BIPOC Nursing Students’ Perceived Barriers to Help-Seeking When under Stress

Achieving diversity in the nursing workforce is dependent upon the success of BIPOC nursing students. Help-seeking is an adaptive process that nursing students can engage in to facilitate success. BIPOC Bachelor of Science in Nursing students construct knowledge about barriers to help-seeking based on their experiences. Method . Tis research was not meant to provide a solution to a specifc social problem but merely to add to the theoretical knowledge about the experiences of baccalaureate BIPOC nursing students with help-seeking when under stress. Terefore, a qualitative descriptive design comprised of semi-structured interviews was implemented. Results . Te lack of BIPOC educators, absence of campus diversity, and perpetuation of microaggressions emerged as themes that describe the barriers to help-seeking when under stress. Conclusion . Te study results indicate the need for ethnic and racial diversity amongst nursing faculty and the need for faculty, staf, and students to engage in professional development programs about implicit bias and microaggressions.


Definition of Terms
Stress occurs as a result of a stressor, which is a stimulus with either a physical or psychological origin. Te stress response occurs as a result of tension caused by the disruption of homeostasis [1]. Te changes that occur as a result of the stress response manifest as physiological or behavioral symptoms. Te term "under stress" is used to describe the state of the experience of the stress response. One can choose to seek help to manage the stress response. Utilization of the term "under stress" allows for the exploration of helpseeking for the underlying cause of the stress and the physiological or psychological response to stress.
Help-seeking is a conscious act of searching for help for a specifc problem. Help-seeking requires the seeker to identify a problem and establish intentions to resolve the problem [2]. For the purpose of this study, help-seeking behavior can be initiated for the experience of stress, the stressor, or both. Te choice to include help-seeking for the experience of stress is to acknowledge that some students may not identify the stressor before engaging in help-seeking.

Introduction
As the human body is exposed to stressors that necessitate mental, emotional, and physical responses, it reciprocates with a stress response [3]. In addition to the stressors of being college students, nursing students who identify as Black, Indigenous, or persons of color (BIPOC) who attend predominately White universities (PWIs) may endure stressors related to their racially marginalized status. Stressors that are specifc to marginalized status are called minority stress. Compared to White students, BIPOC students who attend PWIs are more likely to perceive stressors such as hostility and social isolation [4,5]. Stress associated with the impact of racism on college campuses infuences how some BIPOC students perceive their mental health and their overall perception of their college experience [6,7]. Help-seeking behavior can be initiated for the experience of stress, the stressor, or both. Help-seeking is a conscious act of searching for help for a specifc problem. Help-seeking requires the seeker to identify a problem and establish intentions to resolve the problem [2]. Nursing students are exposed to a multitude of stressors and may use help-seeking to manage stress and stressors. Te purpose of this study was to explore the BIPOC nursing students' perceptions of their experiences with help-seeking when under stress. Understanding cultural infuences on help-seeking attitudes can shed light on BIPOC nursing students' experiences with help-seeking when under stress.
Unfortunately, while stress may be a reason for students to seek help, it is also a primary barrier to help-seeking [8]. Tis study was designed to provide descriptive information about BIPOC nursing students' experiences with helpseeking when under stress. Retention of nursing students is a healthcare priority. Te prediction is that the United States will become more racially and ethnically diverse by 2040 [9]. Te population of Black people in the United States is expected to increase from 13.1% to 14.7% by 2060 [9]. Workforce diversity facilitates the accessibility and afordability of quality healthcare [10]. Te diversity of the nursing workforce begins with diversity in nursing schools. Tirtytwo percent of the enrolled nursing students identifed as coming from a racial or ethnic marginalized background [11]. Of those working as nurses, approximately 23% selfidentify as being from a marginalized racial or ethnic group [12]. Less than 10% of the nurses identify as Black, approximately 9% self-identify as Asian, and less than 5% identify as Hispanic [12]. In the university setting, BIPOC students have a higher perceived stress than those representing the majority population [13]. It is known that racism is experienced on college campuses. Research has also found that racial microaggression can negatively impact emotional health [14]. Tus, retaining racially marginalized nursing students is foundational to increasing a racially diverse workforce.
How BIPOC nursing students manage stressors can impact the successful completion of their nursing program. It is understood that stress negatively interferes with learning [15]. Galbraith et al. [16] found that when nursing students poorly manage stress, it leads to health problems, absenteeism, and attrition. Terefore, managing stress is important for the success of nursing students. Because BIPOC nursing students' college experiences can include their race and ethnicity stressors, so, research indicates that help-seeking behavior can vary by culture [16], and it is important to understand the BIPOC students' experiences with help-seeking to provide a proactive support.

