2020; Sedgwick et al., 2014; Vukic et al., 2016). The limited diversity in the Canadian nursing workforce can also restrict Black students’ feelings of safety in the workplace (Jefferies et al., 2019). The underrepresentation of Black nurses within the Canadian workforce and health disparities of Canadian's Black populations—exacerbated by the COVID-19 pandemic (CNA, 2020; Dhunna & Tarasuk, 2021)—highlight a need for the Canadian nursing profession and universities to commit to dismantling race-related inequities (Bell, 2021; Montgomery et al., 2021).

Theoretical framework

This study was guided by critical race theory (CRT) and intersectionality (Ali et al., 2010; Crenshaw et al., 1995; Delgado & Stefancic, 2012). CRT, which is widely applied in research pertaining to education (Ladson-Billings & Tate, 1995), is a salient theoretical framework for this study. CRT challenges researchers to examine participant narratives for information related to racism, unfairness, oppression, social exclusion, and other related aspects, all of which are relevant. Combining CRT analysis with intersectionality permitted us to unveil how Black students navigate ways to progress or succeed (Ali et al., 2010; Delgado & Stefancic, 2012) in nursing programs to racialized participants and the study purpose.

This study utilizes CRT and intersectionality to analyze Black undergraduate nursing students’ experiences as well as the intersection of identities that mutually constitute and impact them (Ali et al., 2010; Patton, 2016) in undergraduate nursing programs. Against this background, this paper explores the experiences of Black students in two undergraduate nursing programs in a Western Canadian province, reviews barriers affecting Black nursing students’ retention and successes, and suggests strategies to mitigate barriers that affect these students. CRT allowed the researchers to understand the ways Black nursing students navigate their learning experience and embedded inequities through centring their voices in relation to how institutional policies enhance or limit opportunities for success (Crenshaw et al., 1995; Ladson-Billings & Tate, 1995).

Ackerman-Barger and Hummel (2015) contend that CRT elucidates stories to “bear witness to racism … enable[ing] nursing scholars to better understand systemic and institutional racial oppression” (p. 45) experiences. A CRT analysis informed by an intersection of multiple factors permitted us to unveil how Black students navigate to progress or succeed in nursing programs (Ali et al., 2010; Crenshaw et al., 1995; Delgado & Stefancic, 2012).

Moreover, understanding how Black students’ experiences interconnect with race inequality, class, gender, (dis)ability, and identity over time in different contexts is important (Gillborn, 2020, p. 278). Unquestionably, oppression and racial bias can be experienced within divergent settings and across multiple domains, such as race, ethnicity, national origin, and power inequities (Ali et al., 2010; Delgado & Stefancic, 2012). To understand racialized experiences in academic programs, we need to appreciate how race intersects with other aspects of oppression at different times and in different context (Gillborn, 2020) for Black nursing students.

This study utilizes CRT and intersectionality to analyze Black undergraduate nursing students’ experiences as well as the intersection of identities that mutually constitute and impact them (Ali et al., 2010; Patton, 2016) in undergraduate nursing programs. Against this background, this paper explores the experiences of Black students in two undergraduate nursing programs in a Western Canadian province, reviews barriers affecting Black nursing students’ retention and successes, and suggests strategies to mitigate barriers that affect these students.

Method

Research design

This pilot study used a focused ethnography design (Wall, 2015) grounded in CRT and intersectionality (Ali et al., 2010; Delgado & Stefancic, 2012) to explore the experiences of Black students in two undergraduate nursing programs in a Western Canadian province. The design enables examination of the norms and opinions of people sharing similar experiences of a common phenomenon or topic (Wall, 2015).

The inclusion criteria were as follows: (a) self-identifying as Black, (b) English speaking, (c) aged ≥18 years, (d) current or former (whether graduated or withdrawn) student of one of the two undergraduate nursing programs in a Western Canadian province in the last 6 years (aligning with institutional program completion policy), and (e) willing to participate in an individual interview and/or focus group.

Purposive and snowball sampling techniques were used to recruit potential participants to share information-rich experiences (Creswell, 2013; Patton, 2002) related to the study aim, i.e., explore the experiences of Black students in nursing programs in a Western Canadian province. Two community partner organizations supporting newcomers and Black people in the province also facilitated the electronic distribution of an information flyer about the study. Potential participants who contacted the graduate research assistant (GRA) to express interest in being interviewed also received the flyer. The GRA followed up with interested participants via email or phone, sent them an information letter and consent form, and set a mutually convenient time for an interview.

Ethical considerations

Study approval was obtained from a harmonized research ethics review board (REB ID# 2021-127). Informed written consent was obtained, virtually, from all participants, before the interviews and focus group, and verbally confirmed at the start of each. Participants were informed they could withdraw from the study at any time without repercussions. To ensure confidentiality, the GRA created digital de-identified data files that were stored and shared using encrypted password-protected computers.

