My two greatest fears before starting my pediatric rotation were finding common ground with a critically ill child and looking incompetent. The second fear seemed easy enough to conquer if I studied the material prior to my clinical days. The first one, however, would be more difficult and out of my control. How would I care for a child that might not have long to live? What topics do I bring up in conversation? What if I slip up and make an inappropriate joke? These questions would prove to be a hinderance to my care of a patient who just wanted to be treated like everyone else.
My clinical partner Diana and I were tasked with taking the vitals of our patient, J.R., first thing in the morning. The 18-year-old, schedule 1A cardiac transplant patient we were assigned meant that this was not going to be an easy day. My approach was very professional as I used my penlight to find the patient’s blood pressure cuff and inspect the safety measures of the dimly lit room at 7:15 a.m. With my free hand hiding the beam of light from my sleeping patient’s eyes, I searched around the bed for a mere second before I heard a voice from above saying, “Are you looking for this?” As J.R. handed me the blood pressure cuff that was wrapped around the left side rail of his bed it was clear to me that my second fear had just become realized.
Unfortunately, my initial visits with J.R. did not
help alleviate my second fear at all. This was a patient who had been in and out of the hospital for heart issues since the day he was born, rattling off medical terminology as if they were names of his favorite pop stars: pacemaker; hypoplastic left heart syndrome; and open-heart surgery. Clearly, I wasn’t going to outsmart J.R. using fancy textbook words and techniques. This became abundantly clear on the second day of my clinicals when I tried to show him my fancy nursing tool kit including reflex hammer, tuning forks, and scissors, only to be met with a bewildered look from J.R. and a question, “Where’s your gown?” J.R. had acquired C. Diff in between our meetings, and I cannot think of another way that I could have looked more incompetent than not donning my isolation precautions before entering the room.
What I was left with was my first fear, finding common ground with my patient. I asked J.R. about his hobbies and learned how cooking was one of his passions. He told me how he planned on attending culinary school once he was out of the hospital, returning to his hometown in Long Island, and opening a casual dining style Mexican restaurant. This felt like progress. Still, there was a sense of detachment in our conversation. Even though J.R. was divulging all this information about himself, he constantly looked towards the entrance of his room, watching everyone walk by as if he longed to be outside with them. It was then that I began thinking about the social aspect of J.R.’s day.
I decided to approach this teenager as I approached my own teenaged social interactions, with a group of friends joking around, teasing each other, and even mildly insulting our favorite television shows. I reasoned this because I imagined being in and out of the hospital ever since the day I was born, not being able to have a steady group of friends because I had a heart condition that had to be constantly monitored. The group of friends in this case would be my classmates, a handful of pop culture movie and food enthusiasts who would spark an engaging conversation. It was obvious from the start that I was the least knowledgeable about the latest Netflix series, and once again my ignorance was the focus of the experience as I was teased for seeming uncool. I may have even uttered the phrase, “They don’t make movies like they used to,” more than once. Although, being the butt of their jokes was the last thing on my mind when I noticed that J.R. was enjoying himself as part of the group and having a laugh at my expense. If my ignorance bonded my patient with my classmates, then it was to my benefit. The group could tease me all they wanted for sounding out of touch, but I could smile through it all because through my failures I had pulled from my resources to improve patient care. My team had done the job of finding common ground.
Maybe I don’t need to worry about playing it safe. Maybe this was part of patient care. The obstacle of overintellectualizing my approach had been removed and I gained a confidence in my ability to speak with this pediatric patient that I felt I could carry to future patients. Moreover, I look forward to the day I can visit J.R.’s casual dining Mexican restaurant, walk into the kitchen to see him cooking, give him a bewildered look and ask him, “Where’s your hairnet?”
Homelessness is a global issue. It is on the rise and it impacts health physically and mentally. According to a recently published article in BMC Public Health, emergency departments are more often used by the homeless population for acute health care versus accessing preventative health care services. A 2018 study published in SAGE Open reported that the homeless population experiences health disparities with multiple chronic health conditions, mental illness, substance abuse, and depression.
The U.S. Department of Housing and Urban Development, Office of Community Planning and Development provides an Annual Homeless Assessment Report (AHAR) to Congress. On a single night in January 2018, there were
552,830 people who experienced homelessness in the United States. Most were sheltered (65%, 358,363) compared to 35% (194,467) who were in unsheltered locations. In the United States, 17 people per 10,000 experienced homelessness in 2018. Some of those who were in shelters (3,864 people) stayed in beds that were funded because the president declared natural disaster after four Hurricanes (Maria, Irma, Harvey, and Nate) and wildfires in the west. Twenty percent (111,592) of the homeless were children, 71% were over 24 years of age, and 9% ranged from ages 18-24. There were more men in unsheltered locations compared to women. Almost half (49%, 270,568) of the homeless people identified themselves as white compared to black/African Americans (40%, 219,807).
