Barriers to career advancement in the nursing profession: Perceptions of Black nurses in the United States

Abstract Background There is a paucity of Black and minority ethnic group nurse leaders and faculty in the nursing profession, even though the overall number of nurses within this demographic has increased. This study aimed to examine Black nurses' perceptions of the barriers to career advancement in nursing profession in the United States. Procedure Participants included 30 Black nurses aged 25 to 65 from health care settings across five US states recruited through purposive sampling. The study used a focused ethnographic design with semi‐structured interviews to elicit responses about participants perceptions and experiences of seeking leadership and faculty positions. Results Thematic analysis revealed seven main themes: maintaining white comfort, distrust, no one like me, paving the way, worthy of representation, leadership role not expected of Black nurses, and an advanced degree does not equal advanced opportunities. Conclusion The findings suggest that Black nurses face significant challenges in entering leadership or faculty positions. They face racial discrimination and lack access to mentorship and support which discourages sufficiently qualified and experienced nurses from applying for high‐level positions. Ensuring all nurses are afforded equal opportunity for career advancement is essential for the nursing profession's continued growth.

implement measured aimed at the recruitment and retention of nursing students from diverse backgrounds. The report also recommended strategies to increase the number and diversity of nurse faculty, scientists, and researchers. BN leaders are in positions to act and engage with their communities to work towards achieving health equity. With such a significant need to diversify the nursing workforce, we must understand and mitigate issues preventing career progression.
Ethnic minority nurse leaders play an integral role in mentoring, advancing new knowledge, and fostering diverse perspectives among nurses and nursing students who will advance equity in a diverse and global society. However, 5 expressed great concern for the small number of ethnic minority nurses in leadership, especially in the higher-level and influential leadership positions. Additionally, 6 suggested nursing should prioritize preparing racial or ethnic minority individuals to assume greater leadership roles as a means of reducing health disparities. Many colleges and universities have instituted programs and initiatives to increase the diversity of nursing school Bachelor of Science in Nursing (BSN) graduates. However, data from the 7 indicates that there is a compelling need for colleges and universities "to take a more focused approach to enhance the diversity of the nursing workforce if they are to catch up to, and keep pace with, the country's demographic changes" 8 (p. 58).
The lack of BNs in leadership and academia is cited as one of the reasons for the poor success of ethnic minority students in nursing, career advancement, and consequently continued health disparity. The AACN recognizes the need to recruit more faculty from the minority population as a strategy for attracting diverse nursing students. 4 However, the paucity of ethnic minority leaders and faculty undercuts this transfer of political and social capital. 9,10 Diversity, as stated by, 11 is a prized resource which should be viewed as a criterion for excellence.
Nurse leaders are aware that BNs and other ethnic minority nurses are needed in leadership positions of the nursing workforce to work on policies and procedures affecting Black and other ethnic minority patients.
Besides helping students be successful in nursing education, or new nurses acclimate to their new practice environments, good mentors of diverse ethnic backgrounds ensure nurses from similar backgrounds understand that they have a place in the nursing profession and are capable of doing the work. 12 The experiences of racism are often cited in studies of ethnic minorities in nursing. For instance, a study of managers' perspectives on the promotion of nurses by 13

indicated that nurse managers felt
BNs were not as capable as other nurses and were not motivated to seek higher-level positions, therefore were denied professional development and promotional opportunities. 14 identified exclusion and control strategies which faculty of the color stated affected their roles as nurse educators. 15 reported that African American faculty experienced challenges related to racial discrimination; however, this reinforced their commitment to remain in academia.
As the US racial landscape continues to become more diverse, with the ethnic minority projected to become the majority, it is vital that nursing continues to work diligently to reverse the historical trend of minority group underrepresentation in nursing leadership and academia. It is imperative to understand all factors contributing to the paucity of Black nurses in leadership and faculty roles. A leader in the context of this study is defined as any nurse individual in a position of authority who is responsible for managing staff, patient care, and implementation of the organization's stipulated policies and procedures (nurse managers, directors, educators, supervisors in practice and academia), as well as nurses in academic faculty or instructor roles.

