Support and Its Impact on the Lived Experiences of African Caribbean Nurses as Students and Practitioners in the British National Health Service (NHS)

Current participation by the children of immigrants in UK nursing education is very low. There are implications for culturally sensitive care delivery and the increasing demographic shift towards an ageing population. Those who arrived during the HMS Windrush period immediately after World War 2 are now beginning to use NHS services more frequently. This paper will provide insights into Black British African Caribbean nurses’ perceptions of support as students and clinical practitioners. It draws on original research, which explored factors, that impact on participation of British African Caribbean people in careers in nursing. The paper is specifically concerned with support which was one of four key findings from the research. UK policy requires that all services, including health services, should reflect the diversity of the communities they serve. This presents opportunities and challenges that need to be explored and addressed, as the UK grapples with increased nursing shortages and low retention rates of qualified staff. The British National Health Service (NHS) has benefited from major contributions of African Caribbean communities who were specifically invited and recruited to help to rebuild the economy and the infrastructure. There is some evidence that Children of the post Windrush era, who were born here, may choose not to participate in nursing as a career because of the experiences of discrimination suffered by their parents and grandparents in the NHS. This paper explores the views of British African Caribbean nursing participants as students and workers, in their own voices. It specifically highlights the role of support in their experiences and its direct impact on their decision making and success with regards to career choices in nursing. It will consider the role that bespoke support can play in enabling successful participation, career building and the implications for nursing education.


Introduction
This paper is based on original research which explored the perceptions and experiences of Black British African Caribbean participants in nursing careers as students and practitioners. The research identified support as one of four key influencing factors in their experiences of schooling in the UK primary, secondary and university education systems and while working as clinical practitioners during their nursing careers. The paper aims to explore through their own voices, their perceptions of support as students and while practicing after qualifying, in an attempt to build successful careers. It will also consider the implications of this for a more integrated NHS workforce.

Background and Literature Review
There is evidence to suggest that people of Black British African Caribbean origins, are under-represented in the NHS as students and as practitioners [1,2]. This has implications for a diverse representation in the NHS workforce, which is expected by government policy to be representative of the communities that it serves [3,4]. There are also implications for service provision for the increasing numbers of Black African Caribbean senior citizens from the Windrush era, who are now beginning to use NHS services in greater numbers and more frequently [5]. The evidence of low representation and participation spans a period of over two decades, and was originally identified by Baxter [1] as making black nurses an endangered species in the NHS. Baxter's research identified that they may be discouraged from joining the profession because of the negative experiences of their parents and grandparents, who serviced the NHS during its post Windrush period. In addition she argued that they are also being actively discouraged by their families from choosing nursing as a career.
The numbers of people of British born African Caribbean origins being accepted for training has indeed diminished (Nursing and Midwifery Admissions Council (NMAS) 2004-2007), University and Colleges Admissions Services (UCAS, 2008(UCAS, -2012. However, applications to join the profession have consistently increased even though their acceptance rates continue to be quite low when compared to white and black African applicants [2]. Black British African Caribbean people who are born in the UK with their only experience of education being in the British Education system ought to be able to navigate education systems effectively and successfully. However, it is well known that this is not the case [6,7]. The implications for successful career choices and social integration may be problematic. In relation nursing careers, the search for answers is an important requirement when planning for service delivery needs of the community, and specifically of Black Caribbean seniors.
For this research, the choice of mixed methods provided an opportunity to explore the issues from a variety of perspectives enabling a much more in-depth consideration.

Ethical and Other Issues
Work which involves the use of children and young people requires sensitivity and has to be conducted within the remits of the relevant United Kingdom (UK) legislation regarding contact with minors (DH, 1989, DBS, 2012). Even though any contact with school-aged participants for this research would only always be in the presence of parents and/ or members of the school staffing body, the requirement remained essential, and the researcher had to confirm that the criteria for safeguarding children had been met by presenting evidence of a Criminal Records Bureau (CRB) check, now reconfigured as the Disclosure and Barring Services (DBS).