In the state of Texas on a given night in 2018 there were 25,310 homeless people. There were 9 homeless people per 10,000 in the general population of the state. Individual estimates of homelessness in Texas was 19,199; 6,111 for people in families with children; 1,379 for unaccompanied homeless youth; 1,935 for veterans; and 3,269 for the chronically homeless individuals, according to the 2018 AHAR report.
Houston is the fourth largest city in the U.S. with over 2.3 million people, according to the U. S. Census Bureau. In January of 2019, there were 3,938 homeless individuals (unsheltered and sheltered) in the cities of Houston and Pasadena and Harris, Fort Bend and Montgomery Counties.
Risk Factors
There are various reasons that may cause an individual to experience homelessness. A 2009 study published in Psychiatric Services reported a significant association with childhood adversities and homelessness. The childhood adversities with significant findings include: having a history of running away, being ordered by a parent to leave the home, being neglected by a parent or caregiver, having a biological father incarcerated, being adopted, being in foster care, and the duration of welfare assistance before 18 years of age. Significant findings regarding socioeconomic situations included grade when respondent left school, economic difficulty in the past year, and currently employed. Mental health problems such as being diagnosed with depression and having a psychiatric hospitalization in the past five years were significant predictors of homelessness.
More recently, a 2019 study in the Community Mental Health Journal indicated the individuals with mental illness had high rates of homelessness. Addiction problems such as drugs in the past year was also a significant predictor of homelessness, according to the 2009 Psychiatric Services study. Oftentimes veterans return home after deployments to war zones suffering with invisible wounds such as post-traumatic stress disorder and traumatic brain injury. These individuals are at risk for experiencing homelessness, according to the National Alliance to End Homelessness (NAEH).
Homelessness can also be due to loss of property, family violence, or domestic violence. A 2018 study in the Journal of Community Psychology reported loss of support systems and social networks can also lead to a path of homelessness. Lower incomes often lead to an inability to pay for basics such as food, clothing, shelter, and transportation—and this places individuals at risk.
The Problem
It is a common sight in Houston to see homeless people living and sleeping on the streets. Whether you walk or drive around the city, you cannot help but see individual men and women panhandling in the streets, standing at corners and intersections. They will routinely walk up to your vehicle with signs, cups, and stretched out hands for money. The homeless can be seen sleeping on the sidewalks and huddled up against buildings and fences. Although shelters for the homeless exist and initiatives have been implemented in attempt to get the homeless off the streets of Houston, the homeless population is huge. Many people who are homeless still live in tent cities under freeways.
One might say, they want to be on the streets. One might say they do not want to follow the rules of the shelters. Therefore, they chose to be out on the streets. All of those sayings might be true. All the same, someone remains homeless.
One night during November 2018, I was driving home and it was very cold outside. The temperature was in the 30s or low 40s. I was overcome with sadness and sorrow to see so many people literally sleeping on the sidewalks without any shelter. I noticed that some did not have blankets. I found myself feeling so blessed and fortunate to not be living on the streets. But then, I wanted to do something. I said they need blankets and warm clothes if they will be sleeping on the streets in this cold weather.
The “BLESSED” sign
Community Outreach Project
As a Christmas project for the Black Nurses Association of Greater Houston (BNAGH), we decided to give out blankets and socks to the homeless people in Houston. One Saturday afternoon (December 8, 2018), nurses from the BNAGH gathered the donated items to be distributed and walked the streets where a group of homeless men and women gathered. We drove to a local fast food place near Midtown, between downtown and The Texas Medical Center, and parked with permission from the manager. While still in the parking lot, a man asked me if we were getting ready to do something with the homeless. He was told we were going to pass out blankets, hats, socks, bottled water, and brown bags with snacks (peanut butter cracker, cuties, and peppermint candy canes). He stated his name and the name of his company and said he was there with his crew to do a film about the homeless in Houston. He asked if he could film us passing out the items and we told him yes. He said he would put us in the credits.
As we gathered all the items in large black plastic bags and started walking with the water, people started coming toward us to get the blankets and socks and other items. We gave away every item that we had. We even had a set of towels and a bar of soap to give out. One man said he wanted the soap. One man and lady were yelling for us to throw a blanket over the fence to them. One lady asked if we had anything girly. She asked for a pink hat. Everyone was so appreciative. Only one person did not want the items. He said he wanted dollars. He walked back into the street, running from car to car begging for money. Overall, it was an awesome experience. We provided items to approximately 60 homeless individuals.
