Degrees of Success - Wiley Online Library

DIVERSITY EXCELLENCE

Degrees of Success Safeguarding an Ethnically Diverse Nursing Workforce in Nursing Education Stacy Johnson, MSc, BSc, RN, Janet Scammell, DNSci, MSc, BA, DipNEd, RNT, SRN, SCM, and Laura Serrant-Green, PhD, MA, BA, RGN, PGCE

By the end of 2013, all programs leading to the registered nurse qualification in the United Kingdom will be at the bachelor’s degree level. There is concern that all-degree nursing education might threaten the diversity of the future nursing workforce in the United Kingdom. This article reports on a qualitative pilot study exploring the critical issues for access, recruitment, and retention of Black and minority ethnic (BME) students in U.K. nursing degree programs from the students’ perspective. The study utilized action research, and this article reports on the first two stages of the action research cycle, problem identification and identification of actions. The data were collected through focus groups and interviews with BME students and then analyzed with iterative thematic analysis. The objective was to inform an action framework for U.K. universities devising access, recruitment, admission, and retention practice for BME students when U.K. nurse training becomes all degree.

Introduction After years of debate, the Nursing and Midwifery Council (NMC), nursing professional bodies, and the government in the United Kingdom have decided that all training programs leading to registered nurse (RN) qualification in the United Kingdom will be at the bachelor’s degree level by the end of 2013. Thus, the two-tier initial qualification system leading to nurse training (qualifications at degree or diploma level are accepted for entry to the nursing practice register) that has existed since the 1980s will cease to exist. In the United Kingdom, diploma-level qualification has been the traditional level required for nursing practice. Training historically took Journal of Psychological Issues in Organizational Culture, Volume 3, Number S1, 2013 © 2013 Bridgepoint Education, Inc. and Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) • DOI: 10.1002/jpoc.21069

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place in hospitals but moved to universities, alongside degree-level qualifications with the introduction of Project 2000 in 1986. This project was aimed at increasing the educational standards in nurse training by aligning them with higher education (Lord, 2002), which resulted in the two-tier level of nurse training (degree and diploma). The move to make nursing an all-degree profession provides an opportunity for increased status and power for the U.K. nursing profession, which is one of the few health care roles in the United Kingdom that is not yet a fully graduate profession. Opinion remains divided among nurses and other health care providers as to whether this will translate into better care for the diverse range of patients accessing the health care system in the United Kingdom. Black and minority ethnic (BME) student participation in higher education (HE) in the United Kingdom is quite a complex picture. Historically, BME students have been underrepresented in nursing education as in many other areas of HE in the United Kingdom. There is a wealth of research in education and around academic achievement indicating that BME children in the United Kingdom consistently have relatively poorer educational achievements than their White peers (Tackey, Barnes, & Khambhaita, 2011). This has had a major impact on the number of BME children leaving post-16 education (stage of eligibility for HE application in the United Kingdom) who had the education levels of attainment required for university entry (Johnson et al., 2009). Following efforts in recent years to increase the number of BME students attending universities in the United Kingdom, this number has risen to 17.2% of university students in 2009, compared to 14.9% in 2004 (Weekes-Barnard, 2010). This percentage of engagement with HE maps closely with the latest national census statistics that report that BME populations account for approximately 16% of the population in the United Kingdom

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Journal of Psychological Issues in Organizational Culture, Volume 3, Number S1 • DOI: 10.1002/jpoc

(Office of National Statistics, 2006). Although the overall picture of BME engagement in HE has improved, disaggregated figures from the wider HE sector, including all subjects, reveal that some ethnic groups, particularly Pakistanis and Bangladeshis, continue to be seriously disadvantaged, with reported lower levels of engagement and poorer outcomes than their peers, both BME and non-BME (Broecke & Nicholls, 2007; Richardson, 2008). There is also concern that, overall, BME students in HE have persistently reported less satisfaction with their student experience than white colleagues (Higher Education Funding Council for England, 2011; National Union of Students, 2011). BME engagement in nursing education in HE trends have followed that of the broader picture, according to the Council of Deans of Health (2010), the professional leading body for nurse education in the United Kingdom, with 17% of those studying nursing coming from a BME group. This reflects a great change from 1987, when the current two-tier system was introduced and BME students accounted for only 3% of nursing students at a time when 5% of the U.K. population came from a BME group (Chevannes, 2001). Participation rates for BME student nurses in HE are not an isolated concern; reported conversion rates, or the ratio of HE applications to acceptances from students who eventually enroll in a university program, suggest that BME students applying to study nursing are less likely to be accepted than their White counterparts (Chevannes, 2001). BME students are also less likely to be accepted to more selective universities in the United Kingdom (Tribal, 2006) and achieve lower grades on completion of their nurse training programs compared to White students (Higher Education Academy/ Equality Challenge Unit, 2008; Singh, 2011). Additionally, BME students in HE are overrepresented in diploma (subdegree) programs in the United Kingdom (Tribal, 2006). After 2013,

subdegree entry will no longer be accepted as a validated training route for RN status in the United Kingdom. This change was introduced in the United Kingdom in 2009 but will become compulsory for all nurse training only in 2013. This poses a challenge to nurse educators in HE, because nursing in the United Kingdom has had a strong history of participation from BME students at the subdegree level with proportionally less BME representation on existing degree-level training programs. If this trend were to continue after 2013, there could potentially be a risk of generating a two-tier health care workforce with BME workers disproportionately populating the lower, unqualified care practice grades due to underqualification for positions requiring the RN qualification. These trends have implications for access, recruitment, and retention of BME nursing students when nurse training is at all-degree level. These factors, from reduced entry to HE and lower achievement levels at the end of training programs to increased likelihood of a diploma rather than degree qualification, have implications for job prospects and may explain why BME nursing students leaving HE are more likely to be unemployed or underemployed (Tribal, 2006). It appears from current literature that the planned completed move to all-degree nursing education may have unforeseen implications for ethnic diversity and equality in the U.K. nursing workforce. In the United Kingdom, where all nurse education and training for initial entry into the NMC register for practice occur within universities, any possibility that fewer BME students will be accepted into or succeed at degree level will affect the ethnicity profile of the nursing workforce in the future. National U.K. reports such as Frontline Care (Department of Health, 2010a), the Darzi review (Department of Health, 2008) and the U.K. government’s 2010 White Paper (Department of Health,

2010) reinforced the view that a diverse nursing workforce that reflects the diverse population it serves is desirable is essential for culturally responsive nursing, and produces better care in the United Kingdom. To maintain an ethnically diverse student population and, by extrapolation, a diverse future nursing workforce, universities offering degree programs leading to initial nurse registration need to be able to continue to recruit and ensure the successful retention and achievement of BME students in nurse training programs.

