Discrimination in Nursing School: Thing of the Past or Alive and Well?

In recent years, nursing schools throughout the country have gone to great lengths to recruit more students from populations that have been traditionally underrepresented in the profession: racial and ethnic minorities, men, people with disabilities and older, “nontraditional” students. But despite this growing emphasis on diversity, that doesn’t mean these students always find a welcoming environment in the classroom where, ironically, they are taught one of the most nurturing of professions.

Today, of course, it is illegal to intentionally deny anyone admission to a college or university on the basis of race, religion, gender, disability or similar factors. And in our politically correct society, minority nursing students rarely hear racial or ethnic slurs from instructors, staff or fellow students. But even though such blatant forms of discrimination are pretty much a thing of the past, students whose race, gender, disability, etc. causes them to be perceived as different from the majority student population may still find themselves feeling acutely aware of their “differentness.”

For instance, they may have feelings of isolation, of being “shut out” by other students or of being “tolerated” rather than accepted. (See “What Students Say.”)
In some cases, they may feel they are being treated differently than other students, or even that they are being singled out or picked on by an instructor for no apparent reason. At its worst, this situation can result in complaints–whether real or perceived–of minority students being held to different standards than their majority counterparts–e.g., given more or different assignments, undeservedly low grades on tests, less opportunity to rewrite a paper or harsher treatment when it comes to absences and make-up work.

“Some students just feel targeted. They don’t fit the image of what the faculty think a nurse should be,” says Sheldon Fields, PhD, RN, APRN, BC, FNP, AACRN, assistant professor at the University of Rochester School of Nursing in Rochester, N.Y. “Maybe you have a different cultural background, language, skin color or gender; maybe you’re a little older or younger, or maybe you’re out about being lesbian or gay. [Whatever it is, it makes you stand out and] it can make you a [potential] target.”

A Subtler Form of Bias

“Discrimination in nursing schools is becoming less of a problem, that’s the good news,” says Chad O’Lynn, PhD, RN, an instructor at the University of Portland School of Nursing in Oregon and author of the forthcoming book Men in Nursing: History, Challenges and Opportunities. “But when it is present, it’s more covert.”

While he still hears stories of overt discrimination from male nursing students–like the one about a professor who said, “I’ve never passed a male student and you aren’t going to pass either”–O’Lynn believes these situations are happening less frequently these days. They are being replaced, however, by a more subtle bias that manifests itself in a learning environment that doesn’t recognize the strengths and talents that ethnic minority and male students bring to the profession, he says.

“The nursing profession is still teaching students how to care for patients in one way,” O’Lynn argues. “The underlying message [to male students] is that if you want to be a nurse, you have to behave like a woman. Although that message isn’t stated explicitly, it is often implicit.” For example, he says, men communicate differently than women and the male style of communication is not valued in nursing schools.

Furthermore, O’Lynn feels there is an overall lack of sensitivity to the issues and concerns that male nursing students face–or even to the fact that male students are present at all. There is the constant referral to nurses as “she,” not only in lectures but in textbooks, he points out. There is the lack of curriculum content concerning men’s health issues, although numerous courses are taught on women’s health.

As a board member of the American Assembly for Men in Nursing, O’Lynn says he hears from many male students who are nervous about examining female patients, particularly in sensitive areas, because they’re afraid of being accused of sexually inappropriate touching. Here, too, he feels that nursing educators are not acknowledging the needs of male students, let alone addressing them.

“It’s the elephant in the living room that nobody talks about,” O’Lynn maintains, adding that nursing programs must do more to help male students learn to work through these issues.

Susan Fleming, MN, RN, a nursing clinical instructor/lecturer at Washington State University’s Intercollegiate College of Nursing in Spokane and a board member of ExceptionalNurse.com, an online resource for nurses with disabilities, agrees that there is less discrimination nowadays than when she first started her nursing studies, but that it does still exist. Fleming was born without a left hand and was denied admission to the first nursing school she applied to because of her disability. She was subsequently accepted at a different school and completed the program successfully.

“[Today] it’s usually an instructor or group of instructors who can’t see past a student’s disability,” she says. “They usually have a problem with [the student’s ability to perform] one skill and they focus [all their attention] on that.”