Taking it to the streets takes courage and a compassionate heart. The needs of the homeless are many. One might feel overwhelmed if trying to take on every issue alone. It will take many people and resources. However, everyone can do something to help improve the health and lives of others. That is what the nurses of BNAGH wanted to do and that is why you might see homeless people in Houston with a sign displaying the words “BLESSED.”
Houston nurses handing out supplies
Relevance to Nursing
Homeless Individuals are a vulnerable population and are sometimes considered invisible. However, they are not invisible. They can be seen and counted. They are at risk for health disparities including mental health issues. There were so many obvious needs. One was just basic hygiene. Nurses can advocate for housing because personal hygiene is important. Hand hygiene is the most effective way to prevent and control the spread of infection. Individuals experiencing homelessness face barriers to personal hygiene. For example, personal hygiene and self-care barriers are limited access to facilities for bathing, taking a shower, doing laundry, and washing hands. Such barriers to self-care and personal hygiene can cause one to be at risk for an infectious disease.
Some things that nurses can do to bring about change:
Contact local coalitions for the homeless for information about their goals and objectives;
Advocate for jobs and housing for the homeless;
Contact and lobby local and state congressional and legislative officials regarding policies to help alleviate homelessness in America.
Such efforts will help reduce health disparities among this vulnerable population.
Stepping out of one’s comfort zone is not always easy to do. The first step seems to be the hardest. However, if nurses are to make a difference, then we must rise to the calling, step up to the plate, and do something positive to make a change. There are so many things that can be done. What I attempted to do was to provide warmth and comfort to a few people on the streets of my hometown. However, I have been inspired to do more. Hopefully you will be inspired to do something to help the homeless in your community feel encouraged and strive to be healthier.
Acknowledgements: The author wishes to thank Betty Davis Lewis, EdD, RN, FAAN and the Black Nurses Association of Greater Houston (BNAGH) and Prairie View A&M University College of Nursing faculty members for donations, and the three other nurses from BNAGH (Patricia Boone, RN, BSN; Vivian Dirden, RN, BSN, MS; and Dametria Robinson, BSN, RN-BC) who also walked in the streets of Houston to distribute the items to the homeless and provided photos. In addition, the author wishes to thank Carmen Lewis, MSN, RNC-MNN, IBCLC for providing the “BLESSED” photo.
If you are a nursing student, I would like to welcome you to the fabulous field of nursing! There is nothing more rewarding than serving in this meaningful profession. I anticipate you plan to practice in this arena upon graduating and passing the state board exam. However, be cognizant that one of the most challenging transformations your nurse educator will be responsible for will be in assisting you to become a professional in the medical field.
I know that you think that your instructors are always nagging you about your appearance, but at the end of this process, you will understand how important this transition is in order to socialize you. You have certainly heard educators discussing first impressions and how important they are in establishing credibility and rapport with your patients and with the health care team. As health care professionals, our demeanor affects everyone around us while we are on duty. Since I am a nurse educator, I would like to disclose some of the dos and don’ts of your daily conduct that you should be aware of as a student entering the nursing profession.
Let us start with the basics:
punctuality. Have you ever heard the statement that when you are on time, you are late and when you are early you are on time? This applies to both the classroom and clinical setting. It is disturbing and disruptive as latecomers arrive to the classroom once lecture or testing has begun. As you enter the room tardy, open and close the door, remove extraneous clothing (coats, scarves, etc.), retrieve necessary items from your book bag… Well, you get the idea. While you catch up with the rest of the class, your colleagues have preceded you in doing so. Consequently, the energy in the room shifts as you now settle in for a long day of studies. Have you considered how your lack of punctuality affects those around you? Maybe it is time you do so.
You may ask, “How about makeup? How much is too much?” My answer for this is that if you are putting false eyelashes on before attending class and clinical, you clearly have too much time on your hands. Why not spend those extra 10 minutes reviewing notes taken during lecture or take a quick peek at those index cards? Why not work on those intravenous drip calculations you have been struggling with? It only takes a few minutes out of your day to commit to tackling the less desirable tasks. Facial makeup now takes second place once you realize that the extra minutes you use to embellish your outward appearance would be better spent on nurturing critical thinking skills.
Do you ever have downtime? By this I mean the time you have during breaks and lunch. How do you spend this time? Watching kitten videos, catching up with the celebrities, or perhaps finishing a movie or television show? I tire of overhearing the latest on the pop stars—the Kardashians, etc. You must know that your instructors are observing you and that we are very much aware of what occupies your time. No, we are not telepathic. We know by the incomplete homework you turn in (or not) and by the multitude of excuses you have for late assignment submissions. We know by the test scores that you feel are acceptable, even when we, as instructors, know you can perform academically better. I implore you to spend all the time that you have honing your skills for nursing. There is plenty of curriculum to embrace, so do so every moment you have. I promise you will not be disappointed.
