This review summarizes the results of articles published in peer-reviewed nursing journals from 2008 to 2019 dealing with Black African born nurses and nursing students. The purpose of this integrative review is to:

• describe the experience of being outsiders in nursing and nursing education as described in literature by Black African born nurses and nursing students in the United States.
• give voice to the experiences of BABN&SNs and highlight the need for open dialogue in schools of nursing and healthcare settings to address racial bias.
• discuss the implications of othering of BABN&SN in the nursing profession in US.
• offer recommendations from literature based on the statements from BABN&SNs.

The search strategy (Fig. 1) and the search were designed and performed with the assistance and guidance of the College of Health Professions Librarian. Using a combination of the search terms listed above and the filters as guided by the Librarian, the following databases and electronic journal collections were searched using a detailed and broad search strategy from 2008 to 2019: CINAHL, OVID, EBSCOhost, PubMed Central, and Google Scholar. Reference lists of articles selected for full text review were manually searched. Table 2 is an example of search terms and filters used for the CINAHL database.

This integrative review follows the five stages of review as proposed by Whittemore and Knafl [31]. These stages include problem identification, literature search, data evaluation, data analysis, and presentation. There has been much published in nursing journals offering expert opinion and suggestions to the experiences of African Americans in nursing in the U.S. However, studies do not often differentiate the experiences of African born nurses and students from that of other Black nurses. Evidence showed that due to the racial and national hierarchies in the nursing profession, Black African Born Nurses (BABN) are at the bottom of the nursing profession’s hierarchy [8, 32-34]. This present review provides the first integrative review of studies on reported alienation and othering of Black African born Nurses and Nursing students in the United States.

All the reviewed studies indicate that social isolation and loneliness are important obstacles experienced by the BABN&SN in the academic and clinical settings. The low numbers of Black minority faculty and students in nursing programs limits the opportunities for students to connect and develop relationships with faculty and other nursing students leading to the feelings of social isolation and loneliness [4, 7, 14, 35-44]. Contributing to the sense of isolation are language and accents [45]. Love [39] conducted a descriptive phenomenology study to explore the lived experiences of African American baccalaureate-level students with socialization in one nursing school. A major theme that emerged from this study was isolation and sticking together. Participants in this study reported that they “felt isolated from their classmates and singled out.” One stated “I noticed I was put on the side” [39]. There was also self-imposed isolation by the BABN&SN in attempts to distance themselves from their peers to avoid embarrassment related to course grades and accents. The participants reported that the painful experiences of discrimination and isolation came from many sources, including teachers, students, nurses, and nurses’ aides. One of Love’s participants described her appalling experience of discrimination and isolation as follows: “Being with White people feels like you are sitting on pins and needles. Like you are sitting on something that’s going to hurt you any minute” [39]. Such feelings as described above limited interactions with the majority peers and heightened the feeling of being othered for these students.

Compared to White nursing students, Black nursing students experience higher attrition from nursing programs [35]. This high attrition has been attributed to poor sense of belonging, lack of connection, and poor academic performance [7, 37, 39, 40, 45]. Evidence from literature indicates that the attrition of Black students related to isolation can be mitigated by both academic and interpersonal support [7, 35, 38, 39]. Social connections and friendships beyond the classroom and the work environment are important in building a sense of belonging that fosters peer support, a sense of community, and improved academic and work performance.

Collegial/peer isolation hinders these BABN&SNs from being assertive and successful [4, 14, 35]. Studies affirmed that the African-born Nursing students’ experiences of isolation and non-inclusive institutional climates have significant effects on their academic performances and outcomes [7, 14, 40, 41, 45]. In the Love [39] study, almost all the participants indicated that they experienced a lack of confidence, diminished self-esteem among the white students, fear and isolation from their classmates, and the pervasive sense of being alone. This finding was consistent with that by Ackerman-Barger & Hummel [35] that reported the need for inclusion and equity in nursing education and, ultimately, in healthcare. Ackerman-Barger & Hummel (2015) used a narrative inquiry to capture the educational experiences of nursing students of color. The participants shared their stories of racism, prejudice and isolation in the theme of exclusion and reported that these issues were prevalent with both their peers and nurse educators. One participant shared the experience of peer racism and isolation stating:

“Serena: ‘Sometimes you don’t have any support and you have to do everything on your own. Like even in the classroom I feel like I can’t ask a question, I have to do it later. I have to wait to talk to the professor. It is really very lonely. And you have to be really careful. I don’t know. I don’t know how to explain it’” [35].