Background Published literature about BME experience and engagement in nurse education and training in the United Kingdom was reviewed to set the context for the study. The aim was to explore the range and scope of existing evidence relating to access, recruitment, and retention of students from BME groups on nursing programs. This would help establish the context in which BME student experiences occurred and the precursors and influencing factors for this decision making pre-entry and during completion of nursing degree programs. Reports, policies, and reviews not published in journals were reviewed to ascertain the issues that may influence BME student experiences. The main themes arising from the literature are identified next and are presented in relation to the student journey through the HE system in the United Kingdom. Applying to University: Decision Making, Choice, and Selection Decision making accompanying students’ move to apply to university to study for a nursing degree and the factors that influence students’ choice of university or nursing program are not extensively explored in the literature. Chevannes’s (2001) study is one of the few that examines nursing students’ choice of institution from the students’ perspective.


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Chevannes found that while BME students were choosing to study nursing and making applications to nursing programs in relatively large numbers, the numbers of BME applicants diminished as they completed the selection process from application to interview or offer of a place to study. Grainger (2006) explored choice and decision making as secondary considerations among applicants to nurse training to explore whether the low rates of BME students in nurse training programs could be accounted for by a lower level of applications to study nursing. Grainger similarly found that the numbers of BME student applicants appeared to be negatively affected by the process of selection. Grainger also presented data to illustrate that this had been a persistent phenomenon over the preceding 20 years. Applications from BME students account for more than 30% of preregistration nursing applications (Grainger, 2006). Despite this, in 2005, the Nursing and Midwifery Admissions Service (NMAS) published figures suggesting that applicants from BME backgrounds had less than half the chance of being accepted by a university than their White counterparts (Grainger, 2006). Grainger (2006) analyzed 3 years’ worth of NMAS data, generating what is known as the success ratio for the years 2001–2002, 2002–2003, and 2003– 2004, and found that all BME groups had lower success rates, with success ratios of less than 0.4. Grainer pointed out that this was not simply an issue of “biased processes.” The image of nursing in the wider public, including schools, and the attractiveness of nursing as a career in BME communities also factored into the decision making (Grainger, 2006; Modood, 1993). Other factors, such as student identification with the university, its vision, or purpose, and the presence of BME staff role models, also affected student identification with the institution (Campbell & Davis, 1996). According to the National Union of

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Students (2011), BME students generally considered these attributes: • Prestige and reputation of institution • Program type • Content and reputation • Entry requirements • Location of institution • Cost and affordability • Diverse student body • Job and work experience opportunities • Personal reasons • Political progressiveness of university • Social life including student union societies and activities • Student support networks • Extracurricular activities • Campus atmosphere • Campus and institution facilities The student attributes that affect the ability and likelihood to access HE are educational attainment; qualifications; performance at interview; and aptitude in language, numeracy and literacy (Deary, Watson, & Hogston 2003; Grainger, 2006). Analyzing NMAS data for applications in the period of October 1993 to September 1996, Iganski, Mason, and Humphreys (1998) identified unequal access rates between White and BME applicants. They found that the lower success ratios remained unexplained even after they had statistically controlled for confounding factors such as educational qualifications, branch of nursing, gender, and age.

NHS Employers (2005) cited poor performance at interview and deficiencies in basic numeracy and literacy skills as reasons why BME applications may be unattractive to universities. Students often may view university selectiveness as elitism (Grainger, 2006), unconscious or conscious bias or prejudice of staff involved in selection panels or interviews, and poorly designed selection procedures (Culley & Mayor, 2001; NHS Employers, 2005). Shared experiences reported within social and cultural groups may affect BME students’ perception of the welcoming nature of some HE institutions toward BME student populations; this, in turn, can also act as a barrier to application and perceived barriers to access to study (Wilson, Aiyegbayo, & Stephenson, 2007). BME Student Success For all students, including BME students studying nursing in HE, success is characterized by program completion, retention and attrition rates, attainment of a good degree classification, good job prospects, and employment appropriate to their qualification (student destination). The review conducted by Tribal (2006) on behalf of the National BME Education Strategy Group and funded by the Higher Education Funding Council for England found that there were persistant issues surrounding the success of BME students in HE in all disciplines. Actual and reported attrition—the rate at which students drop out of programs, sometimes referred to as “wastage”—varies between programs. U.K. government statistics (Department of Health, 2010b) show attrition rates were marginally higher for nursing degree programs than nursing diploma programs for the years 2006 to 2008. It is difficult to assess what the picture of attrition for BME nursing students might be nationally because data by ethnicity was not reported. Despite sustained political, professional,

and educational concern attrition rates on a national scale vary as much as 5% to 50% (Mulholland, Anionwu, Atkins, Tappern, & Franks, 2008). The comprehensive literature review on ethnicity and degree attainment in HE (Higher Education Academy/Equality Challenge Unit, 2008) highlighted lower degree attainment for BME students even after adjusting for the major contributory factors. This supports the conclusions of Connor, Tyers, Davis, and Tackey (2003) and Connor, Tyers, Modood, and Hillage (2004) and the 2006 report by Tribal, which found that White students were more likely to achieve higher degree classifications while BME graduates had poorer job prospects and higher unemployment and underemployment rates. Tribal also reported disproportionately higher numbers of BME students studying at subdegree level and White students studying at degree level. There are no comparable U.K. national, nursing-specific statistics available. Therefore, it is only conjecture that the same rates apply to nurse education. Academic, sociocultural, and financial factors, alone and in combination, have been found to affect the success of BME students in HE (Gardner, 2005; Mulholland et al., 2008). Glossop (2001) identified these academic factors as contributors to attrition: academic failure, poor program management, program pressures, inadequate preprogram information, lack of tutor support, and theory and practice imbalance. Some of these factors, such as poor program management and inadequate preprogram information, affect all students equally, but others may have a disproportionate effect on BME students. For example, Gardner (2005) identified absence of acknowledgment of individuality and lack of support from tutors as academic barriers to success for BME nursing students. Social factors affecting BME nursing students’ success include feelings of differentness,