It is not cool to have your shoelaces or velcro straps untied. This look appears anything less than professional. It is hard to take anyone seriously who has not taken the time to attend to such details before entering the clinical arena. Another detail worth addressing is gum chewing. Along with the former offenses, it is difficult to accept that the person who is chewing gum is focused on anything other than smacking idly while passively listening or speaking to their audience. In my profession, potential candidates for employment were simply dismissed during an interview because of gum chewing. Do not let this be your fate while seeking employment.
Confine all cracks, cleavage, tummies, and tattoos for activities aside from nursing. Let me be clear: cover all external crevices at all times while in uniform. Having these body images in view is unprofessional and if you want to be taken seriously, save this look for socializing (e.g., dating, clubbing, or spending weekends with friends). Your patient nor your instructor desires to be distracted.
While we are noting external appearances, there is a reason for us to request that you not wear jewelry larger than stud earrings and a wedding band. The focus on you should not be about your taste in jewelry. Jewelry is a vehicle for the transmission of germs, and while I am addressing the chain of infection, allow me to broach the topic of nails. Remember your lecture on infection control: hand washing in between patients, before and after meals, after smoking and toileting? You discovered how microbes harbor under long nails and in cuticles. The studies have been done, and the results are in. Nails are to be no longer than one-quarter of an inch. You cannot effectively palpate or percuss body contours and abnormalities with long nails.
Uniforms: the glorious look of a uniform, but only if it is clean and ironed. No wrinkles are allowed on uniforms or lab coats. Your first impression from your mentors and patients should exude professionalism as noted in unsullied and tidy apparel. Your patients want to know that they are safe with you—that you will protect them, not infect them. Not only does appearance count but so do scents. I will take the fresh aroma of antiseptic soap from thoroughly washed hands any day over the stench of cigarettes. While you are observing your patients, let it be known that they are observing you, too. Leave them with an impression you can be proud of. Think about your appearance this way: when you are practicing in the clinical setting, you are interviewing for potential employment.
When you are in class or clinical, you are in a work zone. No cell phones allowed! Please stop checking them. Instead, check the cell phones at the door and place them on silent, in your pocket, or in your car. I am looking forward to the day when administrators will mandate that cell phones be left with the instructor or outside of class and clinical altogether. I am aware of the potential family emergencies, children, health-related issues, etc. There must be arrangements for emergency calls. If a protocol does exist and despite this, we find our students clinging to these electronic devices making it difficult for instructors to maintain our students’ attention. For example, during clinical orientation (I am ashamed to say) students and educators are now being in-serviced regarding prohibiting cell phone use. Cell phones are not to be used in the facilities while practicing. It should be common sense that when you are at work, you should not have time for texting, checking emails, or Instagram. You should be working, which means meeting the needs of your patients.
In meeting patient needs, how do you communicate with them? Do you use “honey,” “sweetie pie,” or other affectionate terms with your patients? This is unacceptable as it is highly probable that your patients are older than you and as such, deserve your utmost respect. Along with respect for your patients, I would also like to add appropriate communication to use with your instructor: never use obscenities. You will develop a plethora of new words in this profession, none of which is profanity. Good communication skills entail proper dialogue with your instructor, among colleagues, patients, and health care providers. Using the last name with the prefixes Miss, Mrs., or Mr. is acceptable unless your patient has given you permission to call him or her otherwise. And how will you know how you should address your patients? If the patient does not inform you that they would like to be called by another name, simply ask them after having addressed them formally. You will always gain the respect of your patients by being respectful.
Did you know that your posture and gait say so much about you? Walk like you have purpose. Strut up that hallway and answer those call lights as if it were necessary, because it is. Exhibit energy and enthusiasm as opposed to being lethargic. You may be tired, but keep it moving! Your patients want to know that you have the vigor required to take care of them. For this emotionally and physically exhausting profession, I would advise you to follow the Beatitudes: be well rested, be fit, and be well nourished. Nursing is a taxing profession. Take care of yourselves so that you can take care of others.
Let’s rewind back to the summer of 2014. I was in the midst of my senior year of nursing school taking classes, working, and doing my best to survive the New York City summertime heat. While working on an assignment one evening, my mother called me to say that my uncle had been in a near-fatal motorcycle accident. He was put onto a ventilator and had to endure an extensive hospital stay. This news was incredibly upsetting and unexpected. I have always been close with my uncle and couldn’t help but feel devastated.