Although the increased need for diversity in nursing is not new and many positive impacts of cultural diversity have been reported, concrete plans to successfully address the issues that contribute to collegial isolation in nursing is lacking. Mulready-Shick [45] stated that some of the setback factors may include faculty bias and perspectives towards the minority nursing students. Black students in Love [39] reported being the last to be chosen as partners in class/clinical group work and being unable to find classmates willing to form study groups with them. Junious et al. [38] reported that many black students shared an extremely strong desire for support, understanding, and overall acceptance from nursing school classmates and faculty.

Consensus on how to eliminate this pervasive issue has been negatively affected by multiple factors including but not limited to poor implementation of organizational/institutional policies, cultural incompetence of faculty and staff [7, 35], and inability or unwillingness of nurse leaders and faculty to confront and address the issue head-on. Indisputably, professional socialization in nursing programs is more congruent to white majority students than those of racial and ethnic minorities [7, 14, 35, 37, 39]. A participant in Ackerman-Barger & Hummel [35] study described the experience of isolation from nurse faculty as “an eye-opener to me on the power of racial mind-raping in the classroom” (p. 41-42).

The discrimination experienced by the BABN extends beyond racial differences and relates also to their accents and perceived cultural differences from their country of origin [7, 38]. The perception that nursing faculty members have negative biases and attitudes toward minority students was expressed in many of the studies [7, 35, 39]. Ezeonwu [7] analyzed the views of African-born nurses on their RN-to-BSN education experiences in the United States. Results showed that socio-cultural adjustment associated with language barriers, discrimination and psychological intimidation was a top challenge identified by the participants. Describing her experience of discrimination, one student said: “I felt like an outsider in the school. It was hard to know anybody in the school when you are a minority” [7]. Issues related to language, heavy accents, and overall communication emerged as significant stressors and a key source of discrimination [4, 7, 38, 43]. The minority students of African descent were often looked down on. They lacked confidence in their own capabilities because of their inability to speak and sound American [4, 7, 36, 37, 39, 41, 42]. International students have different learning needs, more obstacles to overcome, and require additional coping strategies compared to their non-international classmates (Vardaman & Mastel-Smith, 2016), which may increase the feelings of otherness that they experienced.

The reviewed studies concur that increased diversity in nursing will improve the problems of racial discrimination and intimidation experienced by the black/minority nurses in both academia and the workforce. The distressing impacts of discrimination and racism expose these individuals to both physical and psychological ill-health (Ezeonwu, 2019). Ezeonwu’s (2019) findings indicated that working with faculty and advisers that are good listeners, patient, and approachable had great positive impact on Black African students’ success. The reviewed studies agreed that discriminatory/racial based barriers hinder internationally born nurses’ ability to working at their highest professional skill and advancement. As a result, BABN&SN may be forced to remain fearful outsiders, and may not be able to succeed in nursing education or aspire to their fullest potential in the nursing profession [4, 36, 38, 41].

The negative effects of language and accents among minority students, including its association with the concepts of language bias and racism, are replete in the literature [14]. Often accent bias led to low grades and misinterpretation of the students’ ability to interact with peers and patients. The most common reason given by educators for failing students was that the student was a poor communicator [14]. Communication encompassed both verbal and written interactions with patients, faculty, and staff nurses. DeBrew et al.’s [46] study of nursing faculty decisions to fail or pass students in clinical courses indicated that foreign students with English as a second language were likely to fail clinical courses due to faculty’s perceptions of the students’ ability to communicate. For example, a participant in their study reported: “ I had a student that was really afraid of patients. She just didn't know how to communicate with them” [46].