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alienation, loneliness, and isolation, attributed to being in programs with predominantly White students and staff (Gardner, 2005; Kirkland, 1998). BME students in nursing programs also reported lack of understanding and knowledge about their personal cultural difference from their peers and described coping with insensitivity and discrimination (Gardner, 2005). Cultural factors, such as language and religion, interact with social factors and can be problematic with implications for attrition, retention, and student experience generally. In summary, the literature suggests that BME nursing students and students from other disciplines choose a university and program based on the university’s academic standing and facilities as well as the nonacademic considerations, such as extracurricular opportunities, social life, and perceived diversity of the staff and students. Access, recruitment, and selection processes in nursing programs, however, seem to disadvantage BME students, who are less likely to be accepted into programs than White applicants. Students from BME backgrounds appear less satisfied with their student experience, which affected completion of programs, success, and attainment. Although this may also be true of BME students in other disciplines, little is known as to what affects the experiences and achievements of nursing students undertaking degree-level programs. This lack of information is particular to the United Kingdom in the current context, in which nursing is not yet a wholly degree-level profession and BME students are found predominantly in diploma-level nurse training programs.

The Study The qualitative study underpinning this article explored the factors acting as barriers and enhancers to access, recruitment, and retention of students from BME groups in nursing degree programs in the United Kingdom. It provided insight from the

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students’ perspectives into the underrepresentation of BME groups in nursing degree programs. The findings were used by one U.K. university in the Midlands to review and inform planned policies for improving access, recruitment, and retention of students from BME communities. The university concerned was located in an area with a diverse population with approximately 19% of the population identifying themselves as being of BME origin. In addition, approximately one in eight is classified as a university student (Nottingham Insight, 2012). The study was funded by the Mary Seacole Nursing Leadership award, which is a government-sponsored fellowship in the United Kingdom.

Aims and Objectives of Study The objectives and intended outcomes of the study underpinning this article were: • To identify and define the critical issues acting as barriers and enhancing access, recruitment, and retention of BME students in nursing degree programs from the perspective of BME students in the United Kingdom. • To develop recommendations and a framework for action for all universities to support sustained access, recruitment, and retention of BME students in nursing degree programs in preparation for allbachelor’s degree-level training. Intended Study Outcomes This study aims to elicit: • Recommendations for improving access, recruitment, and retention of BME degree students • A framework for action that can be used by U.K. universities devising access

recruitment, admission, and retention practice for BME nursing students when training is mandatory at the degree level for new registration with the NMC in 2013

generate solutions to identified problems by engaging with the individuals and communities at the center of the issue and work with them to develop self-help competencies to increase selfefficacy and resilience of marginalized people and communities (Rapoport, 1970; Susman & Evered, 1978). AR is thus aligned with the study aims and provides a framework within which there was potential to contribute to improving the welfare of future and current BME degree nursing students and supporting the action of those working for progressive social change within the training experiences and success of BME nursing students, namely, the authors, university students, and university faculty staff. A number of AR models exist (e.g., Checkland, 1981; Zuber-Skerritt, 1996), but for this study, Susman and Evered’s (1978) five-phase model, shown in Figure 1, was chosen because of its simplicity and the fact that it is centered on

Methodology: The Action Research Approach The study used an action research–informed approach to provide insight from the nursing students’ perspective as to why students from some BME groups are underrepresented in nursing degree programs, why they may be less successful, and why they report less satisfactory student experiences. Action research (AR) is an umbrella term for a family of methods aiming to achieve inquiry, action or change, and evaluation simultaneously as part of a research project (Grbich, 1999; O’Brien, 1998). AR also seeks to

Figure 1 Cyclical Process of Action Research DIAGNOSING Identifying or defining a problem

SPECIFYING LEARNING Identifying general learning and making it public

EVALUATING Studying the consequences of an action

Development of a client-system infrastructure

ACTION PLANNING Considering alternative courses of action for solving a problem

ACTION TAKING Selecting a course of action

Source: Susman & Evered, 1978.


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development of understanding and solutions to a problem through investigation of the infrastructure of a system in which the client (participants) is located. The model has five phases: Phase 1: Diagnosing—Identifying or defining a problem Phase 2: Action Planning—Considering alternative courses of action for solving a problem Phase 3: Action Taking—Selecting a course of action Phase 4: Evaluating—Studying the consequences of an action Phase 5: Specifying Learning—Identifying general learning and making it public Susman and Evered (1978) acknowledge that AR projects may differ in the number of phases carried out depending on the stage of development of an issue and the pragmatic options available in differing contexts. This article reports on the findings after completion of the first two phases: diagnosing the problem and action planning. In the first phase in the cycle, data collection occurs and evidence is gathered to identify the key issues arising from the participants’ experiences. During the second phase, suggestions or solutions for actions to address the issues raised are identified directly and indirectly from the analysis of the phase 1 data. The objective in publishing these two phases is to highlight some of the contextual viewpoints of the BME students engaging in nurse training and education in the United Kingdom in relation to access, recruitment, admission, and retention practice for BME nursing students. The authors believe that the issues raised, although generated

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in the United Kingdom, may be useful to other subject specialties or geographical locations in improving access, recruitment, and retention of students from BME backgrounds. In addition, reporting these two phases may have application in other education and training environments in which organizations seek to understand and reflect on the experiences of BME students and clients when planning services and training opportunities.

Sample The study participants were BME students currently studying nursing at universities in the Midlands area of the United Kingdom. All students were currently enrolled in 3- or 4-year programs leading to RN status. The programs were a mixture of degree- and diploma-level qualifications, mirroring the current situation of dual-level registrant programs in the United Kingdom. Five focus groups with BME students in nursing degree and diploma programs at four U.K. universities were planned. The lead researcher gained permission to approach students via email from the dean of each relevant faculty or school of nursing at each university. The lead researcher then sent e-mails via the university e-mail system to all students in the nursing training programs asking those who identified as coming from a BME group to consider participating in the study. Students self-assigned their BME identity and expressed their willingness to participate by e-mailing the lead researcher directly. Ethical approval was granted by the Medical School Ethics Committee at one of the universities involved. Two of the three universities where the further focus groups were conducted accepted this approval to give permission for the study, while one university required a full ethics application.