Literature Review
As a way to manage stress, nursing students can engage in help-seeking. However, research has found that acknowledgment of stress was not enough to motivate college students to engage in help-seeking [17]. One of the fndings of a meta-analysis about barriers and facilitators to helpseeking was that attitudes about help-seeking were a dominant infuence of maladaptive help-seeking behaviors [18]. Galbraith et al. [16] posited that nursing students' attitudes toward help-seeking for stress may infuence their helpseeking behaviors. Culture, race, and ethnicity may play a role in the attitudes that BIPOC nursing students have about help-seeking [16]. Barnett et al. [19] proposed that research on African American college students includes the consideration of how culture infuences physical and mental health. When asked about their perception of health, Black students did not separate mental from physical health [19].
Cognitive constructivism, a theoretical framework used in this research, is based on the notion that people construct knowledge through experiences they encounter in their daily lives [20]. Barriers to help-seeking may develop as a result of past experiences with help-seeking. Galbraith et al. [16] reported that study participants developed some of their maladaptive attitudes towards help-seeking when under stress before becoming nursing students, largely from the experiences of their family members. Barriers to helpseeking experienced by BIPOC nursing students included discrimination from staf, peers, and faculty, isolation, and faculty grading bias [21]. Another barrier to help-seeking was BIPOC students' fear of being perceived as being weak as a result of help-seeking [22].
Ahmad and Mushtaq [13] found that BIPOC students had a higher perceived stress than the majority population of nursing students. Discrimination stressors can lead to negative outcomes. Te BIPOC stress framework was used to explore the positive link between race-related stress and high-risk drinking behaviors [23]. A positive relationship was found between depressive symptoms and perceived discrimination [24]. Racial and ethnic microaggression can lead to feelings of isolation in the university setting [25]. Interviewing BIPOC nursing students may uncover if and how racial microaggressions infuence their experiences with help-seeking. Understanding BIPOC students' perceived barriers to help-seeking is an important step toward facilitating help-seeking behaviors.
MWe knows that stress is a response to stressors and that the marginalized students across disciplines may experience stress. Much of the current research regarding stress related to racially marginalized status in college is found outside of the feld of nursing. Te results of this study will add to the body of knowledge in nursing education.
Stress negatively interferes with learning, leading to absenteeism and attrition problems [15,16]. Understanding the BIPOC nursing students' experiences with stress may help with the retention of this population in nursing education. Retention of BIPOC nursing students is a healthcare priority. Diversity in the workforce helps to ensure accessible, afordable, and quality healthcare [26]. Diversity in the nursing workforce begins with diversity in nursing schools. Exploring BIPOC nursing students' experience with stress related to their racially marginalized status may help institutions of higher learning better understand the needs of their BIPOC nursing students and foster conversation about how to meet their needs.

Teoretical Framework.
Piaget's theory of cognitive constructivism was used to explore BIPOC nursing students' perception of perceived barriers to help-seeking when under stress. Cognitive constructivism is an acknowledgment that 2 Nursing Forum individuals' constructions of reality include knowledge that was passed onto them from previous generations [27].
Constructivists view the existence of diversity as normative [27]. Using constructivism as the theoretical framework, constitutions of the reality of the BIPOC nursing students' were explored through their intrapersonal and interpersonal experiences. Constructivism posits that there are multiple representations of reality [28]. Cognitive constructivism was used to explore the construction of the realities related to stress and racially marginalized status.