I pushed on through my classes and day-to-day routine, but I noticed that I was suddenly sleeping more, eating less, and often feeling unfocused and unmotivated. I chalked it up to stress from school and work, especially since it was my last year and I was expected to graduate that upcoming spring. Reaching out for help was a fleeting thought, and I firmly decided that I could handle these feelings on my own.
Turns out, I was wrong.
Feeling down, unmotivated, and overwhelmed consumed me. I received a C minus in one of my summer classes, which coupled with a C minus that I had received earlier in my nursing school career. For a while everything felt so slow, but suddenly it was as if I were thrown into a time-lapse getting caught up with reality. I frantically reached out to my academic advisor who monotonously told me that if I was struggling with a personal issue I should have spoken up sooner and that two C minuses are not acceptable in the program, but I could speak with my professor directly about the grade. There was hope. Except there wasn’t, because my professor would not budge on the matter. With that being said, I was kicked out of nursing school the fall of my senior year.
My recently furnished dorm room had to be dismantled—clothing back in suitcases, photos taken off the walls. I had to say goodbye to my roommates who were confused and concerned. I had to say goodbye to my friends of four years. The reality that I would not be graduating after years of hard work crushed me.
I experienced panic like never before. I couldn’t breathe, couldn’t move, couldn’t feel anything but my lungs constricting. I felt like I was going to explode. A counselor diagnosed me with both panic disorder and generalized anxiety disorder.
I moved back home and tried to figure out what to do next in a frenzied state. No nursing school would accept someone who was dismissed for poor academic performance. The panic attacks only got worse. I was having them at least three times per day. Most people would have given up at this point and settled for less, but I had always known that nursing is the only career I wanted for myself. I would not settle, no matter how much I was hurting, no matter how impossible things seemed.
I began seeing a regular therapist in an effort to get my life back on track. Things seemed to be improving. During the winter of 2015, about four months after my dismissal, I was driving home from a therapy session down a road I’ve known my whole life. Suddenly, a car pulled out in front of me, taking me off-guard. I slammed on my breaks, but it was too late. I smashed into the car head on. My insides were screaming panic, but I couldn’t move. Bystanders got out of their cars to help, but my doors were locked and could not be opened. People were asking me through my window if I could move my legs and I didn’t know if I could. I heard sirens and thought to myself, “I have to be dreaming.” Paramedics had to cut through the top of my car, hoist me out, and strap me to a board that was put into the ambulance. More panic.
Though I questioned my faith during that time, I thankfully left the hospital banged up and bruised, but not detrimentally damaged. I sustained a treatable back injury. After my recovery, I applied for a job at an urgent care clinic because I wanted to maintain medical practice in my life. I thought it would help, both with my practice as a future medical care provider as well as my emotional state. I was happy to get the position, but that meant having to drive again. During that period of time, my drives to work consisted of multiple instances of having to pull over and having countless panic attacks. But I got there. I kept up with both my therapy sessions for the anxiety and physical therapy for my back.
That spring, I attended the graduation ceremony of the friends I was forced to leave behind. I can’t begin to describe how happy I felt for them. At the same time, I worried that they would end up leaving me behind. I felt that in a way, they already were. I felt awkward being with them in public because I didn’t want people from outer circles asking questions that I was too embarrassed to answer. I didn’t know how to fit in anymore with my best friends. This caused panic that I cannot forget.
Rather than closing in on myself, I mustered up the courage to apply back to the same nursing school that I was dismissed from for entrance the upcoming fall semester. I was asked back for an interview, which I graciously accepted and prepared for rigorously. On the day of my interview, I walked into a familiar building unable to control my shaking body. As I sat across from my old professors, I was asked what will be different this time around, should they allow me back. I told them the truth. I spoke about my journey dealing with anxiety and ways that I am now able to manage it, though it goes without saying that it is challenging. I highlighted my relentless drive to be a nurse, and that if the past year wasn’t enough to stop me, then nothing ever could. I was accepted back into the program; my faith was slowly being restored.
I was taking classes with students who had known each other their entire nursing school careers. I also struggled to grasp the material at first, being that I was rusty from having to take time off. I felt disoriented and like an outsider, but I didn’t let that distract me from achieving greatness. I made the dean’s list at the university that only a year ago had told me that I wasn’t good enough. I eventually made friends with my classmates and strengthened the relationships with my old friends.
That May, I graduated proudly. All my friends and family were there to support me. Panic took the backseat.
After passing the NCLEX, I worked in a couple of different clinics and health systems gaining invaluable experience. Despite my fear of rejection, I applied and was accepted into a master’s program for midwifery. I now happily work at a fertility clinic and am excited to graduate the midwifery program stronger than ever. I have discovered my interests within the nursing field, which include researching the United States’ shockingly high maternal mortality rates and normalizing breastfeeding, especially among women of color.