Fields believes that one reason why bias still occurs in nursing schools today is that even though the students have become more diverse, the nursing faculty has remained virtually unchanged. They are still predominantly white and female. “The nursing faculty hasn’t changed, they’ve just gotten older,” he says. “They’re not adding enough diversity to the workforce to make a difference.”

Systemic Bias

Some diversity experts argue that it’s unfair to place all of the blame on a few insensitive faculty. “It’s not so much individual acts that people do,” says G. Rumay Alexander, EdD, RN, director of the Office of Multicultural Affairs at the University of North Carolina at Chapel Hill School of Nursing. “It’s systemic. Any ‘ism,’ whether it be racism, sexism, or ageism, can only operate if the system perpetuates it.”

Take admissions policies, for example. Alexander believes many nursing schools have admissions criteria that, while not deliberately exclusionary, may unintentionally be creating an unequal playing field for applicants from underrepresented populations.

“Admissions committees struggle with how to meet mandates in the [institution’s] vision and mission statements to meet the demand of a demographically changed world,” notes Alexander, who also is an associate clinical professor in the School of Nursing. Although nursing schools are incorporating these ideas into their public statements, they aren’t necessarily living them out, she believes. While the intent in many nursing schools today is to be inclusive and have a diverse student body, admissions committees are often operating from outdated guidelines that can actually achieve the opposite effect.

What the schools value or give credit for in their admissions policies can inadvertently keep certain students out, and even perpetuate past discrimination without the school being fully aware of it. For instance, says Alexander, the purpose of promoting legacy is to reward the alumni, but an unintended consequence is excluding students from populations that weren’t accepted in the past. “You can’t have a legacy if [your parents were denied admission],” she points out. Rather than doing away with legacy, she suggests that schools can add an admissions policy that rewards individuals who are the first generation in their family to attend nursing school.

Another issue is how nursing schools define leadership for admissions purposes. Typically, schools value individuals who have demonstrated leadership roles, such as serving as president of the class or a sorority. Many students of color may not have had those opportunities, but they may have served as president of their church choir. “Cultures can have their own ways of crafting a leader,” says Alexander. “To be fair, you need to expand the definition.”

Admissions essays can be still another source of unintended bias. Writing styles may be influenced by a student’s culture, Alexander explains. For example, if the faculty is subconsciously biased toward essays that display emotion about why the student wants to enter the nursing profession, a minority student from a culture that is stoic about expressing emotion would be at a disadvantage.

Conversely, if the admissions committee looks for how knowledgeable about the profession the applicant is and he or she comes from a culture that emphasizes story- telling, that student may be penalized on the essay, says Maria Warda, PhD, RN, dean of nursing at Georgia Southwestern State University.

Admissions criteria that don’t give applicants credit for being multicultural or bilingual also can be inadvertently exclusionary, adds Warda, who is vice president of the National Association of Hispanic Nurses. She notes that current admissions standards are predominantly qualitative, focusing on measurements such as grade point averages and SAT scores. She recommends using admissions criteria that focus on a combination of quantitative and qualitative measures.

Problem or Perception?

Antiquated admissions policies that fail to acknowledge cultural differences can result in bias against minority students before they even get into a nursing program. But what if you are a current nursing student and you feel that you’re experiencing unequal treatment because of your race, ethnicity, gender, religion, disability, sexual orientation, age, etc.? Should you turn the other cheek and just try to focus all your attention on your studies? Or should you speak up about it?

Obviously, it’s hard to just ignore the situation if you feel it is jeopardizing your chances of passing the course, getting a good grade or graduating from the program. Most of the experts interviewed for this article agree that students who believe they have been discriminated against–whether by a faculty member, administrator, clinical instructor or another student–should discuss the situation with the individual involved.

But before you initiate that discussion, you must do what psychotherapists refer to as “reality testing.” In other words, is it really discrimination or is it just your perception? Is there a possibility that you’re being oversensitive? Could you have misinterpreted or overpersonalized the individual’s comments or actions?

Alexander recommends writing down the incident as soon as it happens. “Record it immediately while the details are still fresh,” she says. Then you should process it past someone you trust to get another perspective.

Minority or male students may feel more comfortable checking their perceptions by talking to a student or faculty member of their same race, ethnicity or gender. If that is not possible within the nursing department, O’Lynn suggests seeking out a minority or male professor from another academic department.