The small number of BME students in each program warranted use of convenience and snowball sampling to select focus group participants, but response rates between universities varied. Ideally, a focus group should include 5 to 15 participants (Litosseliti, 2003), but as the ideal minimum number of 5 participants was not recruited across the five focus groups planned, it was not possible to complete the anticipated number of focus groups. It was important, however, to utilize the experiences of all the participants who wished to take part in the study, as the numbers of BME students in the nursing programs were relatively low. Therefore, three focus groups (20 participants in total), one grouped interview (3 participants in total), three paired interviews (6 participants in total), and a single one-to-one interview (1 participant) were carried out. A total of 30 participants took part in the study. Table 1 shows the composition of the data collection events. Participants were predominantly

female (90%), and most were Black, with 27 of the total 30 participants identifying themselves as either Black African or Black Caribbean (90%). One student identified as being of dual heritage, and two identified themselves as Asian. There were 7 firstyear students, 19 second-years, and 4 third-years. Diagnosing the Problem: Data Collection All participants were given a written information sheet and asked to sign a consent form before data collection commenced. The focus groups were conducted by the lead researcher and supported by a comoderator. Focus groups were chosen as likely to elicit participatory and collaborative responses required by AR, ensuring that participants felt that they were part of the process identifying issues and proposing actions. The focus group topic guide was developed from this initial literature review and was refined and adapted as focus groups and interviews were conducted.

Table 1 Participant Characteristics Number of Participants

Gender (F/M)

Black Caribbean

Black African

Asian

Mixed ethnicity

Focus Group 1

5

4/1

3

1

1

—

Focus Group 2

5

5/0

5

—

0

—

Focus Group 3

10

10/0

5

5

0

—

Paired Interview 1

2

1/1

—

1

1

—

Paired Interview 2

2

1/1

—

2

0

—

Paired Interview 3

2

2/0

—

2

0

—

Group Interview 1

3

3/0

—

3

0

—

Interview

1

1/0

—

—

—

1


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Data were collected via audiotape. All recordings were transcribed verbatim by the comoderator. The researcher acted as moderator, facilitating and guiding the discussion rather than leading it. A coresearcher took field notes, recorded the seating plan, and kept track of the order in which participants spoke.

Action Planning In the action planning phase, alternative programs of action arising from the diagnosis of the problem and generated directly (from suggestions or solutions identified in the focus groups) and indirectly (through interpretation of focus group discussions) were identified and reported in a framework for action. This phase was the initial data analysis stage of the AR process. An iterative, interpretive approach (Grbich, 1999) suited to AR was used to analyze the data. First, preliminary analysis involving extraction of emerging themes was conducted, followed by reflection, then return to the field for further data informed by the preliminary analysis. After repeated readings to achieve familiarity, the transcripts were annotated to highlight matters of importance. The annotations included self-assessment comments and comments on areas of the discussion where there was misunderstanding and clarification was required. Initial recurring issues were identified to gain a broad view of the key emerging themes. The advantage of this emergent methodology is that themes identified from this initial analysis were then used to inform the focus groups that followed. As Grbich (1999) suggests, a summary of initial themes was attempted after analysis of every couple of transcripts (initially from focus groups, then the group and individual interviews). These are represented in the maroon zone of the analysis pyramid in Figure 2.

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Initial themes were reviewed, additional issues were generated, instances of duplication were resolved, and similar concepts were grouped. Each theme was then contextualized, and relationships between themes were identified. The themes were then arranged into categories. Overarching themes reflecting the notion of choice emerged and were used to code the data. The findings reported relate to the first two stages of the AR cycle: problem identification and identification of actions. Data were collected through focus groups and interviews with BME students and then analyzed using iterative thematic analysis.

Findings Four overarching themes, shown in Figure 2, emerged from the completion of the first two phases of the AR cycle: choosing nursing, choosing to go, being chosen, and choosing to stay. The main issues arising from discussions within these overarching themes are presented as findings. The authors used participant numbers to attribute the quotations to illustrate themes to preserve anonymity but to allow links to be made between participants’ comments (e.g., P2 indicates that the statement had been made by participant 2). Choosing Nursing Choosing to study nursing emerged as a significant theme, a preamble to students embarking on the HE journey. Participants reported support and resistance as factors in decision making. This process and act of choosing nursing correlated to where applicants eventually studied and the factors facilitating their remaining in programs. The choice to nurse was seldom simple, often involving issues of both aspiration and conflict.

Figure 2 Main Themes and Subthemes

Choosing nursing Choosing to go Being chosen Choosing to stay • Contemplation phase • Perceptions of quality • No too black, no too white • Wanting to stay • Support to stay • Pressure to stay • Application and recruitment • Interview experience

• You can do better • Choosing with resistance • Perceptions of nursing in BME communities • Ranking • Location, location ,location • Opinions of practice staff • Recommendations from friends • London calling • Being close to family • Diversity • • • • • •

Desire/choice to nurse Nursing as aspirational Nursing as bad career choice, low status Reasons for resistance Rational decision making Conscious choice requiring resistance

Most of the participants saw nursing as aspirational and progressive. It was seen as a way out and a way of moving up in the world. Some reported being the first or only one in their family to be studying at degree level. There remained some dissonance. For example, participants referred to doing not “just nursing” and highlighted previous career and study in other fields. Participants identified role models as being influential in the choice to pursue nursing as a career. The notion of role models was important in two ways. First, participants identified strong nursing roles models in their personal lives who had inspired their desire to enter the profession.

• • • • • • • • •

Wanting to be treated the same The importance of role models Recognise me as different Me: internal resolve Being a role model Structural support Wanting to fit in A better life Job prospects • Ease of application process • Why are they asking me that? • Will my answer work against me • First in family/BME good or bad?