Mulready-Shick [45] argued that since the students’ communication provides incomplete evidence of their thought process, the inclusion of other multi-contextual instructional strategies should be considered. The findings from Smith and Smyer [14] indicated that the nursing faculty struggled in grading the BASNs in classroom and clinical settings due to their accents and as such viewed them as outsiders in nursing education. The fear of being mocked or saying words incorrectly detracts from the chances of successful program completion, especially when working with language biased faculty [7, 38, 45]. Similarly, test questions may be answered or graded incorrectly by the faculty because of language confusion [14, 41]. The BABN&NS endure discriminatory and prejudicial treatments that predisposed them to stress related to acculturation, thus negatively affecting their assessment and evaluation [14, 36, 39, 42, 44]. Students whose cultural norms do not allow public assertiveness are viewed as inefficient nursing students and that can affect their level of success in nursing programs [42]. The participants of the Smith & Smyer (2015) study reported that the culture was noted as the basis of fear of participation in both clinical and classroom settings as described by one participant:

“Being raised in a society where you are told you have to be polite, you cannot be talking in front of your elders, so we are not graded on participation, so you have to force yourself to answer questions. You are competing with what you are taught not to do” [14].

The experience of discrimination was further highlighted by the following statement from another participant in Smith and Smyer (2015) phenomenological study of Black African nurses experience in nursing education in the US:

“When the instructor said you need to participate in group studies, there is differentiation, people tend to segregate based on their racial perception of self…You find the African students tend to go to African students. Americans tend to go to Americans, whites tend to go to whites, Indians tend to go to Indians, so it is more of a segregation of some sort, and if you didn’t have anybody from your culture, from Africa, then you are stuck and you are having to go through trying to fit in” [14].

Smith and Smyer [14] affirmed the importance of understanding Black African culture as a facilitator for success of BASN, particularly related to their own cultural competence in navigating the new western culture and the new educational environment.

Similarly, Allen’s [36] study found that the Black nurses transitioning into the managerial roles are also faced with the challenges related to discrimination and language. Allen [36] explored the experiences of internationally educated nurses (IENs) in management positions in United States health care organizations. The problem of discrimination related to language /accent was a significant finding. The participants described various difficulties related to their accents and communication methods. The author reported that the participants were seen and treated as “outsiders” in hospitals with homogenous Caucasian nurses and as such they struggled to find their place in the organization’s culture. The author stated that the internationally educated nurses’ feelings of exclusion may indicate that their supervisors had low levels of multicultural understanding or recognition of cultural differences and their values. Studies have reported that the leadership strategies that are effective for US-educated nurses are not always appropriate for internationally educated nurses [36, 43].

Several studies exploring the experiences of minority students and nurses have contributed to the knowledge of BABN&SNs’ adjustment to their new environments [4, 7, 14, 35, 38-42]. These studies consistently found that international students and nurses experience new cultural practices and detachment from home, a place where they felt comfortable and secure. Although results showed that some minority nurses and students easily adapted to their new environments, a majority were faced with several adjustment challenges when transitioning into their new environments [4, 38]. Acclimatization into the new culture was noted to be very challenging to the participants in Junious et al. [38] study, which worsened the silencing of voices. One participant described the situation as:

“In my culture, when you talk to someone...that has authority above you, like an [older adult], we try to show respect I will just look down. I’m listening, but I don’t have to necessarily look into [his or her] eyes, but when my teacher does this literally do this (participant demonstrated how the instructor pulled her chin up) looks at me and gets so close, I’m so uncomfortable” [38].

Iheduru-Anderson and Wahi (2018) used a qualitative descriptive phenomenology to examine the transitional experiences of Nigerian internationally educated nurses (NIENs) transitioning to US health care settings. On the most predominate theme of fear/anger and disappointment, the participants reported that the humiliation from both peers and patients created an unwelcoming and hostile work environment. The NIENS were seen and treated as outsiders by both peers and patients (Iheduru-Anderson and Wahi, 2018). One participant reported:

“The nurses I worked with there were horrible. They were insensitive, they acted like they did not want me there. They gang up on me and they were always reporting me to the manager, for no apparent reason Overall, it was a hostile environment” [4].