Now, I have been invited to become a member of the Sigma Theta Tau International Honor Society of Nursing. Once more, I have to ask myself whether I’m dreaming, only this time it’s under completely different circumstances. I won’t lie, a sense of underlying anxiety persists within me, but I can now recognize that I have valuable coping mechanisms that I have learned through therapy, a group of friends and family members who are my rocks, and a sense of proudness and empowerment in what I have accomplished that cannot be taken away. I am eager to make my mark on the field of nursing. I can’t wait for what will come next.
In this essay, I present my firsthand account of my experience as an African American nursing student in a predominantly nonminority nursing program as well as my perceptions and interactions with fellow students. As an autoethnographer, I sought to answer the following question: What is the African American student nurse’s experience of education in a predominantly nonminority school of nursing and university, and how does that experience affect her as an individual?
Pre-Nursing School: Being “White”
In high school, I was called “white” by the majority of the few African American students in a high school of nearly 500 students in the Northeast. Initially, when they said this to me I was shocked. I had been on the receiving end of racially charged comments by white peers, and now I had to deal with this from my own race and ethnicity, too? I wondered why I could not catch a break. I remained confused but focused on my schoolwork. Since being a freshman, I was in honors classes, those with the maximum rigor in the entire school. It was viewed as if only the elite were in these classes, but I surely did not feel like the elite. My white peers in those classes assumed I came from the ghetto and asked me to teach them Ebonics and about rap music (which I did not listen to). I was isolated in those classes because of such stereotypical comments and the competition to be number one of the entire graduating class, but mainly because I was the only African American student in such classes. The comments from my African American peers only intensified as I was enrolled in both cosmetology in vocational school and Advanced Placement courses (which could alleviate me from taking college courses, once enrolled).
One of my African American acquaintances, who I thought seemed amicable, approached me purposefully one day in the hall. She looked like she was on a mission to find me as I put my things in my locker. I met her with a kind hello—I did not have many friends in school. I blamed myself for that, being so quiet. She stated loudly with a greeting, “Do you think you are better than us?” I said, totally confused, “Us? Better than who?” She quipped, “You know exactly who I mean, the few blacks in this school.” My face must have looked blank. I just stared at her with curiosity due to the fact that, besides the “white” comments, there was never an extended conversation or association besides my distant friendship with several other minorities. She continued to badger me, “You know you think you are better than us since you are in those special classes. Who do you think you are?” I simply responded, “Nothing.” At the time, my self-esteem was low; I had become tired of my lack of association. She was not buying it. “You know what? It must be true that you are white because you even talk like them,” she said. “Don’t ever think you are better than us. We are just as smart, although we may not be in the AP classes.” Taken aback, I explained, “I never said you weren’t. You should talk to your advisor about enrolling in one of the classes.” Without acknowledging my reply, she stormed away, saying, “Wow, you are white.” As she walked away, I blinked at her and said to the dust trailing behind her, “It is funny because my skin is black like yours.” I went on to finish my day; however, the episode never stopped playing in my head, even after I became a nursing student.
Katie Love, PhD, APRN, BC, AHN-C, wrote about the lived experience of African American nursing students in a predominantly white university in a 2010 article published in the Journal of Transcultural Nursing. One of the themes of her phenomenological study was that of fitting in and “talking white.” She reports about a study participant who had grown up in a predominantly white secondary school and had become accustomed to experiences with white students. African American nursing students who did not have such an experience described some African American students as being “Oreos…Black on the outside and white on the inside.” Such “Oreos” are described as African American students who are black but “act White, socialize, and talk like White people.” One of the participants of the study shared the following observation: “To me it’s kinda a funny thing that it’s such a problem in the Black community that you could not talk in a certain way…but if you start talking slang, then to them you’re trying.”
I could identify with Love’s study as my isolation from peers—from within my own race and from without—began in high school. In high school, I was excluded by white students because of the color of my skin and, at the same time, excluded by my African American peers because of the way I carried myself and spoke. In nursing school, my isolation continued. It would eventually lead to my depression.
Nursing School: Feeling Isolated and Excluded
Fast forward to nursing school. The faculty and advisors began our edification with a talk about the rigor of the courses. I remember a gentleman announcing, “Look around the room. See everyone here? Not all of you will be here in four years. The truth is, nearly half of you may not make it to graduation.” I remember sitting in the warm amphitheater and feeling intimidated by his words. When I looked around, as instructed, I noticed the class was made up of only three African Americans. The largest minority group were of Hispanic background.