Study Design and Sampling
Recruiting participants for the research was aided by the use of purposive sampling in order to ensure that there was appropriate availability of required participants for each stage of the process. This allows for aspects of random sampling, on a self-selecting basis, also typically known as opportunistic sampling, with its own set of benefits and possible problems to the process.
Community newspapers, word of mouth, community organisations such as local churches and popular independent websites which serve the black community were all utilised. Contact was then made with those who responded, initially by telephone, then by face to face meetings for the interviews, or through the schools for administering of questionnaires. Data was collected in three phases through a pilot study, questionnaires, and interviews.

Findings and Discussion
Support and its impact on experiences in education and clinical practice emerged as one of four main research themes from respondents. It was identified as the key requirement throughout their experiences while at school, during their decision making for career choice, while studying on a nursing program and as a qualified practitioner in clinical practice. The role of support in enabling them to make appropriate career choices and to progress uneventfully provides a major link to enable successful navigation of educational institutions and the NHS workplace. Respondents identified strong support from parents, family, peers and community (emotional and educational). Tutorial/ pastoral guidance, learning support and help throughout their studies (institutional support) from all educational settings were problematic.

Parental and Family-Emotional Support
Parental, family, peers and community support included emotional social and learning support, careers guidance, encouragement to persevere with their choice of nursing as a career, despite major challenges and obstacles in some cases. It was clear that without support at a variety of levels, participants felt severely disadvantaged, especially while on a program of study. Support was also a major contributor in sustaining resilience discussed elsewhere. The literature identifies a lack of support for Black students in HE for those who successfully finish their degrees, and also for blacks in the workplace. Furthermore, the NHS workplace has consistently emerged as one where BME's experience racist actions from colleagues and patients. Being unable to access support in the form of parental emotional, moral, financial technical, school and university support with a culturally sensitive approach forms a key barrier to a successful HE outcome for black students, not just here in the UK, but also in the USA.

ARCHIVOS DE MEDICINA ISSN 1698-9465
Journal of Healthcare Communications ISSN 2472-1654 All interviewees identified the importance of their parental and family support starting from their experiences at school through to decision making about nursing as a career choice, as nursing students in HE and eventual practitioners, for those who successfully completed. One participant described parental support and encouragement provided throughout the whole of her schooling, even though her mother's working schedule in the NHS meant this was very difficult.

'Mum had to do night duty but … ….she paid a black lady to help me and my brother with my maths and other subjects….'
This participant's response highlighted a school system which is unsupportive to the extent of having to warn her child not to tell the teachers at school that they were having extra lessons from a paid tutor. Some white parents, who can afford to, regularly pay for additional lessons from paid tutors, for their children.
That this appears to be seen as a negative factor which works against the best interests of black children did not go unnoticed by parents and their children, as this participant comments: 'Mum warned us not to tell the teachers about the lady who was helping us…..said they would say that she is confusing us…but one day the…. teacher noticed how well we were doing and asked ..Who is helping you with the work?? I did not answer him….. pretended I didn't hear…..' One participant chose to attend a university near her home so she could stay close to her parents while studying nursing. Having easy access to their continued support was an important factor in her choice: 'I did not want to be too far away from my parents… so I chose somewhere close by…still had to travel.. but it was close enough for me to go home at weekends'…..
As the only black student in her nursing degree cohort, she felt isolated and alone. This was not an expectation she had anticipated and it came as a shock to her. This made getting back to her parents at weekends all the more imperative, for emotional support.
'….It was great going off to uni….but I got a shock really….when I went to classes for the first time…..there were fifteen of us on this degree program and erm..I was the only black student on it……' The comments of the above participant reinforced the issue of the impact of ethnic density on personal experiences and of its potential to provide support with the ability to cope in education, or in the workplace. Ethnic density is described as an asset which enables support that promotes health, wellbeing and encourages coping strategies that help to act as a buffer against racism and discrimination. However, the image of urban conurbations with high numbers of BME people is considered problematic because of the possibilities of high poverty levels and of being stigmatised as having a greater criminal tendency. As a result people are usually willing to move away from the stigma of such communities, even where theirs may not be typical of the negative social construct.
Ethnic density is therefore problematic for white people, who move away from those environments as soon as they are able to afford to do so. While it may be positive for black people, they are also stigmatised by the perceptions which come from living in such an environment. Additionally, ethnic density in an educational setting also identifies an institution with lower level qualifications and large numbers of black students. Similar to the schools system they are not the places that white people may wish to educate their children. Black British African Caribbean people may be better supported in areas of higher ethnic density, but if they wish to become progressive, this usually means having to move out of those areas into more middle class environments where ethnic density is much less obvious. So although Munshi et al. identify positive effects on mental health, there are other issues which also come into play when considering the overall effects of living in communities with high ethnic density. However, its potential to provide support cannot be denied, as the above participant identified.
For another interviewee, the support from her family included her grandmother who was a retired nurse. Her grandmother was instrumental in helping this participant to choose the profession by supporting her with child care help while she was a student.
"My Nan…she would say….you can do it…. don't worry about them and their racist ways…..it is not all about them you know…. you will make a very good nurse".
This respondent identified a close family member, a former registered nurse (RN), but retired, who actively ensured that she could stay on a programme of nursing and successfully complete and qualify. As with other respondents in this research, this finding indicates a shift from previous research findings which identified that Black British African Caribbean people are discouraged by their families from choosing nursing as a career [1].