As reported in similar studies, the participants survived the problem of fear and isolation through resilience, hard work and determination. In congruence with the above findings, Jose (2011) conducted a study using the qualitative psychological phenomenological method to elicit and describe the lived experiences of internationally educated nurses (IENs) who work in a multi-hospital medical center in the urban U.S. The author reported that nearly every participant revealed their experiences of fear, criticism, and discrimination from their peers. These created unwelcoming work environments and hindered their transition to practice in the US.

Many decades of research on stereotype threat suggest that concerns about negative stereotypes can undermine performance and create group differences in the educational and organizational outcomes achieved by stigmatized groups. The academic underperformance of racial and ethnic minorities at select colleges and universities is well-documented [38]. Junious et al. (2010) conducted an interpretive phenomenological study to examine stress, experiences, and perceptions of faculty support among foreign-born generic baccalaureate nursing students. The finding showed that all the participants experienced some form of cultural ignorance at some point during their nursing education. The experiences included language issues, stereotyping, discrimination, and cultural incompetence by the dominant culture. The participants reported that they were viewed as “dumb” because of their accented English.

Negative stereotypes of BABN&SN are evident in how BABN&SNs are treated by their peers. As discussed by a participant in Ackerman-Barger and Hummel [35]:

Yeah, sometimes when we have a group project and we come together and people have different suggestions and that was okay, but when I give a suggestion, they looked like they were not hearing what I am saying, or you are a dumb person. It make (sic) me feel like I was dumb or something like that. But when they check it out later, they would say, “Oh that was a good idea!” or “Oh yeah you were right.” But that would be maybe two or three days later. People don’t get to know you. They judge you!” [35].

Stereotyping of Black nursing students created self-doubt, a sense of paranoia, lack of confidence, and diminished self-esteem. Students felt like they did not belong and should not get “too comfy,” but “they are sitting and waiting for you to fail” [39]. Participants in Love (2010) discussed negative stereotypes experienced from faculty and peers. For example, the following excerpt was reported by a participant after a nurse instructor discussed with a white student an interaction she had with a black student stating: “She (the instructor) told a White student who said ‘be careful what you say before you get run over in the street or hear gunshots outside of your house.’ The teacher laughed” (p. 346). As Love appropriately noted, the previous negative stereotypical and prejudicial comment not only implied that the Black nursing student was “violent or involved in a gang… the teacher’s behavior fostered another type of discrimination” (p. 346). The instructor did not make any effort to reprimand the student for the negative racist comment but instead acknowledged and condoned it by laughing [39]. Comments like the one described above created hostile learning environment for the students.

One of the major shared experiences of Black African Student Nurses (BASN) was financial challenges and many reported that it was necessary to have multiple jobs in order to make ends meet [7]. However, several studies have attributed the financial difficulties/stressors of the BASN to cultural obligations of supporting families in their homelands [7, 14, 45]. The result from the Ezeonwu [7] study indicated other identified barriers to include intimidation by faculty and staff, poor awareness of and accessibility to financial aid information regarding scholarships and grants, technology, and problems with communication. The participants asserted that the orientation and exposure to other support networks and resources included but was not limited to friends, peers, provided support, and strength. The lack of knowledge regarding how to access available financial resources may heighten the feelings of otherness experienced by BABN&SN. Working long hours also limited the time available to socialize with peers.