For example, P17 said: “ [M]y mum’s a nurse, she is my role model.” However, they also identified that by entering nurse training, they then became role models for others, their own children, and their community. Participants said that this had been a key factor in their choice to enter the profession and later remained a strong motivator for staying in their programs. Participants reported that their families, schools, and wider communities viewed their choice to nurse positively. Some even reported feeling they had gained transitional status almost immediately, although they had only just started


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training, with neighbors and relatives asking for health advice. For the Asian and middle-class BME students, participants reported the opposite. In these communities, participants cited that nursing was low status. Here the participants reported not only encountering resistance from parents, relatives, and even their schools when they expressed intention to nurse; they had to apply their own resilience not to succumb to pressure to choose something else. P12 said: It’s not good in my community . . . my mom became specialised, she did a degree. . . . Then she became somebody but before that she was just a nurse, she was no one. The participants reported that opposition arose from traditional stereotypes of nursing as a “girl’s job” and that it was menial labor and of low status. There was a general perception that nursing was a backward step for BME students. P8 said: I know that people, they see nursing like a proper downgrade, even my dad, he’s a pharmacist and he wasn’t happy with me doing nursing. Consequently, many parents and schools believed the students could do better. This was particularly the case when they had good school grades, especially when studying traditional A levels. In U.K. education, students may leave compulsory education at the age of 16 after completing the general Certificate of Secondary Education (GCSE) examinations. GCSE qualifications are identified as level 2 qualifications in the U.K. education system. Those wishing to continue education to university level are required to study beyond this to level 3. Advanced level study (A level) qualifications are the traditional level 3 qualifications needed to enter university. A levels are usually studied between the ages of 16 and 18 in

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schools of colleges and mirror the traditional subjects studied at school, such as mathematics, sciences, and humanities. Over the last few decades, the wish to widen participation in universities and encourage further study beyond GCSE has led to development of many other level 3 programs of study that focus on vocational as well as educational skills. University programs are increasing program offerings, such as nursing, with a practice or professional vocation focus. However, there have been debates as to whether these vocational programs are as academically robust as the traditional A levels. Reports suggest that many parents, educators, and universities feel vocational level 3 qualifications and even university programs, like nursing, that accept these entry qualifications are not as prestigious as the traditional subjects (Colley, James, Diment, & Tedder, 2003; Wolf, 2011). Participants’ comments appeared to indicate that these issues underpinned some of these experiences. They recalled family and teachers taking specific and focused measures to dissuade them from their choice of nursing. Some participants perceived that for some “good” schools nursing might reflect poorly on the school’s records but also that with good qualifications students should consider wider options. For example, P1 said: “My sixth form pushed me to do medicine because it looked better on their records.” P4 said: “My school sent me on a Nat Sci programme to consider other options [other than nursing].” Participants occasionally experienced resistance from unexpected sources that further contributed to dissonance. P4 said: My aunt’s a cardiac nurse in London. When I applied to do the BSc, she said, “Don’t! Go for something better.” I thought, . . . But you’re a nurse.

Participants employed a number of very sophisticated strategies to persuade parents, family, schools, and communities that nursing was “worthy,” including stressing that it was a university program and highlighting the uniqueness of a particular program, such as undergraduate master’s or mental health nursing with social work or some other element of added value. Choosing to Go The process that students engaged to choose a university and program was quite complex, involving consideration of parents’ wishes, social factors like the perception of diversity, and more functional factors, such as perceptions of quality and location. Quality and perceived quality were key considerations for participants. They considered objective criteria such as university ranking, though it was not always clear what sources they had accessed. A high-quality program or university was denoted by subjective markers, such as whether the programs sounded academic and challenging, that it was not “just” nursing (combined with something else, like social work), and being the only program of its kind in the country or very few programs like it. Students acknowledged the importance of diversity but were quite clear that it should be balanced. They did report feeling more comfortable when they saw evidence of BME presence in marketing materials and on open house days and interview and selection days, yet they did not want to study with mainly BME students. According to P17: It was quite important for me to go to a uni that kind of reflected balance, so that was the reason why I did not go to certain universities.

University location was a key practical and social factor. Many participants, particularly mature students with families, reported selecting a university close to home because they needed practical help and emotional support from their immediate and extended families. They also needed to give family support and meet familial responsibilities. Some doubted the understanding and sensitivity to BME cultures and needs outside London, which reduced their willingness to study outside London. For others, particularly the younger students, wanting to attend university outside London or simply away from home was a significant factor in their decision making. Being Chosen The participants characterized the recruitment and selection process as being looked over and chosen by the university. They go through the stages of hoping to be chosen or accepted; presenting themselves through the preparation of their applications, personal statements, and so on; and performing to be chosen at interviews and selection days. There was some suspicion about the purpose of questions about social factors such as ethnicity and whether their parents had gone to university. The students were unsure whether the information would work for or against them at the application stage. P5 said: And also on the application, they asked if your parents went to uni. I wondered how important that is; does that mean I can’t go if my parents had not been to uni? There was a chorus of agreement when this participant said this, yet other participants believed that coming from a minority ethnic background would be looked upon favorably, and a couple thought that there might be some sort of quota system in place. P9 said: “They also asked about


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your ethnic background, I thought that would give me a kind of leeway.” P10 asked: “Don’t they have to get a certain amount of ethnic minorities?” Participants perceived there to be a hierarchy of qualifications that affected their chances of getting into programs at some of the older universities, which they described as “stuff y” and “elitist,” despite what the brochures said about A level or its equivalent. According to P2: “I did a BTEC, obviously university looks down on you as it is.” Support received in making an application was varied and affected the experience of the process. Some schools provided detailed and useful help, advice, and support. P21 said: Yeah, you get a lot of help with like being able to write your personal statement and what they looking for in writing it. I did get a lot of help in doing it, that’s just how that college works. Some schools seemed to make the process a bit more difficult. Two participants reported a lack of support and information, and one person reported not being encouraged to attend open days. P22 told us: “I didn’t get any help in, like, writing my personal statement.” And P1 said: My school, they kind of, not look down on you taking time out to go to open days, but they limit you to the amount of open days you could go to in term time. For some participants, being the first in their family to go to university meant that, although supportive in principle, parents and relatives did not have the knowledge of the application process and therefore could not provide practical help. As P9 explained: Neither of my parents went to university, so going to university is kinda out of the