Data collection

Conversational individual interviews were conducted using an interview guide and complemented by follow-up questions, probes, and comments (Knapik, 2006). We mitigated the potential for power disparities and unease and any (in)direct faculty–student dynamic (Karnieli-Miller et al., 2009) by training the GRA, a doctoral student with a similar background (i.e., being Black), to conduct the interviews (and later the focus group). Interviews were ∼1 h long and were conducted between November 2021 and January 2022 via Zoom, enabling the observation of non-verbal nuances. Demographic data were collected from participants’ at the beginning of each interview. The interview guide was based on the published literature, ongoing faculty research, and our experiences with Black students in our respective nursing programs. The open-ended questions allowed participants to discuss their thoughts, feelings, and experiences as Black students in undergraduate nursing programs (Knapik, 2006; Patton, 2002).

Key questions depended on each participant's status with their nursing program. Current students were asked about their experiences starting from application, entry, to their current present status in the program. Former nursing students who had withdrawn were asked to “describe factors which resulted in your withdrawing from the nursing program.” Participants who graduated were asked to “describe personal and professional factors that contributed to their nursing program successes.” Data saturation was reached by the 18th participant (Fusch & Ness, 2015).

Individual interviews were followed by one focus group session, held in April 2022 with five participants who indicated interest in ongoing participation. Also, the preliminary interview findings informed the focus group guide, as the research team reflected on the study aims and questions and identified areas to be uniquely informed by current vs. former students. Questions asked included: “Do you feel being a Black student and/or having an accent holds you back in the nursing program? Could you explain your answer?” GRA field notes (to bolster the verbal data collected) indicated most interviews were laden with emotional overtones and also informed us how the focus group unfolded.

The focus group was conducted by the same GRA using the semi-structured guide and lasted approximately 90 min. Focus group data permitted us “to identify a range of different views around the research topic, and to gain an understanding of the issues from the perspective of the participants themselves” (Hennink, 2007, p. 4), to capitalize on the richness and complexity of group dynamics (Kamberelis & Dimitriadis, 2013), and confirm emerging themes.

Data analysis

Data collection and analysis occurred concurrently. After each interview, the GRA manually transcribed the data, and shared de-identified data with the team for preliminary data analysis. The GRA also manually transcribed the focus group data, after which thematic analysis was used to analyze all interview and focus group transcripts. Thematic approach is suitable for understanding what meaning individuals give to their experience and ensuring structural conditions that enable the individual accounts to emerge. We followed the six steps of thematic analysis indicated by Braun and Clarke (2006, 2012): 1) familiarization with the data, reviewing the transcripts multiple times using a line-by-line coding process; 2) generating initial codes; 3) searching for subthemes by gathering and collapsing similar codes; 4) reviewing the subthemes to generate themes; 5) refining the subthemes and naming the main themes; and 6) creating a report. Our background knowledge as Black academics and of the study population was employed to understand and describe cultural elements such as behavior, identity, values, knowledge, and beliefs of the participants (Wall, 2015). All authors were equally involved in the process, and concurred on the main themes that emerged.

Rigor

As Black faculty and immigrant nurse scholars, we mindfully considered our individual and collective experiences and diverse backgrounds about systemic anti-Black racism in nursing academia; in particular, we sought to be aware of our distinct contextual understandings of the phenomenon of interest, the study participants, and our own experiences as nurse scholars (Leonard, 1994). Beyond drawing from our diverse intradisciplinary backgrounds, we used multiple data sources to ensure triangulation to help substantiate the findings (Creswell & Plano Clark, 2018). Collective cultural knowledge and the multiethnic diversity of the research team worked in concert with the shared cultural perspective of the participants to enhance insight (Wall, 2015). To encourage an interviewee–interviewer sense of trust (Råheim et al., 2016), as well as trustworthiness, credibility, and transferability of data (Patton, 2002), we held regular virtual team meetings to strengthen data collection, critique evolving understandings, identify additional areas to probe in subsequent interviews, and refine our unfolding interpretation of the data and thematic threads.

To ensure rigor or trustworthiness of data, we considered the four criteria of credibility, fittingness/transferability, auditability, and conformability (Houghton et al., 2013). Credibility was achieved via data triangulation, i.e., collecting data from current and former nursing students; data source triangulation via interviews, focus group discussion, field notes, and prolonged engagement with participants during the interviews (Korstjens & Moser, 2018); and investigator triangulation via researchers from three undergraduate nursing programs settings and peer debriefing. Fittingness or transferability was enhanced by collecting data from different settings; excerpts from participant transcripts are presented to facilitate auditability of data analysis.