| REVIEW OF LITERATURE
Although cultural diversity and inclusion are routinely articulated as the ethos of the nursing academe and practice, numerous studies examining the experiences of BNs, students, and faculty, as well as other ethnic minority nurses, cite experiences of racism and discrimination. [16][17][18][19] In nursing education, many ethnic minority students experience different types of ethnic and cultural insensitivity at some point during their education 3,20 which can affect their ability to succeed. However, it has been noted that faculty of color were vital in promoting culture and climate of inclusion for students of color in predominantly white schools of nursing. 21 There are reports of racism among nursing faculty in the form of exclusionary practices. 14,15,19,21,22 In a phenomenological study of 15 BN faculty by Whitfield-Harris et al, 19 participants reported feeling disrespected, feeling uncomfortable, and students questioning their teaching styles. Some participants reported feeling bullied by students and other white faculty. Many of their participants reported, they felt "discriminated against, discouraged, disrespected, undervalued and unsupported by their white colleagues"(p. 611).
Furthermore, BN faculty face significant challenges towards attaining tenure due to limited resources, lack of support, and mentoring as compared to their white counterparts. 14,15,19 Ethnic minority nurses experienced discrimination, marginalization, and unequal career advancement opportunities. 17,[23][24][25][26] They often felt they had to work harder than their white counterparts to earn the same recognition. 24 Nurses in 17 study reported being bullied and treated as less knowledgeable due to minority status and their foreign accent.
Many of the nurses left their place of employment due to experiences of discrimination, lack of support, and feelings of exclusion.
Ethnic minority nurses are often made to feel incompetent by their peers through scrutiny, questioning of their work and ability, as well as challenging their work in front of patients and families. A study of 14 Black African nurses by 23 highlights the everyday experiences of racism faced by these nurses in their workplace. They were stereotyped due to their African origin as lacking the appropriate skills and competency to practice nursing; in addition, they were seen as inferior and lacking in skills required for leadership and management.
Mentoring has been cited as critical to the survival and success of minority nurse faculty 12,18,19,21,27 and is likened to aspirational barriers. 18 described an aspirational barrier as what a person feels they can accomplish. Mingo suggests exposure to role models from the same cultural background who are successful in college, as well as meeting faculty members and persons in a leadership role to whom the ethnic minority nurses can relate, can improve their self-confidence that they IHEDURU-ANDERSON | 665 too will be able to achieve the same dream. When ethnic minority nurses have mentors who encourage them to reach their potential, it can be a strong motivating factor to "make them feel they possess the skills to accomplish whatever they desire" 18 (p. 51). This finding is crucial for the development of BNs and students. As Mingo noted, it will take time to increase the number of BN leaders within all nursing programs to be commensurate with the number of Black students, but we need to understand the barrier contributing to the languid pace of increasing the number of BN leaders and educators. Ethnic minority nurses often described racial discrimination as a barrier to career progression. In a literature review by 28 exploring the state of knowledge related to minority migrant nurses' experiences of perceived prejudice and discrimination in health care work settings, racial barriers to career progression were commonly described as a form of discrimination. The study also found racial discrimination hindered access to promotion and training with some policies lacking transparency or equitable implementation, "allowing for intentional discriminatory behaviors towards ethnic minority migrant nurses" 28 (p. 518).
Although racism and racial discrimination have been cited as a barrier in nursing, no study could be found examining the lack of BN leaders as a barrier to the career progression of other BNs. Thus, to the author's knowledge, the extent to which perceptions of racism affects BNs' motivation to seek leadership and faculty positions has not been studied.
Additionally, although the lack of BN faculty has been suggested as a barrier to the recruitment, retention, and graduation of Black students, I could not find any studies examining if the lack of BN leaders and faculty is a barrier to BNs' intention to seek leadership or faculty roles.

| PURPOSE
The study aimed to (1) Examine BN perceptions of the barriers to career advancement in nursing profession in the United States.
(2) Explore whether the dearth of BN leaders and faculty is a barrier to the intents of BN to apply to leadership and faculty positions in nursing.

| Design
A focused ethnographic study of 30 BNs was conducted to answer the above research questions using semi-structured interviews. Focused ethnography is used when a researcher intends to focus on a specific area of inquiry, especially if there are financial and time constraints. 29 Focused ethnography is appropriate for nurse researchers who plan to "emphasize a distinct issue, situation or 'problem within a specific context among a small group of people' living in a bigger society" 30 (p. 38), and helps the author to understand multiple realities which are socially constructed based on these perceptions. Focused ethnographies may have a limited number of data collection strategies, and participant observation is not a requirement. [31][32][33][34] Focused ethnography is the method of choice in understanding a more specific aspect of life and cultural experiences relevant to the participants' day-to-day experience in their nursing practice. 32 The facilitation of participants' observation for this study was not feasible due to the diverse employment settings and their geographical location.