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norm. I am the first grandchild on my mother’s side to go to uni. There is no one who could relate to me; they support you in what you do, but they can’t relate. Participants felt they had to “perform” at the interview to be accepted into programs. They described encountering a variety of interview processes that meant they could not rehearse beforehand and therefore found it difficult to feel prepared. They felt more confident when they knew what to expect at an interview. Although generating some nervousness and anxiety, the interview process was generally viewed as fair; however, for a minority, there was awareness and fear about the part that race played in the interview and selection process. According to P11: The only fear I had when I was coming. . . In the institution I was working, it was very racist and hierarchical, so to an extent it did affect me. . . . So, going in the interview, it came into the back of my mind. P12 explained: I experienced a lot of racism growing up and we carry that, don’t we? . . . I guess when I came to the interview, I didn’t get that sense. These two participants had paid special attention to the ethnic makeup of the interview panel and felt that this was important to participants’ perceptions of fairness. P12 explained: “But for some reason I think it was because there was a Black person interviewing me, made me feel OK.” Choosing to Stay The nature of individual interactions and how students were treated and perceived in university and

clinical practice shaped the overall BME student experience. This determined how easy or difficult it was to remain, enjoy, and perform well in programs. For a few participants, negative experiences resulted in simply enduring programs, not enjoying them. Participants’ interface with the “University,” symbolized by systems and processes, was a key influence on the student experience. External factors such as family and community support and expectations also influenced completion of programs. Participants wished to be seen by tutors as the same as White peers in terms of academic competence and performance yet be recognized as being of different ethnicity and perhaps having different or additional needs. Participants felt that while commonalities of experience existed, distinctions from White classmates existed. It was significant that identified differences in student experience were always associated with negativity, with most reporting experiences of differentness and being the “other.” Students described feeling relief and comfort when they saw “other Black people” at open days and on the first day of classes, even if they did not come from the same cultural background. Notions of shared experience drove them to gravitate to people from BME backgrounds and to socialize mainly in these groups. Yet they also expressed the desire to, as one participant described it, “break in” and then “fit in” with their White colleagues and expressed frustration at the difficulty they encountered trying to “break in.” As P26 stated: At the same time I get annoyed . . . like I’m always having this battle with myself cuz I don’t wanna be exclusive and like separate from everyone cuz I wanna be accepted at the same time, and I want people to see

that I am different but one of them so it’s almost like this battle. Informants described the weight of expectation they felt from their immediate families as something that kept them in the programs. In P13’s words: Some days, I think, oh my gosh, it’s just too difficult and really the thing that keeps me here is that I can’t go home and say I’ve dropped out, like, that’s not an option for me at all. This pressure to stay also came from the wider community. For some, studying nursing increased their regard in the community, but increased status came with the weight of expectation. Being a role model came up again in this context. This meant that for some, quitting was not a tenable option, which increased determination but also pressure to complete studies. Students developed their own individual and collective coping strategies and mechanisms that helped with retention and distinguished these from formal support provided by their universities. The role of individual persistence and determination to complete their programs and do well was acknowledged. P20 explained: Even think of what you gain at the end of it—that’s the whole reason you went on the programmes in the first place. And it’s like such a short time like in your whole life, so just get through it. You just do it, just get on with life. They also talked about the importance of informal networks of other students and friends, and it was noted that informal networks did not consist exclusively of BME students.


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Participants valued being able to talk to people whom they saw as having similar issues through informal networks of friends from BME backgrounds; however, many of them were part of formal, student-led, national and cultural student groups, e.g., Nigerian Society and the Muslim Students’ Society. Degree students knew about and accessed these to a larger extent than the diploma students, highlighting the issue of limited university integration for some nursing students. Many participants praised the formal structural help available to BME students and students generally. Some of the problems with systems were acknowledged to be of concern for all nursing students, not just BME students; however, students felt that support could be more culturally targeted. There were some exceptions, in which students described receiving no support or not knowing it was available, resulting in a sort of passive, benign neglect. Others related experiencing more active difficulties and being singled out as different in school by tutors and while on placement by clinical mentors and patients. P1 said: “I had some bad experiences in my first year, and my aunt was like, do you think it’s because you’re Black?” It is important to note, as BME participants did, that some of the issues identified were not solely problematic for BME students and affected White students as well. Nevertheless, coming from a BME background often magnified the effect of shared hardships. Participants felt there should be concern for all types of diversity—not just ethnic diversity. They said steps should be taken to ensure that all-degree nurse education does not marginalize other groups seen in low numbers in universities, such as mature students, single parents, and people with disabilities.

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Discussion: Organizational Development Through Cultural Competence—A Framework for Action This section seeks to interpret the findings and synthesize the meaning of the first two phases of the AR process: problem identification and action planning. The accounts of BME students and the literature informed the identification and definition of the problems with access, recruitment, and retention of BME students in nursing degree programs. The concerns and solutions presented by participants focused on choice and equality of opportunity. Participants revealed the importance of having their ethnic and cultural differences recognized and accepted rather than problematized. They felt that individual lectures and university policies and procedures should be tailored to reflect diverse needs. The construct of cultural competence provides a useful framework for exploring these issues as it enables systems, organizations, and professionals to work effectively in cross-cultural situations (Kalyanpur & Harry, 1999). For use in universities, cultural competence can be operationalized as the transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used to deliver culturally appropriate student experiences (Davis, 1997). Cultural competence is commonly pursued in U.K. health care practice and embedded, to some extent, in most preregistration nursing curricula. Yet from participants’ experiences, it appears that the education process itself in the United Kingdom, from marketing of nursing to recruitment of students and creating the student experience, has not been widely analyzed in that context. A rapid review of the literature identified no U.K.-based publications linking cultural competence with university