Confirmability is established when credibility, transferability, and dependability are achieved (Guba & Lincoln, 1989). We used reflective practices to ensure our personal biases, such as knowledge of the literature on the topic, were acknowledged and did not influence the data collection and analysis (Korstjens & Moser, 2018). Furthermore, we met frequently to discuss findings from the data during data analysis to arrive at consensus on the issues or themes.

Results

The 18 current and former nursing students from two undergraduate nursing programs (16 female, 2 male) who participated in individual interviews ranged in age from 18 to over 45 years, but most (n = 15) were younger than 34. Ten were current students, six were former students who withdrew, and two were RNs who had graduated. Of the 10 current students, one was in first year, four in second year, one in third year, and four in fourth year; all but two were international students (the others were permanent residents or Canadian citizens). Five participants (all female, representing current and former students) later contributed to the focus group discussion.

In this study, participant stories unveiled experiences, feelings, and perceptions, interpret myths and misconceptions, critique beliefs and understandings of race, and unpack the ahistorical and often decontextualized nature of law that intersect to render silent marginalized groups’ voices (Henry et al., 2017). Challenges influencing success are discussed in four main interrelated themes, each with subsequent subthemes, and substantiated with direct quotes that flesh out meanings and validate thematic descriptions (Sandelowski, 1986). These themes reflect: 1) disengaging and hostile learning environments; 2) systemic institutional and program barriers; 3) navigating personal struggles in disempowering environments; and 4) recommendations to improve the delivery of nursing programs. Each of the themes/subthemes are substantiated with dicer quotes that illuminate meanings and validate thematic description (Sandelowiski, 1986).

Theme 1. Disengaging and hostile learning environments

Racial discrimination and microaggressions

Participants narrated accounts of racial discrimination and microaggressions by faculty, instructors, and peers that impinged on their progression, dignity, and success. Participant 18 sums this up best by saying, “Let's call a spade a spade. My barrier is being a Black student.” Racism and unconscious bias were highlighted as contributing factors among those who withdrew from the nursing program: “[Before] my last clinical, I got 90%. I didn’t stress [out]. To be honest, what happened [to me later] was pure racism. This tutor always put me on minimum pass. It was very hurtful and frustrating” [P11]. In addition to being placed with instructors who were perceived as unjust, this same participant experienced unconscious bias: “I was always crying in the bathroom multiple times in an 8-h shift. They indirectly said that maybe I wasn’t doing well because I had a child. But there were tons of White students with kids” [P11].

Another former student who withdrew from their program reiterated how her experiences led her to shift previously held beliefs, which including denying the existence of social injustices, racism, and unconscious bias in the nursing program: “I always told my fellow Blacks that everything is not about racism. Until it [happened] to me, I ridiculed ideas about racist. When instructors make up their minds, they use race [bias] to fail students, regardless of [their] effort” [P8]. This same participant also described experiencing anguish and trauma: “I could tell that the instructor didn’t like me from day one. She was racist. Everything I did was wrong to her. After that, I withdrew from clinical, your esteem is gone, and it's hard to focus” [P8].

In addition to unhealthy instructor–learner experiences, participants felt some nursing program processes created additional barriers and hardships for Black nursing students. The decision to withdraw diminished their reenrolment opportunities within a 6-year time frame: “If you withdraw from a clinical twice, you must write to ask to continue. When I wrote to the school, they didn’t approve [it] because obviously I withdrew from it. That's what happened, and finally I couldn’t continue” [P8]. This created a further disadvantage by limiting program reenrolment opportunities.

Accent-based stereotyping

Participants also shared experiences of racial discrimination and unconscious bias that were compounded by accent-based stereotyping. A graduate from one of the nursing programs noted how having an accent affects Black students: “Instructors … have either looked down on Black people or not believed them because they have accents. Then instructors think they don’t know what they’re doing. I think that's something students struggle with that must be addressed, for sure” [P13]. A focus group participant shared this experience: “In podcast assignment feedback, the instructor said she appreciated everything I wrote, but she was deducting marks for my accent. She had no right. I questioned the unjustifiable accent marks deduction” [FG Code 7].

Some participants, especially those who withdrew, found this accent-based stereotyping or undervaluing of their sense of being stressful: “Racist professors would say they couldn’t understand what you’re saying because you have an accent. It was so traumatizing” [P14]. Participant 10 offered a suggestion to counter inflection biases, saying, “Language shouldn’t be a barrier [to learning]. Our accents are different. When you speak, they say, they don’t understand what you’re saying. I recommend that they go beyond that, see the person's values, and don’t focus [solely] on accents.”