| Study sample
Thirty BNs aged between 25 and 65 years, with an average of 15 years of experience, and working in different health care settings located within the urban areas in five US states, were recruited using purposive and snowball sampling methods. Twenty-one of the 30 participants worked in the metropolitan area of the same North Eastern state with a 9% Black population. Purposive sampling ensured the recruitment of participants from the same subculture, who have specific knowledge or experience of interest to the researcher. 32,35,36 Participants may also recommend other individuals to participate in the study. 30,32,37 The inclusion criteria were registered nurses (RN) who self-identified as Black or African American and completion of a BSN with at least 5 years of nursing practice experience.

| Ethical considerations
Approval for the study was obtained from the University's Institutional Review Board (IRB). Every participant signed the IRB approved informed consent form before the interview. Each participant was assigned a pseudonym to ensure confidentiality. 35

| Data collection
A short author-developed survey was used to collect participants' demographic data ( Table 2). The 30 individual semi-structured telephone and skype interviews, of 45 to 60-minute duration, were digitally audio recorded. The semistructured interview allowed the researcher to ask predetermined questions (Table 1) and delve deeper into the discussion by further exploring additional areas of interest and insights the participants raised during the interview. 38,39 In addition, it allowed for the discovery of information which is important to participants, but may not have previously been thought of as pertinent by the researcher. [38][39][40]

| Data analysis
The interviews were audio-recorded, transcribed verbatim, and analyzed using the thematic approach recommended by Burnard et al 41 and Braun and Clark. 42 Each audio recording was listened to at least twice to verify the accuracy of the transcription and to make corrections where necessary. The transcripts were read at least two additional times after accuracy was ascertained. This allowed the researcher to become more familiar with the contents, take notes, and add to the spreadsheet used for coding the data. The findings are clustered into themes with supporting verbatim quotes from the participants. Demographic data were analyzed using descriptive statistics ( Table 2).
Data analysis started immediately after the data was collected from the first participant. When reviewing the audio recording, transcript, and notes taken during data collection, the author identified relevant comments related to perceptions of racism, lack of BN leaders, lack of representation, and how the participant related it to career advancement opportunities. The author carefully grouped and organized these phrases, then checked to determine if they reflected an accurate picture of the participants' story. This was repeated with every participant's transcript and more phrases where added; some were modified, others combined so they represented all the data.
During this process, categories were developed which led to the seven main themes representing the study findings.
The analyses was validated through an audit trail, thick descriptions of the study process, as well as reflexivity, to ensure rigor and trustworthiness of the results. 36,43 The author kept careful notes of all the interviews, including observations made during the interviews, such as changes in the participant tone of voice, prolonged pauses, and change of subject. 35,36,43 The author engaged in reflexivity by keeping a personal journal to record thoughts, feelings, uncertainties, values, beliefs, and assumptions which emerged during the study. [43][44][45] This was especially important since the author is a BN who personally experienced racism in both professional and personal life. The transferability of the findings are challenging because "qualitative studies are very unique and the data may not transfer to another study" 46 (p. 933).

| FINDINGS
The findings of the study are described under seven themes: maintaining white comfort, distrust, no one like me, paving the way, worthy of representation, leadership role not expected of Black nurses, and an advanced degree does not equal advanced opportunities. Relevant quotes from participants for each theme are presented in Table 3.

| Maintaining White comfort
Some of the participants in this study were initially vague at the beginning of the interviews when they talked about the specific details of their experiences. They were reluctant to associate these experiences with racism or racial bias; however, they stated there Some nurses attributed their experiences of racial discrimination to nursing catering to "white comfort." This experience was described as invading "white spaces," where the goal is to cater to white people's needs to the detriment of others. Moreover, participants felt some managers' behavior and responses to their plight are geared towards maintaining their status and membership to the in-group. Others felt that white nurses overall are not ready to have a BN in charge in their workplaces, stating that although their white peers may speak to their abilities and work ethic, many are not ready to be led by a BN because it is not considered the norm.
Some felt having a BN as a unit manager will be disruptive to the way things are. "You can't disrupt the system" as stated by one of the participants. Others discussed going through undergraduate and T A B L E 1 Semi structure interview questions 1.
How would you describe your career experiences as a Black African American nurse in the United States?