lecturers’ pedagogical practice or HE systems and processes. The publications encountered were exclusively about instilling cultural competence in care delivery and care services and teaching it to students. This is not to say that nursing faculties in U.K. universities have not been concerned with diversity, but the discourse seems to be framed instead within different conceptual boundaries— for example, legal compliance, antidiscriminatory practice, and equal opportunities. The proposition is that in the planned completion of transition to all graduate nursing in the United Kingdom by the end of 2013, the construct of cultural competence provides a useful framework for assessing, planning, implementing, and evaluating systems that ensure nursing education in the United Kingdom is responsive to issues of race, culture, gender, and social and economic status—that is, culturally competent nursing education. Kalyanpur and Harry (1999) identify five essential elements that contribute to a system’s ability to become more culturally competent. The system should (1) value diversity, (2) have the capacity for cultural self-assessment, (3) be conscious of the “dynamics” inherent in cultural interaction, (4) institutionalize cultural knowledge, and (5) develop adaptations to service delivery, reflecting an understanding of diversity between and within cultures. These notions provide the basis for cultural competence development and analysis in U.K. universities: a five-point framework for action. The presentation of each aspect of the framework includes suggested action points derived primarily from the views of student participants, as warranted by the AR approach used and the literature. Valuing Diversity: The Need for Institutional Reflection The findings suggest that in the run-up to alldegree nurse training, U.K. nursing departments

might benefit from a period of institutional reflection on the extent to which diversity is valued and how clearly this is reflected in the espoused values of the organization as stated in university or departmental value and mission statements. This is not to suggest that their mission and value statements need overhauling, but there should at least be an explicit focus on how these values are interpreted and enacted during the implementation of strict degree curricula and planning of associated processes and systems. If diversity is valued, then arguably this will be manifested in the university’s approach to access. The voices of participants in this study highlighted how complex “access” was, and this was borne out in the literature. Although access is a function of attributes and responsibilities of both BME applicants and the U.K. universities, the focus here is on organizational attitudes and what universities could or should do to enable, enhance, and ensure the freedom, ability, opportunity, and right of BME students. In this context, the essential essence of “access” that U.K. universities must improve is BME students’ freedom, ability, and opportunity (including permission) to gain entry to university programs and nurse training more specifically. While studying, the opportunity and permission to participate fully in the university experience must be improved. Suggested Action Point Review your department strategy to identify and, if necessary, strengthen reference to diversity in line with university philosophy. Having the Capacity for Cultural Self-Assessment Institutional reflection should be followed by institutional self-assessment of cultural competence. Most universities have structures, systems,


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and processes in place to ensure nondiscriminatory practice. Most in the United Kingdom have revisited these recently in search of compliance with the Equality Act of 2010. Nursing departments should now engage in a period of selfassessment in the specific context of cultural competence for fair access, recruitment, and retention of BME students in an all-degree landscape.

Suggested Action Point Assess your department’s access, recruitment, and retention procedures and processes. Are they culturally competent? Check with your students; do they help or hinder the admission or progress of BME students? Devise and gain approval for an action plan to address the issues raised.

Building Consciousness of the Dynamics Inherent in Cultural Interaction: Staff Development for Cultural Proficiency A good student experience is crucial to retention of BME students. The survey carried out by the National Union of Students (2011) suggests that many BME students have a poor university experience. This corresponds with persistent reports from the National Student Survey of BME students reporting lower satisfaction with their university experience than white students do (Higher Education Funding Council for England, 2011). In this current study, participants talked about wanting individual lecturers to recognize the differences that arose from their ethnicity (e.g., cultural and language differences) that might mean that they had different learning and teaching needs. They also expressed the preference for antiessentialist approaches to meeting their needs, recognizing that even within the category BME,

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there was variation and diversity of need. Universities should adapt academic services and student support to reflect these needs. Although participants talked positively about lecturers, there were also accounts of negative experiences. Participants felt that cultural differences in verbal communication styles (e.g., volume and pace of speech) and nonverbal communication styles (e.g., gesture) were sometimes misinterpreted as aggression or anger. In addition, cultural beliefs about behaviors that demonstrate respect for age and rank often led to restrained and quiet behavior from BME students, which students felt were, in some instances, misinterpreted by lecturers or practice mentors as detachment and disinterest. Consequently, BME students might encounter problems achieving the practice outcomes and proficiencies so central to progress in preregistration programs. Students in the National Union of Students study and the current study talked about not feeling that they could bring their perspectives to the classroom. Consciousness of these types of cultural dynamics and how this trickles down into the student experience has to be instilled at the individual staff level. Nursing departments should consider programs of staff development intended to move staff toward cultural competence and cultural proficiency in pedagogical practice. Staff development should also include initial and then regularly updated training on how cultural issues might influence recruitment and selection, particularly for those involved in designing selection processes and carrying out selection decisions. Suggested Action Point Work with the departmental lead for admissions and the program lead of the degree curriculum to devise training and staff development, including elements of training in cultural competency.

Institutionalizing Cultural Knowledge Universities must convey “institutional permission” to prospective BME students. In the section “Being Chosen”, participants talked about the “elitist” image of the older, selective universities, which they described as stuff y and unwelcoming. These perceptions meant some BME students do not apply to such universities, not from doubting their ability and qualifications but because they believe they will neither fit in nor be welcome. Although universities should be selective and may value being perceived as “elite” institutions, they should avoid appearing elitist; aim to portray an image that welcomes BME students; and ensure that processes, including admission and selection, enshrine equitable and fair access for BME students. In Naylor and Sherman’s (1988) study, provision of targeted information for Black students was found to positively influence Black students’ identification with institutions and the programs that they chose. Participants in this study were clearly not swayed by media approaches to reflect diversity that did not seem to be followed up by embedded actions once in their programs, so simply including a range of ethnicities on websites and marketing material is insufficient. Participants talked about how important it was to see BME staff and students at open days and interviews and made explicit reference to recruiting more BME students and staff. For staff members who are U.K. nationals, the proportion of permanent academic staff from a BME background rose steadily between 2005–2006 and 2008–2009, reaching 9% (Higher Education Funding Council for England, 2011). U.K. universities should seek to engage BME staff in activities aimed at increasing BME student participation in HE, such as help with reviewing marketing materials, outreach activity, and role model case studies. Selection and conversion rates should be investigated. Retention

strategies should address the additional financial burden that BME students may face in degree programs, and for this, one may need to learn lessons from U.S.-style scholarship programs that specifically and aggressively target underrepresented groups. Suggested Action Point Invite BME students to review departmental marketing strategy and gain permission to incorporate suggestions that improve likelihood that hard-toreach groups, including BME applicants, will be reached (student led). Produce video profiles of successful BME nurses who can stand as remote role models for actual and potential BME student nurses (student led). Developing Adaptations to Service Delivery, Reflecting an Understanding of Diversity Between and Within Cultures Participants in this study clearly conveyed that their choice to nurse and the places they chose to go to university were affected by, among other things, public perceptions of nursing and cultural, background, and associated expectations and norms of family and community. In this sense, public perceptions and BME students’ families, schools, and communities affect their ability, freedom, and permission to access nursing and university. The section “Choosing Nursing” demonstrated that there are variable perceptions of nursing as a career choice and worthwhile subject to study in schools among minority ethnic communities and in some socioeconomic groups. Members of the public generally do not completely understand what nursing is and what nurses do. The Prime Minister’s Commission (Department of Health, 2010) exposed the intractable public perception of nursing as low-status, low-paid work and nurses as mere helpers to doctors. In addition,


