From 2030 to 2060, the United States will experience a demographic "turning point" when the population becomes more ethnically and racially diverse, with a growth expectation in 2060 of 79 million people (Vespa et al., 2020). During this time frame, the non-Hispanic white population will decrease by 20 million, while the white population of Hispanic origin will increase by 22 million (Vespa et al., 2020). Furthermore, people of multiracial origin will experience the fastest growth within the next several decades, with Asian and Hispanic populations following closely behind (Vespa et al., 2020).

In contrast to the growing population diversification, the nursing profession remains predominantly white (Fitzpatrick, 2015; Smiley et al., 2018; Villarruel et al., 2015). Survey results from the National Council of State Boards of Nursing (NCSBN) continue to reveal that only 19 percent of registered nurses (RNs) in the workforce represent a minority population (Smiley et al., 2018). This percentage is virtually unchanged from the previous 2015 National Nursing Workforce Study by the NCSBN, despite increasing minority populations enrolled in undergraduate and graduate nursing programs (American Association of Colleges of Nursing [AACN], 2020; Fitzpatrick, 2015; NCSBN, 2019; Smiley et al., 2018). Perhaps career coaching, mentoring, national task forces, and programmatic pathways are not enough, and the advocacy of nurse educators is necessary to create a more diverse nursing workforce (Fitzpatrick, 2015; Noone et al., 2020; Villarruel et al., 2015).

To create a preferred future for nursing education, nurse educators must also advocate for Deferred Action for Childhood Arrivals (DACA) recipients who help diversify the nursing workforce. However, to advocate for DACA recipients, nurse educators must first become aware of licensure pathways for DACA recipients who graduate from US nursing programs. Thus, the purpose of this research was to explore the lived experiences of DACA recipients who are US nursing program graduates and their pathway to professional licensure.

BACKGROUND

The DACA immigration policy allows individuals who entered the United States as children to defer deportation and become eligible for employment in the United States via a work permit (Napolitano, 2012; US Citizenship and Immigration Service [USCIS], 2018). However, the work permit must be renewed every two years as a pathway to citizenship does not exist for DACA recipients (Napolitano, 2012; USCIS, 2018). Since the policy's inception in 2012, thousands of DACA recipients have become RNs in the United States, directly impacting the diversity of the nursing workforce (New American Economy, 2017; Zegers & Cuellar, 2019). However, DACA recipients' future practice as RNs is based upon their ability to achieve and maintain a professional nursing license (Gonzales et al., 2019; Panjwani, 2019; Zegers & Cuellar, 2019).

A professional nursing license for DACA recipients is contingent on state and federal policies (NCSBN, 2017, 2018, 2019, 2020; Zegers & Cuellar, 2019). Many states exclude DACA recipients from obtaining professional licensure because of their lack of lawful presence (Dussault, 2018; Gonzales et al., 2019; Jauregui & Morse, 2017; Pimienta et al., 2020; USCIS, 2018). Furthermore, the DACA policy was not legislated through Congress and can be repealed by the administration at any time (Duke, 2017; Dussault, 2018; Rodriguez, & Ibarra, 2017; Venkataramani & Tsai, 2017; Zaidi & Kuczewski, 2017). Discontinuation of DACA would discontinue work authorization for DACA recipients, thus depriving the nursing workforce of the DACA recipients who have become RNs (Duke, 2017; NCSBN, 2017, 2018, 2019; Panjwani, 2019; Rodriguez, & Ibarra, 2017; Zaidi & Kuczewski, 2017).

Because of their immigration status, DACA recipients are charged international college tuition rates and are ineligible to receive state or federal aid for college despite their paying state and federal taxes (Dussault, 2018; Gonzales et al., 2019; Hsin & Ortega, 2018). Furthermore, DACA recipients do not qualify for federal service cancelable and low-interest loans to promote diversity in nursing professions (Daw et al., 2018; US Department of Education, 2019). Thus, to diversify the nursing workforce, nurse educators must advocate for policies affirming diverse, underrepresented, and vulnerable populations in nursing, including DACA recipients who graduate from US nursing programs (AACN, 2019; Halstead, 2019; National League for Nursing, n.d.). However, although national nursing organizations support DACA or a similar congressional alternative (AACN, 2017; NAHN, 2019), research is limited regarding DACA recipients in nursing education. In particular, a literature gap existed regarding the pathway to professional licensure for DACA recipients who are US nursing program graduates.