Unsupportive clinical learning environments

Many participants had the perception that the clinical learning environments were unsupportive and even hostile because some clinical instructors were racist towards visible minority students. This lack of instructor support was expressed succinctly by one participant: “I was placed in an environment where they set you up to fail. My last clinical [instructor] was not supportive. I had five clients assigned to me; other students got less. The practical hospital supervisor was hostile. She's racist” [P6]. Negative experiences with “racist” clinical instructors were common, with participants noting varying levels of unfairness and limited clinical learning support. One participant expressed their frustrations as follows: “My self-esteem was very low. One [instructor] made my life miserable. She victimized and gave me an attitude. Nurses gossiped about me; instead of learning, the instructor called me aside for follow-ups” [P11].

Power and privilege imbalances

Power and privilege imbalances affected learner–instructor relationships, as participants shared experiences in which they identified White privilege as a learning-centred barrier that impinged on their success. In general, participants felt they were treated less favourably by White instructors and peers than other students. One former student who had withdrawn lamented as follows: “There's power and privilege everywhere. There's nowhere to turn to. If only there was a person within the staff to mentor [or] support students of color, or a social worker to turn to” [P6]. The realities of power inequity in a hostile learning environment impeded student success. Another participant talked about the emotional toll of navigating power inequities with instructors and peers: “She treated me badly, whatever I said, didn’t matter. In a class group project, one group member used my work as a sample. They all got 70 s. I got a 50, I barely [passed]. [The unfairness] was emotionally draining” [P16].

Theme 2. Systemic institutional and program barriers

Lack of diversity or black representation

Black underrepresentation among instructors/faculty led participants to assert their learning needs were often minimized or ignored. As participant 14 noted, “I think what could have helped me to be successful was to [reduce inequity] for Black people, who look like us, teach[ing]. I mean, we needed [representation of] people of colour, be it instructors or deans”. This participant described nursing as “a predominately White profession unlike other helping professions, where there is diversity even in leadership roles.” She further illustrated the difference as follows: “I was suffocated in the nursing program. When I moved to [X] program, it was different. You get goodness in program inclusive of immigrants. Instead, I walked with my head up. I felt the diversity in program [X] …” [P14].

Lack of support for black students

Many participants shared the perspective that Black students were not welcome in their nursing program. Several participants reported that they needed advocates, especially when they encountered racial discrimination as they sought to reach their learning goals. Some participants felt overburdened by the lack of a racially diverse faculty, their fear or inability to engage with White faculty, and/or instructors’ disinclination to create or support learning-centred relationships. Their fear, coupled with the lack of an engaging learning environment, made it difficult for many students to navigate their learning needs. Participant 6 stressed this worry, saying, “You cannot approach instructors because you are scared. When there are [non-existent teaching-learning] relationships, how can you even try? I am scared to ask for help.”

Several participants indicated they struggled “in silence” with issues of racism due to inadequate supports for Black students; this silencing contributed to feelings of humiliation amid the demands of the nursing program [P6]. The following comment illustrates an unpleasant termination experience: “My instructor said I wasn’t going to pass that rotation. Suddenly, we met with the program head. My instructor told her I was not stable. Yet she didn’t communicate that to me. After that, they failed me” [P9]. This disempowering dialogue was not accompanied by due prudence or support for any presumed “instability.” Rather, this participant was placed in an unfair position: “I just sat there shocked. I did not get a chance to even get the student advocate to come into the meeting. I was placed in the [harsh] situation. I could not advocate for myself” [P9]. Another participant talked about the struggles related to lack of support among Black students. “A lot of [Black] people I started with dropped out of the program eventually because of the lack of support” [P12]. The same participant was unable to voice her concerns to nursing program leaders, and thus felt unheard: “I had an unresolved issue. I never got the opportunity to speak to the Dean. They said, ‘I could not talk to [the] Dean but [could talk] to an advisor or her assistant’” [P12].

Without access to nursing program leadership, participants were forced to find solutions on their own or troubleshoot with students who had withdrawn from the program. As one participant pointed out, “There was no support in the clinical [setting]. If you ask students that left, they will say nobody left because of theory classes, they leave because of clinical classes” [P11]. As such, the prevailing perception was that Black students find the clinical learning environments unsupportive.

Exclusion and isolation

Amid a hectic and a busy nursing program, participants also felt excluded and isolated. In particular, White students created their own clusters for team-based projects, excluding Black students and leaving them in a precarious position: “In lab, the instructor asked us to pair up. When I asked people, they blew me off until one student was left. She quietly just stood, looking at the instructor. I was a last resort. The instructor paired us” [P15]. Given that nursing is a discipline that requires teamwork, it is disconcerting that opportunities for teamwork for Black students can be challenging or risky. Difficulties can also arise if the Black students’ contributions are not recognized: “With group assignments, you’re doing most after hours in the library and at school on your own. The professor says they don’t understand me, yet we did the same thing. Other people get [higher] marks than me” [P14].