The first few semesters were full of straight science courses, which translated into nonstop studying. I spent my days in the library enjoying my books and learning. The days went so fast, when all I did was read and study the day away. In the blink of an eye, the end of the first year arrived. All of the Hispanic students were eliminated either by not meeting academic requirements or by choosing to leave the program. I was afraid that I would be next. My classmates were mostly white students. At times, I felt I did not belong. None of my professors looked like me. The nonminority students studied together and did not invite me, much less speak to me.
I remember our professor addressing the class during our sophomore year. She advised everyone in our small section to avoid driving alone to a distant clinical site and to carpool instead. I looked around the room attempting to make eye contact but did not receive any response. My nonminority peers turned around in their seats and, within minutes, had arranged themselves into two car groups, which left me out. I told myself, “You really thought it would be different, huh?” I laughed to myself and stopped looking for a group. That experience solidified the divide for me.
In 2004, Nancey France, PhD, RN, and her colleagues at Murray State University published a pilot study in Visions: The Journal of Rogerian Nursing Science that examined the lived experiences of black nursing students and found many reported feeling isolated and discounted. One of the themes of the data was “You’re just shoved to the corner.” One African American student nurse clarified, “You may get one or two that wants to include you…You may go up to them, you’ll risk to say ‘are you going to study?’ If you think that you know them and everything’s o.k., you’ll say, ‘are you all going to have a study group this weekend?’ And they’ll say ‘yeh’. But, when the time comes…you can’t get in.” Another student reported, “I’m the only black, in all my classes I’ve been the only black. It’s hard because…you got to prove yourself. If you don’t do as well as the other students they just single you out. That’s why I have to strive to do the best I can.”
Black students also reported feeling they were only admitted to schools of nursing to meet a quota. They described the increased pressure exerted on them when minority attrition rates were high in their class. As a result, they experienced emotions such as self-doubt, fear, lack of confidence, and diminished self-esteem before attending class. Many students reported these feelings pushed them “even harder to prove they could be successful.” There seemed to be a consensus that there was an unspoken expectation of African American students to fail, which propelled these students to greater levels of determination to prove that “they were as smart as anyone else.”
Moving Up: The Benefits of Exclusion
During my third semester in nursing school, I became tired of sitting in the back of the classroom. What had once seemed comfortable became an annoyance to me. The students who supposedly knew all the answers sat in the front, always the first ones to raise their hands. However, their answers were the same as mine—always. They weren’t any better than I was. I decided to beat the caste system within my own classroom. I felt my sitting in the back row was perhaps contributing to my isolation and depression that had begun to develop. Humans are not meant to be excluded—we need contact. As a result, I started moving forward, slowly but purposefully, to avoid and overcome my feelings of exclusion.
I remember deciding I would not allow myself to sit in the back anymore. I felt like Rosa Parks as I migrated up to the middle rows of the classroom. I began to raise my hand more. I found that studying alone was beneficial to me, as I knew the full answers to questions that other students merely answered in a general way. As a result, I started raising my hand and answered insightfully each time.
I wasn’t sure of myself until my anatomy and physiology professor approached me and asked if I wanted to become a physician. He tried to convince me to enter the premedical program. I was flattered and taken aback, but I knew it was not what I wanted. I had fallen in love with the few nursing courses we were allowed to take. I could not betray my passion for nursing and really “being” with the people. However, he had not approached anyone else in the class with this offer.
It was after that discussion that I moved up and became the snob who raised her hand to answer every question, at every opportunity. It was not until then that I had my first contact with nonminority students, other than a glance. They soon began asking how well I did on my exams. When interrogated, I replied without emotion, saying I did “okay” when I knew I got an A. They soon lost interest in me again. They did not know that their exclusion of me in their study groups was paying off greatly for me. I had become an independent and successful learner.
As the years progressed, I think they began to suspect I was doing better than just “okay” as I began to earn scholarships and recognition from my professors in class. It was unwanted attention for me because I wanted to keep my head low. What began as a business venture to simply gain a skill that would sustain me as an adult turned into a love for the profession of nursing. I had not expected that—it just happened. As my love grew, I began to excel. As I excelled, I felt the isolation increase. I had become used to it; it didn’t really bother me on the surface. It seemed other students were in school to make lifelong friends and to have a good time. I was in nursing school solely to earn my degree, focusing intently and singularly on my studies; so, most nursing students tended to avoid most nursing students avoided me.
I soon began to wonder if I had isolated myself, but then I noticed in my junior year that professors began to assign more group assignments. In those voluntary group assignments, I observed minority students chose to work together in the same groups, while nonminority students chose to work together in their own groups. I wondered if the professors noticed the same thing I did. It went on like this until the end of the nursing program.