Methods.
Given that the purpose of this study was to explore the experiences of BIPOC Bachelor of Science in Nursing (BSN) students' experiences of help-seeking when under stress, a qualitative descriptive design was conducted. Qualitative research facilitates an understanding of the complexities of personal and social circumstances [29]. Te results presented in this article are part of a dissertation by Authors Owns [30] that explored the experience of BIPOC BSN students with help-seeking when under stress, and the content presentation partly reproduces the wording of the author. Te data presented in this article include details about the participants' experiences that were not presented in the dissertation. Te research was conducted at a PWI in the Pacifc Northwest region of the United States, and the Institutional Review Board approval was obtained from all sites. Purposive sampling was used to identify the BIPOC Bachelor of Science in Nursing students in their third or fourth program year. Purposive sampling also referred to as judgmental sampling, allows researchers to select a sample of a population based on the subject criteria and the researcher's perceived appropriateness of the subjects [31]. Utilizing thirdand fourth-year students ensured that they were beyond their core courses and actively enrolled in nursing courses.
Ethical considerations were made to protect the participants of the study. Before recruitment, the study was approved by the Institutional Review Boards (IRB) of Capella University and the site of the study. Te IRBs determined that the study would not result in any more harm than the participants would experience in their day-to-day life. Terefore, the benefts of the research would outweigh the potential for harm.
Te participants for the study were recruited from a private university in a large metropolitan area. Te criteria to participate in the study included (a) being actively enrolled in the selected university, (b) being a student in the BSN program, and (c) being self-identifed as a BIPOC. Recruitment occurred between January and April of 2019. Te recruitment email included the description of the study, the researcher's contact information, and the consent form for their review. All of the students who volunteered were accepted into the study.
Face-to-face interviews were conducted with each participant between January and April 2019 and lasted for an average of 30 minutes. Before initiating the interview, the description of the study was explained, and informed consent was obtained. Participants received no incentives to be a part of the study. Semistructured interview questions were feld tested by three independent reviewers before the participant interviews. Te participant interviews were audio-recorded and later transcribed verbatim. An automated transcription application incorporated into the personal Apple computer was utilized. Te researcher manually verifed the interview transcriptions for accuracy by proofreading while listening to the audio recordings. Te data were interpreted using inductive thematic analysis.
Identifying as a BIPOC nurse researcher had the potential to lead to preconceived notions about BIPOC nursing students' experiences with help-seeking when under stress. Te utilization of theoretical frameworks while conducting research can be used to minimize bias by minimizing the selective reporting of the fndings [32]. In this study, the theory of constructivism facilitated the understanding that participants could describe their experiences in a variety of ways, thus reducing the potential for bias that identifying as a BIPOC nurse researcher could have on the study.
Te nature of qualitative research is such that the goal is for saturation of data among participants. Saturation was achieved after 12 participants, and no further recruitment was required. Temes were identifed, coded, and categorized using MaxQDA 2018 (VERBI Software, Berlin). Te identifed themes were then sent to each participant for member checking. A total of six participants completed member checking, thus providing consensus on the fndings.

Results
Te participants consisted of 12 BSN students who selfidentifed as BIPOC, including three Black, three Hispanic, and six Asian students. Tis paper presents the results of two questions from the larger study: (1) "How do you feel your ethnic, racial, and or cultural background infuences how you respond to stress?" and (2) "Describe a situation when you were stressed, and you chose not to seek help." Te original study was conducted to answer the question, "How do BIPOC nursing students describe their experiences with help-seeking when under stress [30]?" Te content of this article was part of a dissertation that discussed the perceived barriers that BIPOC nursing students had to face when seeking for help when under stress. Although this paper was submitted to a preprint server and a repository, copyright permission was not required to reproduce the information contained in this paper. Te participants in the study prioritized help-seeking for academic stress, such as those related to not understanding an assignment or difculty studying for an exam [30]. Te participants felt that seeking help for their academics would relieve their stress [30]. Terefore, the barriers to help-seeking when under stress were often described as help-seeking for academics. Te lack of BIPOC educators, limited diversity on campus, and microaggressions were signifcant barriers to help-seeking.

Lack of BIPOC Educators.
Te study's student participants (SP) reported a lack of educators representing their racial and ethnic backgrounds as a source of stress [30]. Tey discussed the lack of faculty as a barrier to seeking help. A Nursing Forum 3 barrier to help-seeking when under stress is created when those in the educational environment who are most readily available for help are also the ones engaged in perpetuating stereotypes. SP3 asked, "What professors can I go to? Who do I look up to? Do they care?" Tere was a sense of uncertainty about seeking help because the participants wondered if the White professors at the university cared about them. SP3 described the lack of diversity as a primary struggle as a student: "Te only thing I struggle with here that kind of is stressful for me is not having someone else in the program that is similar to me when it comes to my race. I feel like I have no one to connect with." Te student's ability to relate to the person they planned to seek help from was an important factor for the participants in this study. SP10 discussed the impact of the lack of diversity among professors, "We just feel like we cannot seek help from them because we cannot relate to them." Te participants validated their views by providing comparative experiences with BIPOC faculty, staf, and or preceptors outside of the nursing school [30]. SP10 stated, "I have gone to ofce hours more with my Spanish professors than I have with my nursing professors [30]." SP4 expressed a sense of pride and motivation when paired with a BIPOC nurse during one of her professional practice experiences: "My preceptor for this capstone is of Asian descent, and I have never had that. Tat was really eye-opening. And she was a charge nurse too. I was like, wow." SP4 went on to explain that she was just happy to have found "someone to look up to."