Peers and Friends (Social Support)-Community Factor
Having the support of their peers and friends was crucial both at school, in university and as a practitioner. Where this was weak, for example, being the only black person in a cohort, challenges were more marked. In primary school environments where there was a marked ethnic density, this support was strongest. However, for those who got places in grammar schools, this was problematic. Many participants however had friends who were white in those settings, but felt that teachers applied differential treatment which tended to weaken the links with white students who were from their neighbourhood and had also won places in the grammar school setting. Despite this attitude from a white teacher, both girls remained friends and went on to a career in nursing together. The respondent identified the teacher as constantly trying to keep them apart throughout their years at grammar school.
"…..…she was always trying to split us up… you know…didn't like it that we were friends…".
Social and community support has always featured as an important helping factor to the achievement of black children and still perhaps represent black parents' lack of confidence with the British schools system with its potential to deliver negative outcomes for their children. Supplementary schooling in the black community is widely documented and is still regularly provided by the voluntary sector and by many black churches at nominal costs or for free [6,8].

Schools, University and Learning Support (Institutional Factor)
Participants identified very weak or absent support from schools, even given the fact they would be considered as children who were motivated, and who consistently worked hard and did well.
The school responses to them as black students appeared to reflect longstanding stereotypical perceptions about their ability, despite evidence which identifies some of them as outperforming, namely girls [6]. This does not go unnoticed by black children at school as this participant commented: "……The teachers were not interested in us at all…..there was a lot of us…black children……and…well… teachers were just going through the motions….. it was a sort of a sink school…. you know what I mean…they did not expect us to get very far really…so…. everyone was just doing their jobs….couldn't care less about us…." The evidence about low teacher expectations and its impact on the achievement of African Caribbean children and young people is previously identified in the literature and discussed earlier [6]. It is articulated by the above interviewee, who showed clear awareness of negative teacher attitudes towards black children in the school, and its impact on their perceptions. Black Caribbean children felt marginalised as the comment below shows: These perceptions continued to feed into low expectations of black children, regardless of how well or how badly they may be performing in the schools system. The erosion to selfesteem remained a continuous and pervasive factor in school life experiences. This was also mentioned by the head teacher of school A, who stated that the aim of his school was to redress the issue of low self-esteem, among black children, which the parents reported to him. However, some parents refused to believe that English schools would discriminate, and tended to believe what teachers told them about their children's behaviour and achievement in school. This is reflective of the way parents behaved in the Caribbean, where the teacher always had the last word and parents trusted them totally both with the children's learning and discipline [6]. This was reflected in the feedback from a participant as follows: 'My mum… well, she was from the old school… you know….she thought teachers knew best… that's the old Caribbean way I hear… parents trust teachers in the Caribbean…... so I was on my own really against white teachers…..but to be fair to my mum….
she did not really know or understand the system..here… you know….she trusted them' Support or the lack of it in this case, remained a recurring issue for participants in HE. Its absence was a factor, which led to the attrition of some of them, and to continuous challenges for all, throughout their educational and clinical experiences as students and practitioners. Yet all HE environments have structured support systems in place to support all students, so the question which needs exploring is why these support systems are apparently not as successful for black students. There is clearly much more at play either overtly or covertly, which has direct impact on retention and attrition for black students [2,6]. One participant commented as follows: She clearly did not expect to be isolated, expressing concerns about this and its effect on her, and about the attitude of the lecturer who had been allocated as her personal tutor. The student's perception that being the only black person on this degree was problematic for her is an issue which is considered in the literature. Ethnic density implies that having similar members of one's group in close proximity has the potential of enhancing coping skills and may have a positive impact on mental health. The extent to which this is could be effective is perhaps dependent on individual's own perceptions, since it is likely that there have been many other examples of black students being the only one in their cohort in many HE institutions across the country. The evidence is yet to emerge about the full effects of this on their mental health and coping strategies. However Picket and Wilkinson argues that there are advantages of ethnic density in health care outcomes. Others contend that there are likely to be other factors at play, which contribute to the way BME individuals, navigate their way around health and education systems where they are clearly minorities in more than one sense of the word. Ethnic density could perhaps become a contributory positive factor for some BME students in HE, but this needs to