Theme 3: Navigating personal struggles in disempowering environments

Lack of preparation

Students’ personal struggles could present as a lack of preparation. For example, participants identified a lack of effective supports for their academic writing as a significant barrier to their success: “I know one of the major issues for Blacks is writing papers, like how to cite or [use] references [correctly]” [P10]. Some also felt unprepared for the different style of academic learning they encountered in nursing school. One participant described the lack of preparedness and readiness that was exacerbated by the intensity of the courses: “I think we’re just thrown into it. I would say not having college preparation courses that others [students] have [is a shortcoming …. Also,] having to do these different courses and the heavy load complicates learning” [P12].

Work-life-school balance

Some participants struggled to maintain a healthy life and learning balance given the demands of their program. As participant 12 noted, the challenges of balancing work life and school life are substantial: I would say not being able to balance work life, school life, and every other part is huge.”

Theme 4: recommendations to improve the delivery of nursing programs

Provide institutional-level support for students and instructors

A few participants expressed the need for support for Black students and suggested the development and implementation of motivational workshops for nursing instructors and leadership:

I feel the program needs [better] support for students of color. Many instructors say they want system changes. Maybe it's the higher ups that are not really doing anything to support or show that they want change. It's discouraging. Support for those students, and maybe motivational workshops [can help] students. [P2]

Many comments from the interviews and focus group related to the need to provide specific support for Black nursing students. Such support could take the form of “hir[ing] a cultural coordinator to lessen cultural challenges and racism experiences of Black students” [P7] or ensuring “Black students … have a representative that they can talk to when they have issues and they're facing [challenges]” [P11]. Such specific support for Black students would align with efforts for other racialized groups that have cultural coordinators: “They have that on the main campus for Indigenous students, they might do something like that [to lessen] racism experiences of these students” [P7]. Overall, the participants felt Black students feel unsupported and hoped the nursing programs could step up and “do [their] best to take care of that one [Black] student having a problem and help and make sure to show or give them the support that they need.” [P2]

In addition, one participant suggested nursing programs adopt anti-oppressive courses: “Bring anti-oppressive course in nursing. There should be a mandatory education for instructors to stop oppressing people of color because of their power. Remember, White nurses graduate to treat people of color” [P6].

Increase diversity in nursing programs

Several participants recommended the programs improve representation by hiring Black faculty and student advisors to advocate for Black students:

There's no one you can raise your concerns to, and … they would understand you and advocate for you, or relate. That's something that's definitely lacking. I think we need diversity by adding advocates for Black nursing students. Whenever me and my friends had issues, there was no one we could talk to. If we talk to a White faculty member, it's difficult for them to relate to struggles we [experienced by] a minority. Adding advocates for Black nursing students [can increase] diversity. [P13]

Increasing representation was believed to be an important step towards empowering Black nursing students, who often feel powerless in institutional settings dominated by perceived racial bias among White faculty and staff:

Nursing schools have few Black nurses that are part of the decision-making board processes. Sometimes, if a Black student is facing an unfair challenge, then the Black instructor or advocate can intervene … I believe … if there are Black instructors … are familiar with you, and where you are coming from. They might even have an accent just like you. An accent will not be something alarming to them. [P8]

Such sentiments were reflected in many student comments, which often brought up the concepts of diversity and approachability:

“Instructors ought to be approachable. I think we need diverse faculty. [Not] only White instructors. Bring in people from different races and backgrounds.” [P11]

Act on student complaints and create safe spaces for dialogue

Students worry they will not be believed if they complain. As such, participants recommended nursing programs take student complaints seriously:

Black people's concerns are usually ignored. [This] affects people's sense of self-esteem, their mental health, and performance in school. An instructor said something racially offensive, I brought it up, and it was minimized. I was told the instructor worked with a lot of Black people; she couldn’t be racist. [P13]

Another participant felt that non-remedial action was disappointing: “You know how when people have these issues and they email the dean, they usually do nothing about it, so I just wish that they fix that issue … that’ll be beneficial to us.” [P3]

As participant 11 suggested, nursing programs need to create safe spaces for Black students to share their concerns: “A voice without representation is nothing. You speak out and put yourself in trouble. With a voice, Black students [can heal]” [P11]. One suggestion put forward was for Black students to feel empowered to form a group, come together, have meetings, discuss, and then have a representative share feedback with faculty:

This is something Black students definitely need. They need to have a platform … I think [platforms] should be led and organized by someone that's also a member of the visible minority because … they can relate … to the struggles that Black students [experience]. [P13]

This paper advances a discussion on the barriers influencing Black nursing student success and related participant recommendations in a context of systemic racism in nursing, unconscious racial bias, and coping mechanisms (Luhanga et al., 2022).