Resilience is defined by Grafton, Gillespie, and Henderson [47] as “innate energy or motivating life force present to varying degrees in every individual, exemplified by the presence of particular traits or characteristics that, through the application of dynamic processes, enable an individual to cope with, recover from, and grow as a result of stress or adversity.” Personal resilience and determination are common findings in the literature that contributed to academic and career success. Although literature is replete with negative experiences related to social isolation, discrimination, unwelcoming environments, and intimidation, personal resilience and determination to succeed seemed to overcome these experiences. Many BABN &SN reported personal and family commitment and responsibility as very strong reasons to remain focused. One nurse in the Iheduru and Wahi [4] study described her resilience with the following: “hard work, determination. I am not a quitter, I still have an accent, but I have learned to speak so they can understand me better” (p. 607). Personal motivation and survival needs strengthened their resilience. Some of the nurses reported not having other choices, meaning that failure was not an option and that they needed to succeed at all costs.

Many of these nurses exhibited the ability to learn from their experiences and adapt in order to build greater resilience in the face of future adversity. As many of the students who fail or drop out of nursing programs were Black students, many of the BASNs feel the pressure and will do whatever it takes to prosper where those students could not. As noted in Love [39], “several students stated that they “pushed even harder” to prove they could be successful” (p. 346). Their belief that the faculty and non-minority students expected them to fail or withdraw from the program motivated them to work harder to be successful. “They felt the expectation of African American students failing, but that belief pushed them to new levels of determination to prove that they were “as smart as anyone else”. One student described, “You feel like there’s a bet going on and if you fail, you’re proving them right” [39]. Studies also showed that family commitment and responsibility converged to drive the personal resilience and determination of BABN&SNs both in academia and in practice. The determination to succeed is common among other ethnic minority populations in nursing [48].

Being included means to belong. Belongingness is the experience of personal valued involvement in a system or environment. According to Maslow, belongingness is a basic human need. Maslow (1987) as cited in Levett-Jones, Lathlean, Maguire, & McMillan [49], described belongingness as “…the human need to be accepted, recognized, valued and appreciated by a group of other people.” Potential consequences of exclusion include anxiety, stress, depression, and a decrease in general well-being [49]. Several of the studies discussed the nurses’ and students’ experiences with eventually gaining a sense of belonging. Being included meant support from others (peers, colleagues, faculty, and nurse leaders), recognition, mentoring, referral for academic support, validation, and encouragement to succeed [35].

The literature revealed that BABN&SN presented a great need to fit in. To establish a strong sense of belongingness and integrate successfully within the institutions, many BABN&SN “transformed their identity” [44]. This loss of personal identity was articulated by Love (2010) and Whitfield-Harris et al. [44]; Black students and nurses who successfully adjusted and conformed to the dominant cultural norms of the institutions had difficulty remaining authentic to their own identity and being accepted while going through the transformation. Changing personal identity and conforming to the dominant cultural norms was viewed as a survival skill. Once full assimilation was achieved, these nurses and students experienced improved relationships with their peers and faculty overall. Communicating with accents was a very strong barrier to attaining a sense of belongingness (Ackerman-Barger & Hummel, 2015; Iheduru-Anderson & Wahi, 2018; Jose, 2011; Love, 2010; Sanner & Wilson, 2008; Vardaman & Mastel-Smith, 2016; Wheeler, Foster, & Hepburn, 2014). Therefore, modifying accents and speaking/sounding more like their American-born counterparts was a tool used to overcome stereotypes.

Notably, the benefits of conforming were increased belongingness and inclusion. For the BABN&SN, that meant increased support from and mentoring by faculty and peers, exposure to academic resources, more friends, invitations to social events, and recognition as a member of the team [4, 7, 14, 35, 39]. Validation was described as being acknowledged as an individual and treated with respect. When faculty and peers took the time to learn about the nurses personally, it increased their sense of belonging. Faculty who made BABN &SN feel included was described as friendly, “engaging, supportive, loving” [35], “approachable, accommodating, accepting, nice,” [42].