He also offers this rule of thumb for assessing whether or not a male student is really experiencing gender bias: If the roles were reversed and the situation happened to a female student in medical school and it would be considered a problem, then it’s a problem for the male nursing student and he is not being overly sensitive.

Taking Action. . .

If a student’s perception of bias is validated, it’s time to proceed with what Alexander refers to as a “courageous dialogue.” As her nursing school’s chief diversity officer, helping to resolve such conflicts is part of her job. “I help people work through it, rather than walk away and make assumptions or judgments and operate out of those for the remainder of their time together,” she says.

If students feel that they can’t approach the faculty member because of the power inequity, they come to her. If the student feels threatened or vulnerable, Alexander suggests having a third party sit in on the discussion, as these types of situations can escalate rapidly. Over the years, she has served as that third party on behalf of students as well as faculty and staff members. “I’m there to support that person who has experienced the inequity, unfairness or injustice,” she says. In certain situations, she has even interviewed other students who were present during the incident.

Alexander not only encourages students to pursue this dialogue, she also offers tips on how to communicate their position more effectively. For example, she says, always use “I” statements, as in “I felt this way. . . .” Using “you” statements, such as “you make me feel. . .,” puts the other person on the defensive.

If talking one-on-one doesn’t solve the problem, then the student should learn the school’s policies and procedures for filing a grievance. “The more you adhere to the process, the better the chance of having your voice heard,” Warda advises.

Following the chain of command may involve talking to the school’s diversity officer, the student’s advisor or the associate dean. At most schools, the academic dean or the director of the Office of Admissions are helpful when trying to work through these types of situations, says Alexander. Talking with a representative of your school’s student nursing organization or minority student association who can share the encounter with leadership may also be beneficial.

Additionally, most schools have an Equal Opportunity office to mediate conflicts regarding discrimination and harassment. Fields encourages students to seek out an ombudsman, a process that he has found to be helpful because it gives access to an outside person who is unbiased.

Students who feel they have not gotten satisfaction from their school’s grievance process can seek outside legal counsel, provided that they have ample documentation to prove their case. Asking national organizations, such as the National Black Nurses Association, the National Association of Hispanic Nurses or the American Assembly for Men in Nursing, to intercede on your behalf may also be an option. However, the decision to take action at this level should be weighed heavily because it does come with potentially steep consequences.

“The problem is that nursing courses are not transferred between schools, so the student could be throwing away an entire academic year or two,” Warda cautions. Or worse, you could be jeopardizing your future career in nursing.

. . .Or Not

Sometimes you really can fight City Hall. Other times the battle may just not be winnable and it’s better to drop it and move on. Ultimately, minority nursing students who feel they are victims of bias must decide which option is right for them.

Alexander notes that not all schools jump to embrace diversity. Some talk about it, but don’t actually do it. “You have to decide ultimately if this school is the right place for you,” she says. “If you’re under physical and mental distress, getting sick all the time, then these are signals that it’s not the best place for you.”

If the situation is so egregious that it’s threatening your ability to progress, then you must stand up for yourself and take action, says Fields. If, on the other hand, the situation is not that bad and you have some support to help you handle it, then “suck it up, graduate and move on with your life,” he advises.

“At some point in your career, you will be able to express how you feel by, for example, never giving back to your alma mater,” Fields continues. “You live to fight another day. You don’t jeopardize your goals, especially if you’re outnumbered or outgunned. Nursing school is hard enough without having to deal with that burden.”

Fleming’s case is a perfect example. When she first applied to nursing school she was given a “skills test” that involved spiking IV bottles. Because she had some difficulty performing the task–which was not surprising, since she had never been taught how to do it–she was told that she would endanger patients’ lives and she was not accepted into the program. Continuing to work as a nurses’ aide and encouraged by a doctor to re-apply to other nursing schools, Fleming found a school that welcomed her. When she asked about the “skills test,” she was told that giving her such a test would be illegal. In hindsight, Fleming realizes that half of her current students wouldn’t have been able to pass the test.

“I realized that I could expend my energy fighting the system,” she says. “But because I found another school that did accept me, I thought it was more important to turn my energy to my education.

“There are no stop signs,” she adds. “They’re just roadblocks. You have to go around them.”

Above all, says Fields, “Never give up your dream of being a nurse just because one particular school doesn’t think you fit its mold for the kind of nurse it wants to produce.”