Absence of Diversity on Campus.
Barriers to help-seeking related to diversity were not limited to the lack of BIPOC educators. Concerns about interactions with peers also deterred study participants from help-seeking. SP9, when considering seeking help from a non-BIPOC nursing student, felt it would be an added burden to herself because "I do not know if they would understand if I went to them." Te participants described their preference for a campus that included more students from their cultural backgrounds with whom they could relate. However, the lack of diversity leads them to seek commonality among other BIPOC students outside of the nursing program. SP1 stated, "I will ask other students that I know are the frst generation or, like, in the same circle." When discussing performing poorly in school, it was important for students to reach out to those who held similar perceptions of the stress caused by the pressure of BIPOC families. When faced with having to repeat a course, SP1 explained how the lack of diversity in the nursing program caused her to seek emotional support from a non-nursing student with a similar cultural background because "he understands how it would be seen" by her family. SP3 listed up some of the stressors that were understood amongst her peers from similar backgrounds: (a) "Most of our parents are feld workers," (b) "have low income," (c) "fnancial burdens," (d) "not enough scholarship," (e) "family that did not go to high school, or has careers," and (f ) "large families with lots of siblings." Te participants felt that the lack of diversity at the university meant having fewer people who understood how foundational stressors, such as those described by SP3, compounded their academic stress. SP6 states, "People here do not understand what you have gone through and how diferent your life is." Te perception that non-BIPOC students, faculty, and staf would require more explanation as to why they are stressed and in need of help resulted in the participants not engaging in help-seeking behaviors when they were under stress.

Microaggressions and Stereotypes.
Participants also discussed microaggressions by professors that deterred them from seeking help [30]. When recalling an interaction with a White professor, the SP4 expressed frustration, "Oh, I remember in one of my nursing classes, my professor was like, oh, your English is really good. I was like, I do not think so. What was that!" SP7 simply stated, "Tere is no faculty that looks like me. Tat is a bit of a stressor." SP12 described microaggression from teachers that included assumptions that they know something about what is being taught when what is being taught is about their race or culture: "Tey are like, you are Latina, you know this, you are familiar with this." Some of the participants, who identifed as Asian, discussed their frustration with the "model minority" concept. SP2 spoke of stereotypes regarding the intelligence of Asian people, "Tere are defnitely all those Asian stereotypes about being really good in school." SP5, an Asian participant, refected on a time she sought help for an academic situation, and the teacher responded as, "Oh, I did not expect this [30]." She went on to say, "Tat model minority mindset has existed a lot in my life, so much that I feel like I cannot identify as a POC [30].
Microaggressions and stereotypes served as a catalyst for stress and inhibitors for help-seeking. Participants of Asian backgrounds discussed their struggles with the model minority stereotype. Te term model minority was coined in the 1960s and is a stereotype that categorizes Asian Americans as "phenomenally successful" [33]. One of the consequences of the model minority stereotype is that people of Asian descent in America are thought to have the socioeconomic equivalence of White Americans. As a result, Asian Americans are assumed not to experience the difculties of other marginalized groups. Americans of Asian descent are at risk of their disparities being overlooked and excluded from research and policy considerations [34].
Te study participants of Asian backgrounds expressed their belief that when it came to being ofered help, they would be overlooked as a result of the model minority stereotype [30]. When discussing perceptions around helpseeking as an Asian American student, SP11 stated, "We are less likely to receive help from a White professor just because they do not understand our culture [30]." Te SPs felt that their professors did not understand the impact of the intersectionality of their identities on their learning experience. While recalling an attempt at help-seeking, SP5 described feeling ashamed when the professor responded to SP5's request for help by saying, "Oh, I did not expect this [30]." SP2 described knowing that others "bought into that 4 Nursing Forum stereotype" when she overheard comments like, "Oh, of course, she is good at math [30]." Te participants described feeling discomfort even when nothing was said. SP7 stated, "Tere is just general looks and stress and questioning, and wondering, and watching [30]." SP10 expressed how she uses her feelings of frustration with stereotypes of LatinX immigrants being unsuccessful as motivation, "I just want to prove to people that, yeah, my parents came here with nothing. But I was able to make a better life for myself [30]." Tere were discussions from students from all racial backgrounds in the study about being singled out as a representative or a spokesperson for whatever stereotype people had about the group [30]. Black students described the assumption of being African American because of the color of their skin. Te Black students from other ethnic backgrounds expressed frustration with the lack of understanding of the diversity among Black people and felt that it made them think further isolated. SP7 stated, "My family was not born in America. I am not a hyphen [30]." SP9 said, "I do not think African Americans represent me because I feel like I do not identify with their history [30]." Tere was a sense that the negative portrayals and stereotypes about African Americans were placed on all Black people despite their ethnicity. SP7 described how his intelligence was being undermined because he was being compared to "some blackface jigaboo [30]."