ARCHIVOS DE MEDICINA ISSN 1698-9465
Journal of Healthcare Communications ISSN 2472-1654 be further explored and researched, especially in the context of earlier discussion where high density of BME students in some institutions may be related to the quality of educational outcomes and the type of institution, and may not be perceived by white people to be providing high quality education for their children if there are large numbers of black students. The same is equally true where they live in environments where there are large numbers of black people. As previously discussed, these are not considered to be the best places to live. They tend to be in large cities in deprived areas where poverty and crime are common. For this student, however, it is clear that she was deeply negatively affected by being isolated.
When asked what she did about the situation, this was her response: "..It was hard….I tried to get support elsewhere…not easy… you can't be seen to complain…… You know if you ever go to anybody to complain that's your career done….just like mine was, and I did complain…big mistake".
Being close enough to home meant that she could get support from her mum, family and community. She was unable to resolve the situation on her program, although she made efforts to take action. Leaving the nursing program at the time and going on to achieve a first class honours degree in business was considered to be her best options at the time, in the context of her mother's observation.

"My mum… she would say…. You have Biology…Maths…English at A level… what's going on?? Don't let them tell you what you can or cannot do… but I was on my own there and it was too much for me to deal with alone."
The effects of isolation on her experience made her determined that she would become a much more proactive parent than her own parents were while she was at university, as she commented: "…I would make sure my child does not go somewhere where they would be the only black person on a program…..I would not discourage them from choosing nursing… but I would help them choose a university with a good mix".
The role of support is discussed widely in the literature [9]. It is not surprising that it emerged as a key feature of coping strategies of black British African Caribbean children, young people and adults throughout the education system at school, at university while studying to be a nurse, and as qualified practitioners working and trying to establish a career. The support came in a variety of forms and could be emotional, physical, social and financial. Emotional support emerged as important in reinforcing the abilities of participants.
Some argue whether student support is really necessary or merely self-indulgence. However, support as identified in this research enabled black students to keep focused, make decisions about their career, persevere with their studies despite the multiplicity of issues, and black adults needed this in their efforts to build a nursing career after qualifying, in the face of challenging circumstances and continuous risks to their practice.
Recognising and adopting institutional support which takes into account the limitations of social, cultural and human capital from an institutional perspective could ensure the provision of structured mentoring which is culturally sensitive and relevant to the needs of BBAC individuals in HE. For example, black academics in HE are reported as under-represented, and also facing continued racism, discrimination and lack of promotion. Yet their visible presence could have the potential of strengthening black British African Caribbean people's resilience and motivation, which they develop in response to the stressful experiences of unfairness, discrimination and racism [9,10]. Institutional support is already a feature of other professional qualification structures in some settings. An example is social work, where a toolkit is used to provide a bespoke mentoring support scheme for Black students. It is proposed that similar bespoke schemes for Black British African Caribbean Nursing students where and if they already exist should be evaluated and disseminated and if they do not exist, that HE institutions consider introducing these as a standard part of their provision.