Positive relationships between the BABN&SN and their peers contributed to an increased sense of belonging and inclusion. Perception of colleagues included feeling welcomed, being treated as an equal, and being defended when bullying, negative comments, or discriminatory treatments were observed. The nurses reported an increased sense of belonging when they had more positive interactions with their colleagues. For example, a participant in Iheduru-Anderson and Wahi [4] described one of her colleagues as a “lifesaver,” while another participant in Ackerman-Barger & Hummel [35] described a connection she had with a professor of the same race and ethnicity as being “supported by someone who understood her” and making a difference in her success in nursing school. In Love [39], participants talked about forming alliances with other Black students stating: “Even if we don’t know each other,” sticking together provided “safety” and “strength” (p. 346). Participants in Vardaman and Mastel-Smith [42] reported relationships with peers from similar backgrounds that were “like a little family” (p. 40). Informal socialization outside of work and school was a powerful mechanism for increasing the nurses’ sense of belonging. Although many of the nurses reported not being able to join some of their peers for after work or school social activities, they felt a sense camaraderie by being included in non-work-related conversations that improved peer relationships. These informal interactions increased trust, self-esteem, and feelings of being valued as members of the team.

Perceptions of discriminatory educational climates and lack of faculty support negatively affected students’ learning and academic performance [7, 50, 51]. There are consequences which could be psychological and physical for nurses who feel excluded in the workplace. Alienation, insecurity and anxiety attributed to psychological consequences may be detrimental to the patients safety [43]. They may not speak up even when safety issues are observed for fear of retribution [4, 12, 14, 37].

The participants’ experiences in these studies diverged from the nursing profession’s philosophy of advocating and caring for others. Nursing leadership must do more with the assessment of workplace culture that perpetuates the othering of its constituents. Creating an environment that champions and supports all individuals, despite their skin color, place of origin, or manner of speaking is essential to promoting the kind of truly diverse and inclusive environment that can address the health and healthcare disparities of the U.S.

Understanding how Black African nurses and students experience nursing practice and education in the U.S. has implications for promoting their recruitment and retention. Nurse leaders and faculty must recognize and value the cultural differences of Black African nurses and student in order to provide a supportive and inclusive work and classroom environment. Debrew [46] challenged short-term fixes such as an occasional cultural competency programs for nurse educators and called for a more robust institutional change to improve nursing education. Most of the studies recommended hiring diverse nursing faculty who reflect the diversity of the patients as well as that of the workforce.

The outsider status of BABN&SN may function to provide their peers with the security of knowing that, whatever the configuration of the nursing professional status hierarchy, they will likely never be found at the bottom because that place is held by BABN&SN. However, reasonable and responsible nurse faculty are in positions to positively shape students’ experiences within the learning environment. Faculty can help BASNs learn to ask questions, improve their communication skills, and talk about their feelings and desires.

One limitation of this review is the number of resources included. The review only included studies published in peer-reviewed nursing journals from 2008 to 2019, therefore studies published in non-nursing journals would have been missed and some of the experiences with BABN&SN would not have been included. All studies of various designs were included in the review; however, no quality assessment of study design was included. Another limitation is the type of studies used in this review. The majority of the articles cited are qualitative articles. This limitation is consistent with Whittemore and Knafl’s [31] approach; including all evidence means that potentially weak evidence is also included. Small sample sizes limit generalization; however, they provide rich data related to the participants’ experiences as outsiders in nursing practice and education. This review was limited to the literature examining Black African born nurses and students; it will be important to examine other minority subgroup experiences to understand how their experiences compare to that of the current population. Another limitation is that this study provides no clear insight on what strategies that the nurses and students used to find success and navigate their actual and perceived challenges. Increased understanding of the processes that enable these nurses to adapt successfully, and of the limitations on successful coping of those who did not succeed in nursing education, can provide insight into the principles underlying their success and resilience. This understanding can also guide intervention efforts to promote success for students and decrease the feelings of alienation that affect full inclusion and engagement in the workplace. Quantitative study with larger sample sizes is needed to further examine the experiences of these nurses and students in the United States. As previously stated, the consequences of exclusion and poor sense of belongingness such as stress, anxiety, depression, and reduced self-esteem significantly impede learning. There must be a greater understanding of the impact of full inclusion on BABN&SN learning and success in nursing.