Discussion

The data collected in this qualitative pilot study yielded four major themes with associated subthemes and suggest current or former students from the two Western Canadian nursing programs experience anti-Black racism barriers and challenges that negatively impact their academic success. The former students who withdrew from their programs experienced feeling disheartened to the point of despair and disengagement: they suffered a loss of dignity and a voice to seek recourse for racial biases. These findings align existing research indicating Black nursing students in the USA and Canada experience multiple anti-Black challenges and barriers—such as silencing, discrimination, and abuse—that ultimately contribute to high attrition and/or failure to complete their chosen program (Beagan et al., 2023; Besa et al., 2022; Ezeonwu, 2019; RNAO, 2022).

Implications of systemic racism

Our findings are consistent with other Canadian studies that reveal similar experiences of systemic institutional racism among BIPOC students when enrolled in nursing programs and clinical practice settings that lack supports (Besa et al., 2022). Black students, for instance, feel unheard, struggle to find a healthy work-life-school balance, and feel disempowered in a silencing or crushing learning environment (Beagan et al., 2023). These findings suggest the urgent need to address systemic institutional racism in nursing academia to increase inclusivity and help Black students build confidence and feel supported (Ackerman-Barger et al., 2020). Institutional commitment to the principles of equity, diversity, and inclusion (EDI) needs to be strengthened and academia must address covert discriminatory practices (Gillborn, 2020; Henry & Tator, 2012). Otherwise, the impact of limited diversity and inclusion will continue to perpetuate Black student experiences of workload inequity and being undervalued (e.g., by clinical instructors) (Beagan et al., 2023). Recent literature (Bouabdillah et al., 2021; Brathwaite et al., 2022) demonstrates that BIPOC students continue to experience racism and related systemic institutional and program barriers. Thus, as Brathwaite et al. (2022) note and participants in this study suggest, developing and implementing systems and strategies in academic institutions to eradicate institutional and Black anti-racism is imperative.

When the learning environment is characterized by undermining experiences, Black students will unsurprisingly encounter challenges navigating their journey and the demands of what they justifiably perceive as an unsupportive program. When Black students face hostility from faculty members who insinuate they do not belong in the nursing profession (Beagan et al., 2023; RNAO, 2022), their ability to interact with peers and patients is bound to be misrepresented (Besa et al., 2022; RNAO, 2022), thus exacerbating negative learning outcomes. When programs disempower student learning and growth in discriminatory environments, Black nursing students’ progress is slowed. Microaggressions are often present as threats, wherein instructors bully Black students with warnings that they “may even fail the student [with an] accent” (Besa et al., 2022, p. 31). Thus, an “accent is a significant marker of inequality, where … racialized students are doubted, and seen as inferior” by faculty (Monteiro, 2018, p. 74). This means they must navigate extra burdens and prove their competency amongst limited supports (Luhanga et al., 2020; Monteiro, 2018). Accent concerns are not uncommon nor unique to Black students (Ezeonwu, 2019; Iheduru-Anderson, 2020; Monteiro, 2018; Sedgwick et al., 2014). Regrettably, accent-based stereotyping or discrimination influenced the learning and teaching experiences of some Black nursing students in this study. Sedgwick et al. (2014) also document nursing student experiences of this type of language barrier and discrimination in clinical settings. A participant in Ezeonwu (2019) echoes this sentiment: “It doesn’t matter how intelligent you are … they hear your accent, you are put in a … a category, and you are not being heard” (p. 285). Maximizing language sensitivity could reduce power inequities (Monteiro, 2018).

This study also corroborates findings from other studies showing power inequity exists, and instructors’ disadvantage how Black vs. White students are evaluated and/or positioned to succeed (RNAO, 2022; White et al., 2020). Likewise, this study validates literature showing White students do not experience inequity in workload assignment during clinical placements; this is a common concern for Black students who are also “assessed more stringently/harshly compared to their White counterparts” (RNAO, 2022, p. 28). Our findings underscore the need for faculty to avoid unjustly diminishing learners’ engagement and alienating Black students (cf., Monteiro, 2018).

Implications of underrepresentation

Consistent with prior studies, this study verifies that the lack of diversity, supports, and Black representation in nursing programs impede the academic success of Black nursing students (Gona et al., 2019; Hill & Albert, 2021; Iheduru-Anderson, 2020; Jefferies, 2020; Montgomery et al., 2021). Awareness and empowerment strategies that proactively and effectively respond to anti-Black racism are needed to support Black students’ success as future nursing leadership or faculty (Iheduru-Anderson & Wahi, 2018). The lack of racial diversity in nursing programs—especially Black ‘underrepresentation’—may generate or exacerbate Black students’ and nurses’ feelings of isolation, exclusion, and being misunderstood. Indeed, the findings suggest underrepresentation of Black faculty is negatively impacting perceived understanding of the (non) academic support needs of Black students in nursing programs. Nurse educators are obliged to meaningfully engage Black nursing students, co-develop programs that mitigate systemic racism in academic institutions to increase educational retention and promote success, and facilitate sustainable harm-reduction strategies (Brathwaite et al., 2022). Tracking retention and success rates with race-based data is urgently needed to validate and support the concerns of Black nursing students. In turn, such data can support evidence-based strategies tailored to empower, improve wellness, and revive healthier learner experiences.