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the history of nursing migration and stories of poor career advancement and discrimination also make the profession unattractive to some BME students and their parents. The impression of some ethnic minority groups of nursing work as dirty and intimate makes it appear incompatible with some groups’ cultural norms and religious beliefs. The middle classes do not see nursing as a prosperous career, seeing it instead as low status, menial, and hard. Consequently, school-age children from these groups might not even consider nursing as a career, and those who do are often dissuaded by schools and families from pursuing nursing. Nursing departments need to use smart, fresh marketing strategies to communicate across these cultures to persuade the public, different BME communities, and families that nursing is a worthwhile career involving a varied range of work. Anti-essentialist strategies like the CANDLES project aimed specifically at South Asians (Anionwu, 2006) recognize the value of this differentiated approach. Different approaches appropriate for different ethnic communities are most effective. Suggested Action Point Work with the departmental lead for admissions and university widening participation team to design an integrated and sustainable community engagement and outreach program aimed at underrepresented groups.

Conclusions This was a small-scale study focused on the first two phases of the AR cycle. Despite the small scale of the study, the findings have enhanced insight into the experiences, challenges, and concerns of BME students undertaking nursing programs at universities in the United Kingdom. In many

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aspects, the students’ experiences mirrored those of other studies conducted earlier, indicating that despite the advances in equality and diversity and moves to widen participation in HE, there are many preventable and avoidable obstacles to studying nursing at degree level for BME students. The aim of this study was to add the voices and experiences of BME students to the existing evidence base surrounding undertaking nurse training in the 21st century. For the United Kingdom, with the move to all-degree training by the end of 2013, enabling equality and optimizing diversity of students are imperative. Student diversity directly affects the demographic and diversity profile of the future workforce, as all qualified nurses are trained via a single entry route. Through the findings of this study, a start has been made on analyzing the issues and identifying actions for the future. This project provides an opportunity for action. The conclusions have been drawn from student accounts of their experiences, synthesis of the findings of existing original research studies on BME nursing student achievement in U.K. universities, and other literature in the field. As such, the action points stated and recommendations that follow represent a credible, although perhaps not definitive, range of options for the improvement of the BME student experience, which can benefit access, recruitment, and retention of such students after nursing education is at the all-degree level in 2013. While research focused on the United Kingdom, some of the issues raised by students and the recommendations made for universities may have resonance or provide platforms for reflection for training organizations beyond the United Kingdom. Six overarching recommendations have been identified: 1. Individual educators should establish their level of cultural competency in

their pedagogical practice through self-assessment. Individual lecturers should use a structured selfassessment tool to assess their level of cultural competence and devise a personal development plan aimed at achieving cultural proficiency in their individual pedagogical practice. 2. Nursing departments should aim to produce global and multiperspective curricula. All nursing departments should review curricula and curriculum themes to ensure culturally proficient curriculum design. Curricula should include global perspectives and multiperspectives. Reviews should consider not just the inclusion of content relevant to diversity but also how the content is framed so that positive images of BME communities are presented, perhaps reflecting contribution to traditional medicine rather than consistently problematized portrayals such as higher rate of schizophrenia and diabetes. 3. Nursing departments should undertake ongoing and proactive assessment of the challenges and action planning. Nursing departments should regularly return diversity data (participation rates, conversion rates, and attrition rates of BME students). Each department should have a named senior academic responsible for receiving these data who should be responsible and accountable for using this information as intelligence to formulate strategy, policy, and action to improve the experience of BME nursing students from inquiry and application to matriculation and completion. 4. Nursing departments should: • Establish the level of cultural competence of the organization; undertake

a period of self-assessment to establish their level of institutional cultural competence and produce a strategy based on the scores achieved. A structured tool should be used for assessment. • Devise integrated ongoing programs of staff training and development in cultural competence. • Invest in integrated, coordinated, and ongoing programs of staff development aimed at continually improving the cultural proficiency of academic and administrative staff. 5. Nursing departments should have targeted, tailored, and coordinated outreach and engagement programs aimed at a variety of communities underrepresented in nursing. Such programs should adopt an anti-essentialist approach acknowledging that the BME group is diverse and that different approaches, information, and strategies will be needed for different minority communities. 6. Commissioners and regulators of preregistration nursing education should make the level of cultural competence exhibited by universities a key quality indicator. Bodies involved in commissioning nursing education and allocating funds for training, such as Health Education England and those involved in the regulation and inspection of universities, such as the Nursing and Midwifery Council, should include the attention that universities’ and local skills networks pay to achieving and maintaining diversity in student nursing population as one of the criteria for quality.


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Stacy Johnson, MSc, BSc, RN, is a lecturer at the University of Nottingham, England. Her research interests include diversity and entrepreneurship in nursing. The research reported here was carried out as part of a Mary Seacole Leadership Award. She may be reached at Stacy.Johnson@nottingham. ac.uk.

Janet Scammell, DNSci, MSc, BA, DipNEd, RNT, SRN, SCM, is an associate professor at the University of Bournemouth, England, and leads the Framework for Undergraduate Nursing as well as units within the university’s postgraduate certificate in education. Her research interests concern inequalities in health care practice and work forces and practice and work-based learning. She may be reached at jscammell@ bournebouth.ac.uk.

Laura Serrant-Green, PhD, MA, BA, RGN, PGCE, is professor of community and public health nursing/ director of research and enterprise, School of Health and Wellbeing, University of Wolverhampton, England. She was appointed to the Prime Minister’s Commission for the review of nursing and midwifery in 2010–2011. She may be reached at l.serrant-green@ wlv.ac.uk


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