Limitations
It is acknowledged that where small samples have been utilised in research, findings should be interpreted with caution, however, it is also possible that the outcomes may be similar if applied to a larger population, given the evidence from the literature relating to racism and discrimination.
Additionally, new insights have emerged, which identify that with appropriate support, Black Caribbean people are able to participate effectively at all levels of the education system and as clinical practitioners, and build strong NHS careers evidenced by present NHS, BME pioneers [11].

Implications for Nursing Education
Mentoring programmes provided by some educational institutions to support BMEs students in Social Work and other programmes of Higher Education have been a positive and responsive way forward by some HE providers. Frameworks for support require focus and commitment across all HE institutions if consistency is to be achieved, and requires attention to more bespoke ways of ensuring successful completion. There have been efforts made to address this by some HE institutions and other disciplines, with supporting funding from the Higher Education Academy (HEA). Support programmes must recognise the need for Black British African Caribbean students to be able to have the opportunity to engage with a culture sensitive approach to their support needs in HE. This has to be done in a manner which does not expose them to further stigma as having or being given special treatment, hence continuing the stereotype of 'underachiever and unable to cope'. From the participants in this research, many black British African Caribbean students who enter the Higher Education system do so with excellent Ordinary and Advanced level (O and A Level) grades.
There is no evidence that black students are major beneficiaries of the widening participation scheme generally or in nursing education specifically. Moreover, access to nursing degrees in Entry qualifications for the recently new development of graduate nursing [3], continue to be determined locally by each educational provider. The possible impact of graduate provision on selection and retention to enable successful completion cannot be ignored. It was identified some time ago that there was a clear need for education providers to take into account the long history of underachievement of Black British African Caribbean children and young people and make allowances for this problem [1,10]. However there is potential for it to further add to the burden of the Black British African Caribbean experience of being stereotyped and stigmatised into and out of roles at the whim of others [9,12].
Improving the study experience is a key agenda, which will ultimately affect funding streams for courses. It is possible that this emphasis will force a new awareness of the responsibility of institutions to ensure that they are contributing to an inclusive approach by addressing issues of recruitment, selection, attrition and successful completion of all students, including BBAC students, given their particular circumstances as reported in the literature. The Higher Education Academy (HEA) currently offers funding to individual academics who may wish to explore and develop support packages that will support BME students. HE institutions that participate could eventually become recognised as centres of good practice in terms of ensuring that BBAC students who join their institution are supported to successfully complete with a good study experience that recognises and builds on their strengths rather than emphasises and exaggerates their weaknesses.

Conclusion
The creation and maintenance of independent black institutions is a critical structural precondition for meeting black needs, particularly in providing education and support to families…….. especially the young…..".
African Caribbean families have a long history of taking action to improve their children's education and continue to do so [8]. The black supplementary school movement has been instrumental in providing resistance and support for black Caribbean children and young people with their educational goals. Support was endorsed and strengthened by the black voluntary sector, and black churches. Andrews [8] argues that the supplementary school movement lost its ideology and focus, initially based within the context of resisting racism in education and not merely on teaching children how to pass exams, although that was an acceptable and desirable outcome. The loss of that approach may have been responsible for its apparent gradual loss of influence on main stream education. Although The UK has seen a very small rise in the number of black nurses who have been supported to break through the academic glass ceiling [13], there is much more work to be done. Structured, consistent support continues to be a key factor at all stages in enabling educational, academic and professional progress for a successful nursing career. From the findings of this study, this is provided mainly by parents, family, friends and peers. This has, however, been identified as problematic in schools, universities and in clinical practice where, the level of support needed by black Caribbean participants to survive and thrive is at its weakest, and is nonexistent in some settings. Further research is required, to enable a better understanding of the underlying factors which drive perceptions towards black Caribbean students and practitioners in the NHS.