The underrepresentation of racialized groups in Canadian academia may indicate these institutions find recruiting or retaining diverse staff and faculty problematic; indeed, 40% of both graduate and undergraduate students identify as visible minorities or racialized groups but only 21% of full-time faculty identify as such (Universities Canada, 2019). Similarly, in the US, the National League for Nursing's (2017) found over 80.9% of full-time nursing educators were White, with African Americans only making up 8.8%. Our findings support efforts to bolster inclusion and diversity in recruiting and retaining BIPOC students, nurses, and faculty.

Implications of lack of formal supports

Montgomery et al. (2021) urge nursing programs to provide effective formal supports for Black students, e.g., non-judgmental academic advising, peer support, and mentorship, that cultivate student institutional allegiance. Our participants agree that such culturally responsive academic support can, in turn, help to improve academic and social success. Empowered to become effective role models, Black students can succeed in nursing careers (Garland & Batty, 2021). As Montgomery et al. (2021) contend, racially diverse nurses can leverage their unique lived experiences, engender inclusive insights, and deliver responsive “quality and overall health” care (p. 23). As a participant in Hamzavi's (2021) study noted, “seeing people who look like you in … positions of privilege and power [restores] one's sense of belonging” (p. 79).

Other studies (Ezeonwu, 2019; Iheduru-Anderson, 2021; Koenigsman, 2017) corroborate the struggles with work-life-school balance noted by participants. Many minority students often work full- or part-time jobs during their undergraduate studies to meet their needs and pay tuition (Ezeonwu, 2019; Iheduru-Anderson, 2021). A poor study time/ work life balance will impact attendance and decreases the time available to access supportive resources and improve success. As noted by participants in Iheduru-Anderson (2021), “when family and work responsibilities collided with schoolwork responsibilities, the schoolwork was relegated to the bottom of their priority list” (p. 6). Challenges and stress in the clinical environment are associated with the intense and rigorous nursing curriculum and are a major barrier to undergraduate nursing student success (Chernomas & Shapiro, 2013; Tung et al., 2018).

Without supports, visible minority students find it difficult to voice their concerns when they feel misunderstood and devalued due to the perceived inability or unwillingness of White faculty to engage in meaningful respectful relationships. The need for effective Black learner–instructor relationships, in the context of limited diversity, is nurtured by healthy dialogue and supported by culturally responsive and helpful interactions (Iheduru-Anderson et al., 2020). Participant recommendations align with calls for responsive racial diversity and supports (Besa et al., 2022; Gona et al., 2019; Hamzavi, 2021; Monteiro, 2018; Montgomery et al., 2021) and reiterate calls for safe spaces for Black students to voice their racial discrimination and oppression concerns in nursing programs (Ackerman-Barger et al., 2020; CNA, 2020; Gona et al., 2019; RNAO, 2022). Gona et al. (2019) challenge nursing programs to create a caring environment in which Black nursing students feel their personhood and cultural perspectives are valued, respected, and contribute to the learning environment. Black students also need clear avenues to report/discuss racist behavior from faculty, staff, peers, clinical instructors, and preceptors without fear of reprisals.

Implications on nursing programs

This study adds to the growing evidence illuminating the experiences of Black students in nursing programs and exposing factors that support or hinder their retention and success (e.g., Beagan et al., 2023; Bell, 2021; Besa et al., 2022; Hamzavi, 2021). Recommendations for leaders in nursing programs shared by Black students in this study may be relevant to other programs that share similar challenges. Notably, one key suggestion is acknowledging racism exists, and for mandatory anti-Black racism and anti-oppressive courses for nursing faculty and clinical instructors (Brathwaite et al., 2022; CNA, 2020; Williams et al., 2022). This echoes calls for cultural sensitivity training for faculty members, instructors, and staff in education and practice settings (e.g., Besa et al., 2022; Brathwaite et al., 2022; Gona et al., 2019; Monteiro, 2018; RNAO, 2022). EDI efforts should be conducted in tandem with hiring Black student advisors/ counsellors who can advocate and support Black students (Koenigsman, 2017; Jones, 2022). Faculty members and advisors must be good listeners, patient, approachable, and with vested interests in positively impacting Black nursing student success (Ezeonwu, 2019; Iheduru-Anderson et al., 2020). Jones (2022) also advocates for counselling to improve the well-being of Black students in Canadian universities and colleges and lessen the psychological effects of racial discrimination and oppression on Black students’ self-esteem. Participants also recommended proactive educational opportunities for both students and instructors. Specifically, reducing the personal struggles of Black students related to navigating a demoralizing learning environment could be addressed via motivational workshops (Ackerman-Barger et al., 2020; Koenigsman, 2017). Workshop content could include active responsive learning exercises, expert panels with audience participation, small and large group discussions, structured action planning, and a monthly learning collaborative to foster peer-to-peer engagement and community building (Ackerman-Barger et al., 2020). Nursing program commitments to diversity can be demonstrated in how they address discriminatory learning environments (Bell, 2021; Besa et al., 2022; Montgomery et al., 2021). In Canada, such efforts are urgently needed to boost the integration of Black nurses and address inequity in student experiences.

