Underrepresented Health Care Students' Self-Perceptions of Stereotype Threat and Marginalization: An Interprofessional Perspective

Purpose:

            This presentation should benefit educators interested in deepening their understanding of the experiences of health professions students related stereotype threat (ST) and marginalization. The purpose of this study was to contribute student perspectives to the body of knowledge related to promoting student success for underrepresented groups in schools of nursing and medicine. By understanding the degree to which ST exists among marginalized groups and how individuals experience it educators can, not only support students, but help them reach their full academic potential. Through an examination of interprofessional student perspectives, strategies to promote retention and student success were explored.

The experience of marginalization diverts energy from learning and performing to anxiety and vigilance. In order for faculty and students to interrupt this process it is crucial to understand and find commonality in the nuanced individual student experiences of marginalization. Through a mixed methods approach student insights are shared that elucidate experiences of marginalization and the critical decisions that students must make in any given moment to succeed in academia. The students represented in this study are nursing, physician assistant and medical students with rigorous academic loads and daunting school schedules. The research team includes an interprofessional cadre of researchers. The primary investigator is a nurse educator and researcher. Co-investigators include a physician who is also a chief diversity officer, a community health nurse who is a PhD student, and a PhD student from the school of education.

Background

            Diversity among students, faculty and staff can offer in schools of nursing and schools of medicine provide a robust learning environment where students’ attitudes regarding to care and interest in working with underserved communities increases (Glazer & Bankston, 2014; Saha, 2014; Scott & Zerwick, 2015). Page (2010), using a logics model to validate the need for cognitive diversity, states that diverse working groups are more productive, creative and innovative than homogeneous groups. Arguably, to optimize the benefits of cognitive diversity institutions need students to contribute their individual perspectives which are a product of their unique and nuanced identities.

            All students, no matter their racial and ethnic background, experience challenges in higher education such as academic load and financial constraints. However, underrepresented minority (URM) students have additional burdens they must navigate in higher education. Orem, Semalulu, and Underwood (2013) found while studying the social and learning environments experienced by URM medical students that almost unanimously, “URM students have experienced less supportive social and less positive learning environments, have been subjected to discrimination and racial harassment, and have been more likely to perceive that their race negatively affected their medical school experience” (p.1769). Some of the struggles URM students experience relate to the many phenomena they experience such as, stereotype threat, internalized bias, unconscious bias, imposter syndrome, micro-aggressions, and discrimination. Although these phenomena are happening at an individual and interpersonal level it is important to note that these experiences due not occur because of a character deficiency or lack of motivation on the part of the student. In fact, many of these characteristics occur in students who are very motivated and care deeply about their success (Steele, 2010). All of these experiences originate from outside messages that have become part of an individual’s identity. Each of these experiences exemplify the burden URM students carry and are worthy of examination. Although this study focuses on the phenomenon of stereotype threat, because of the intersection of these phenomena the general concept of marginalization is also addressed.

Aronson, Burgess, Phelan, and Juarez (2013) defined stereotype threat as a disruptive psychological state that people experience when they feel at risk for confirming a negative stereotype associated with their social identity- their race, gender, ethnicity, social class, sexual orientation and so on. This does not mean the individual has to believe the stereotype; the individual simply needs to know that it exists. The result of stereotype threat is that at a high stakes moments, like an examination, when there is the possibility of confirming a negative stereotype, hyper-vigilance and anxiety about validating that negative stereotype can make the individual vulnerable to underperformance. Research shows that stereotype threat can affect the performance of any individual from any stereotyped group for whom ability is doubted.

Stereotype threat causes vigilance and heightened arousal, impaired self-regulation, and impaired working memory all of which individually or in combination inhibit intellectual performance (Aronson et al, 2013). When an individual is experiencing vigilance and heightened arousal cognitive resources that could be used for the task are tied up in this mental state. Impaired self-regulation refers the state of worry and negative self-talk about one’s ability that, again, detracts from the task at hand and impairs working memory.  Ultimately energy spent on worry, anxiety and vigilance is energy not spent on learning or performing. The long term effect of stereotype can create ongoing performance anxiety and dis-identification. Steele (1997) describes dis-identification as a potential coping mechanism where an individual removes themselves from a domain or identity as a way to alleviate anxiety and preserve self-esteem. For example, a nursing student or medical student who continually experiences stereotype threat may cease to see themselves as a nurse or physician and stop putting effort into this role. As students dis-identify with their view of themselves as a successful students or healthcare professional they are at risk for studying less or ultimately leaving academics.

 Methods:

            IRB approval was obtained from University. Quantitative data were obtained through a 32 item Likert scale survey. The survey was sent to all students in the school of nursing (including nursing and physician assistant students) and the school of medicine (606 students) and the final sample size was 161 students. Chi-square tests and Fisher’s exact test were used to identify associations between the primary dependent variable, risk for experiencing stereotyping, and each potential predictor race/ethnicity, gender, first-generation college student, and socio-economic status). Qualitative data were obtained through 4 focus groups (ranging in size from 4-6 participants) and 5 individual interviews (n=24). Focus group sessions and interviews were audio-recorded and transcribed. Qualitative data were coded using thematic analysis.

Results:

A key finding from the qualitative data indicated: 1) URM students were at greater risk for experiencing stereotype threat than their White counterparts. All URM students were either at moderate or high risk for experiencing stereotype threat. URM students also were more likely to state that they experience anxiety related to an awareness negative stereotypes about the groups with which they identify. Further,  that they believe their anxiety has negatively affected their performance in the academic setting.

            The qualitative data revealed that students have a multi-dimensional identity experiences that are unique, nuanced and complex. The intersection of identities that include experiences of marginalization adds to the burden that students must navigate in the academic setting. Some identities that often contribute to marginalization were explicitly explored. The centrality of identity based anxiety emerged as something that affects a student’s sense of belonging may have an impact on student success. Some students were able to or chose to activate their agency and some were not able to or chose not to. From a sociological perspective the term agency refers to an individual’s ability or capacity to make decisions of their own free will. Agency can be limited by sociological factors such as race/ethnicity, gender, social class, etc. (Barker, 2005). The activation of agencyin this study elucidates the difficult decisions students from marginalized groups must make regarding whether to exert their agency and their unique identities in discussions, classrooms and in their overall academic programs. Student comments that led to this theme included “I am going to show you” or other statements that indicate the opposite of giving up. This can be perceived as defiance by faculty and peers. However it may be a vital component of individual success and ultimately dismantling stereotypes of academic ability of marginalized groups. The other decision students can make is to conform to or comply with institutionalized or stereotyped expectations of social groups. This means they may choose not to speak up in class or in group discussions. This study explores the consequences of activating agency or not activating agency for the individual student as well as the academic institution.

Conclusion:

The overall goal of this study was to transform our academic healthcare organization into an inclusive, empowering and equitable environment that promotes workforce diversity in the health professions, thereby promoting health equity.  Students who participated in this study have contributed courageous insights about their struggles. If faculty members and academic institutions leverage these insights into best practices we have the opportunity promote the success of students who experience marginalization and create learning environments where healthcare students have what they need to reach their full academic potential.