2.
How would you describe your career advancement opportunities and experiences?

3.
How have your experience so far affected your motivation to apply to leadership or faculty positions in nursing?

4.
How has the lack of Black nurses in leadership and faculty positions affected your intent to apply for these roles? T A B L E 3 Participant quotes from Interviews organized by the main theme in the order they are discussed in the text

Theme Example participant quotes
Maintaining white comfort I work with nurses who can vouch for my work ethic but will not want me to be their unit manager. Why you may ask, because they are not ready to see a BN, no matter how experienced, or educated, be in charge of them… These white nurses we work with here, they are okay with you working at the same level but not higher. They will prefer a clueless white nurse manager to a smart, opinionated BN. To your face they will tell you, you are a good nurse, but if it comes to supporting you to advance, they will not support you… As a Black person, you cannot aspire too high in this profession.   It is also an easy way for them to get rid of you. I have seen many BNs come and go quickly because they took a supervisory position. Once you do that, the union cannot protect you. you can get fired for nothing. someone cared about them, providing safe spaces to ask questions when they were overwhelmed and allowed for the opportunity to reach out to someone who understood their challenges. This emphasizes how the development of personal and interpersonal relationships is essential for professional development and job satisfaction.

| Distrust
As nursing continues to work to increase minority representation at all levels, providing nurses with mentors of the same cultural background with whom they can relate becomes imperative. Mentors are key to career development and advancement in any field; therefore, BN mentors who are experts, willing and able to facilitate the advancement of BNs' careers, are invaluable assets for these nurses.

| Leadership role not expected of BNs
A number of nurses in this study felt that leadership roles were not expected of BNs. Historically, the nursing profession has been dominated by white nurses fueling participants' belief that their white counterparts prefer BNs at the bedside.
…they really want you to stay at the bedside forever. In fact, they prefer that you don't apply for managerial positions, when you do, they don't know what to do with you. Some may even wonder at your audacity to think that you can become a manager. It's like how dare you. [P17] The perception that the leadership role is not for BNs was described by many of the participants who worked in community hospitals or hospitals catering to a predominantly white population. One to accept managerial roles and declined to participate in governance roles even after receiving encouragement. The current study participants indicated a collective willingness to take on leadership roles but were denied opportunities or were not provided support. Some, however, were unwilling to apply to leadership roles due to prior experiences of lack of support from peers and leaders. are prepared to actively participate in the decision-making process, and share the perspective of diverse stakeholders they represent.
American Association of Colleges of Nursing 4 calls for academic leadership and faculty to examine any conscious and unconscious biases that may undermine efforts to enhance diversity, inclusion, and equity, including the use of daily verbal, nonverbal, intentional or non-intentional messages which devalue the perspectives, experiences, or feelings of individuals or groups. Experiences of racism and racial discrimination in the profession may hinder the number of Black youths who view nursing as a viable career option. As one of the participants stated, she will never "advise any youth to become a nurse" due to her experience of racial discrimination within the profession. To ethnically diversify nursing leadership, we need to recruit ethnically diverse people into the profession. Moreover, by encouraging Black students to take the academic plunge, mentors play a critical role in expanding the nursing universe at the earliest possible juncture. 12

| Limitations
The author's cultural and ethnic background allowed her to form a close and trusting relationship with the participants, which allowed them to speak freely about their perceptions of a sensitive subject. The data presented include the participants' verbatim quotes supporting the identified themes. Since a researcher's cultural and experiential background contain biases, values, and ideologies that may affect the interpretation of a study, 36 this researcher took steps to ensure the interpretation of the experiences represent those of participants and not of the researcher. 35,36,42 The author sought to decrease bias by taking the time to interview each participant, ask for clarification of statements, and in some instances, returned to participants to verify their statements. Furthermore, participants may have had a particular motivation to participate in the study, which raises concerns about such influencing factors. Therefore, the findings of this study could only be generalized to the study participants. This is the first study to explore the lack of BNs as a deterring factor for other BNs seeking leadership or faculty positions.
Further research is warranted to explore the factors that contributed to the success of the BNs and other ethnic minority nurses in leadership or faculty roles, and what other resources and development opportunities may be available to assist BN's advancement into these roles. It will be essential to continue to assess the nurses' work environment to develop and test the effectiveness of innovative, evidence-based strategies aimed at remedying the consequences of unpleasant nursing work environments that have caused these nurses to experience racial prejudice and discrimina-  behaviors from peers and managers that acted as a deterrent to apply for higher-level positions. Continued lack of Black nurse leaders and faculty may suggest to potential students that nursing does not value diversity or offer career advancement opportunities. Perceptions of racial inequality in employment and promotional decisions create a hostile and unproductive work environment. Nurse leaders need to examine the career advancement practices within their organizations and ensure that all nurses are afforded equal opportunity for career advancement in the workplace.