To improve diversity in nursing programs, the concerns of Black students—who represent a growing Canadian population—need to be heard. Findings from this study can inform strategies to improve supports for Black students, retention decision-making, and policy in this Western Canadian province and other nursing schools with Black students. The findings corroborate literature highlighting the systemic racism in post-secondary nursing academia that Black students experience and which regulatory bodies must address (RNAO, 2022). The findings also illuminate ways student input can inform efforts to reduce anti-BIPOC racism (Besa et al., 2022; RNAO, 2022).

Disaggregated data collection that delineates different nursing programs is necessary to determine if recruitment and retention align with the experiences of our participants. In addition, the nursing discipline has a mandate to safeguard and demonstrate social justice values towards all students (CNA, 2020; Rice et al., 2019). Black future nurses who plan to pursue nursing in Canadian institutions ought to be able to navigate their education free of racial barriers or challenges. Students are empowered when they know how or where to obtain supports if racism or microaggressions are encountered where they learn. Safe spaces for healthy dialogue/advocacy skills to voice or question their concerns is one way for student needs to be met (Garland & Batty, 2021; Prendergast et al., 2020).

Strengths and limitations of the study

This was a pilot study with data collection limited to two undergraduate nursing programs in Western Canada. As such, the findings should be interpreted with caution and not generalized or transferred out of context (Polit & Beck, 2010); nonetheless, they can inform work at Canadian universities, colleges, health care institutions, and related settings that aims to improve inclusivity.

Our study participants are diverse including those who withdrew from nursing programs providing additional insights on the supports or barriers to success. The use of a convenience sample and self-reported data is a potential source of bias related to qualitative methodology (Jager et al., 2017). Another limitation of our study could be the unbalanced gender representations (i.e., few male participants who are a minority in the nursing program). Future studies could compare experiences of Black male and female undergraduate nursing students.

Findings draw attention to Black nursing students who bear the impact of racism, limited support, exclusion, isolation, and inequity, with some alluding to “being Black” as an underlining barrier. This study adds voice to the literature, making visible the racism-related learning issues experienced by Black students amidst disengaging and hostile learning environments, systemic and institutional program barriers, and personal struggles in disempowering environments. It also provides recommendations based on participant experiences to improve the delivery of nursing programs.

Conclusion

Four interrelated subthemes emerged from this study and illuminate barriers affecting the success of Black students in undergraduate nursing programs as well as recommendations to improve program delivery. Collectively, they reflect how unwelcoming learning environments, systemic institutional and program barriers, and personal struggles rooted in disempowering learning spaces can impact Black student retention and success and need to be addressed to improve program delivery. Systemic racism in academia has a profound impact on Black nursing students’ academic advancement and subsequent career trajectories. BIPOC students deserve to find meaning in their nursing education; like their White peers, they have a right to expect equity and effective learning-centered supports. By addressing the barriers and issues identified in this, and other, studies, more Black students may complete their nursing education programs and impact the growing need for a diverse nursing workforce.

Author Biographies

Florence Luhanga, RN MEd PhD is an Associate Professor and Interim Associate Dean (Graduate Studies & Research) in the Faculty of Nursing at the University of Regina. Her program of research has been primarily in the area of field teaching and unsafe student clinical behaviors. Her current research relates to factors influencing success and equity in ethnic minority student in undergraduate professional education programs and Black faculty in academia.

Sithokozile Maposa, RN PhD is an Assistant Professor and Graduate Chair in the College of Nursing at the University of Saskatchewan (Prince Albert Campus). Her program of research is on women's health and health inequities, and advancing nursing in a global context.

Vivian Puplampu, RN PhD is an Associate Professor in the Faculty of Nursing at the University of Regina (Saskatoon Campus). Her program of research is on equity and housing security for older Black Canadians, and factors influencing success among future Black nurses and faculty.

Eunice Abudu (Masters of Adult Education and Community Engagement), is a faculty with the Saskatchewan Polytech and Adjunct Professor with the University of Regina. Her program of research focuses on promoting student success in their nursing and clinical education, supporting internationally educated nurses to transition and practice effectively in a Canadian context.