Discussion
Te additional stressors that BIPOC nursing students experience due to racism can infuence their perception of barriers to help-seeking. Te results describe the participants' construction of reality about their perceived barriers to help-seeking when under stress based on their experiences with the lack of BIPOC educators, campus diversity, and stereotypes [30]. Educators and university administrators may utilize the results of this study to develop policies and resources that address what BIPOC nursing students see as barriers to help-seeking when they are under stress. Universities should conduct assessments to address perceptions that students have about White professors not being able to understand the impact that the intersectionality of BIPOC nursing students' identities has on their learning experience and help-seeking behavior. It may be prudent to explore the faculty's perception of their ability or preparedness to address the students' needs through an intersectional lens. Diversity, equity, and inclusion (DEI) programs can facilitate the retention and recruitment of faculty from traditionally marginalized backgrounds [35]. University support of programs such as Maximizing Opportunities for Scientifc and Academic Independent Careers (MOSAIC) may help to retain faculty from marginalized backgrounds [35]. MOSAIC is a National Institute of Health (NIH) funded program that supports the mentorship of faculty from postdoctoral researchers to tenure-track faculty positions [36].
As of 2019, only 20% of nurse educators in the United States were non-White [37]. University administrators can evaluate the diversity on their campuses to assess the ratio of BIPOC educators to BIPOC students.
University administrators in nursing programs can utilize the data in this article to help validate their request to recruit nurse educators from underrepresented populations. Another important step is to allocate funding for professional development to educate faculty and staf on how stereotypes, including microaggressions, can infuence the perception of BIPOC nursing students with regard to barriers to help-seeking when they are under stress. Institutions of higher learning provide resources for all students; however, the recommendation is that PWIs ofer resources to support the unique experiences of being a BIPOC student. Te fndings in this study support a previous study that found that Black students needed interpersonal and academic support catered to their unique needs [38]. Academic advisors can utilize the fndings to initiate conversations with BIPOC nursing students regarding the barriers to help-seeking that they are experiencing. Once the barriers are identifed, the advisors can help facilitate the removal of the barriers. Nursing faculty can incorporate the fndings of this research in their classrooms to facilitate inclusive environments.

Study Limitations
Tis study's relatively small group size of 12 participants limits the ability to generalize the results to all BIPOC nursing students [30]. Te fndings do not represent the experiences of all Black, Asian, or Hispanic nursing students. Another limitation is that this study included students from one predominately White university. Students from ethnic and racial minority backgrounds that attend historically Black universities (HBCUs) may have diferent barriers related to help-seeking when under stress.

Conclusion
Lack of diversity in faculty and students, stereotypes, and microaggressions in the university setting can act as barriers to help-seeking. Future studies are needed to further understand the impact of perceived barriers to help-seeking when under stress in BIPOC nursing students. When colleges and universities implement programs to address stereotypes and microaggressions, the efects of such programs should be studied. Research can strengthen what is known about barriers to help-seeking when under stress and interventions to mitigate the barriers. Future study on this topic is important to increase the diversity of the workforce to meet the needs of the population the nurses' care for.

Data Availability
Additional data from the study may be found in the Sigma Teta Tau nursing repository and on ProQuest under the name "Minority Nursing Students' Perception About Helpseeking When Under Stress."

Conflicts of Interest
Te author declares that they have no conficts of interest.
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