A 2015 integrative review published in Nursing Education Perspectives reaffirmed that there are several studies where African American nursing students reported feeling “voiceless, not part of the important conversations, left outside of the cliques, alienated and insignificant.” Many minority students coped with these conditions by forming their own network among other minorities and “sticking together.” Additionally, Love noted in her study that African American students familiar with “being left out” from high school experience were better able to accept exclusion and move beyond the experience.
All that studying and exclusion seemed to work better for me. It worked out because I graduated. During graduation, I knew a select few would earn special acknowledgement for their achievements. I was sure it would not be me. I was so focused on getting out of there. I had the chance to extern on a unit in a teaching hospital where nonminority staff embraced me as if I was family. I just wanted out of nursing school. At the end of four years, it felt like prison only being able to talk to and connect with six minorities who made it to the end of the program. Now, I was free to explore the world as an adult with a real job—not just a student building up debt.
These were my thoughts as I was called up to shake hands with all of my professors. I was so focused on receiving my degree that the moment when they called my name seemed only a second. When they began to announce the special recognition awards for academic and clinical excellence, I kept looking back at my family and realized I was one of the few students wearing a purple tassel, which meant we were part of a special group: the Honor Society of Nursing, Sigma Theta Tau. We had high GPAs.
Then I heard one of my professors say my name. I looked around and those around me whispered, “That’s you! Get up! They called you!” I had earned the award for clinical excellence. I was speechless and nearly stumbled up to the stage. I thought my professors were not interested in me, but they had nominated me for this award (and I assume they voted that I receive it). I was flabbergasted but filled with pride because I—the quiet African American student nurse—had earned this great honor. I thought I had not deserved it, because there were so many things I did not yet know, and I knew I was not the perfect student. I critiqued myself for those few senseless Bs I had earned. It was not until I returned to my seat the second time that I realized maybe I did deserve this award. Just maybe, I had worked hard enough in that I enjoyed putting the entire patient picture together—staying in their rooms, discussing how they felt about their illnesses while taking it all in, and figuring out how I could use my knowledge to prevent one less complication. I was more than a student nurse in those moments with my patients; I assumed the role of nurse and took such opportunities with the utmost seriousness. I remember a great exhalation as everyone threw their caps to the roof of the auditorium. I was deserving.
Soon after graduation, I passed my licensing exam on the first try and began working on a medical-surgical floor at a teaching hospital. My work was challenging and kept my attention, but I soon began to crave schooling. I decided to enroll in an online program. The main reason for doing so was so no one could see my face and perhaps I could fit in for once. And I did. I felt since no one could see the color of my skin or the youth of my face there would be no divisions. It proved true. I enjoyed my online schooling and soon pursued a doctorate program online after completing my master’s in nursing education.
In a 1998 study published in the Journal of Nursing Education, author Mary Lee Kirkland, EdD, RN, concluded that the most successful coping strategies of female African American nursing students are active coping and social support. She explains that “although they may have faced times of discouragement or despair, they did not waver in their pursuit of their goals. They relied on their inner strength to take the action needed to conquer their stressors and move on successfully.” I had a support system of my spirituality, my family at home, and my friends of the same faith that kept me strong. They probably were unaware how they were the one thread that held me together through emotional turmoil and numbness.
Enlightenment Upon a Return to the University: Six Years Postgraduation
Aside from the anatomy and physiology professor, who was from the biology school, I was never sure how the true nursing faculty viewed me. It was not until I returned six years later as a clinical nurse specialist to become a mentor for nursing students like I had been—of the minority. I was also pursuing a scholarship for my doctoral education with a focus on nursing education.
When I met with one of the professors, I was sure she had forgotten me by the e-mail she had sent back when I asked for a letter of reference and to meet to discuss a mentorship program for minority nursing students. However, when I walked in the door in my professional attire, she told me, “Wow, I remember you. I wasn’t completely sure in your e-mail, but now I know who you are exactly…You were always so bright. I knew it then, and look at you now and all you have accomplished. You have your master’s and are a clinical nurse specialist….[Another professor] and I are rooting for you to get this scholarship.” Our conversation ran long before a student showed up for her advisement. The professor told me warmly, “Keep in touch. We are so proud of what you will become and have become already!” She had written my letter of recommendation. However, the recognition she provided in those moments proved to me I did not know myself those years as well as I did right then.
I had not been invisible, after all, and the award I received upon graduation was not for show, but because my professors saw such great potential in me. I had become visible to myself and the world. My confidence soared as I left the campus. I had driven in, but I seemed to fly home, alongside the clouds.