Research that impacts a diverse nursing workforce is vital at this historic moment within the United States. Nurse educators must be aware of the need and the right for marginalized individuals, groups, and communities to tell their stories. The lived experiences of DACA recipients will help lead advocacy efforts to push back against issues of inequity and identity in nursing education. The authors sought to provide, within this study, valid and credible data for nurse educators to begin the process of advocating against hegemonic policies and broader constraints that have intensified nationally. Such advocacy by nurse educators can provide the necessary efforts to transform DACA recipients' lives and contribute to a more diverse nursing workforce (Gonzales et al., 2019; Halstead, 2019; Veltri, 2020; Zegers & Cuellar, 2019).

METHOD

The purpose of this study was to explore the lived experiences of DACA recipients who are US nursing program graduates and their pathways to professional licensure. Through a phenomenological study, the researcher explored, interpreted, and gained an understanding of the phenomenon related to the research question, "What is the lived experience of DACA recipients who are US nursing program graduates and have obtained professional licensure?"

Husserl's descriptive phenomenological approach guided the study; this approach was appropriate for examining an experience that has yet to be identified in the literature (Husserl, 1970; Husserl & Bonnemann, 2011). In Husserlian phenomenology, the participants are viewed as integral to their lived experience, and through active listening, the researcher becomes a coparticipant in thinking about each participant's experience. Furthermore, because the essence of witnessing occurs in the witness's consciousness, by examining the conscious awareness of participants' experiences, the researcher collaborates in cocreating the meaning of the experience as the participants describe it (Husserl, 1970).

Participants were recruited nationally based on current knowledge of the phenomenon, as optimal recruitment methods are not identified in the literature to reach this population (Polit & Beck, 2017). A stepwise recruitment process was designed to protect undocumented participants' identities by separating all other data from contact information. After a full-board institutional review board approval, the researcher recruited a purposive sample via national nursing associations and advocacy groups. These groups included Black Nurses Rock, the National Association of Hispanic Nurses, the Philippine Nurses Association of America, FWD.us, Immigrants Rising, New American Economy, PreHealth Dreamers, TheDream.US, and the National Immigration Law Center.

The researcher ensured that data were collected anonymously by distributing surveys through anonymous links. First, an invitation survey, which contained an embedded recruitment video, was distributed to the organizations mentioned above via websites and social media. Next, consent was implied as informed participants accessed the second anonymous survey to confirm eligibility via the study's inclusion and exclusion criteria. Finally, only participants who met the inclusion criteria were provided a link to a third anonymous survey.

Within the third anonymous survey, the researcher requested a telephone number to schedule a future interview. The requested telephone number was not required to be associated with the participant but merely accessible. Seventeen participants were interviewed based on data saturation and the redundancy of collected data (Colaizzi, 1978; Polit & Beck, 2017). Participants were not compensated for their interviews, as all traceable information was limited to a telephone number within the third anonymized survey. The primary investigator (PI) conducted semistructured telephone interviews guided by an interview tool. Interviews lasted approximately 20 to 60 minutes and were audio-recorded, transcribed verbatim, and analyzed using Colaizzi's methodological process of data analysis.

Following Colaizzi's (1978) process, each interview transcript was read a minimum of three times to obtain a general sense of the content as a whole. The PI and co-investigator independently coded data after each interview into descriptive codes. Topic and analytic coding emerged into themes supported by the data. During the organization of themes, both the PI and the co-investigator continuously referred back to the original transcripts to discuss any discrepancies or contradictions in the findings (Colaizzi, 1978). Direct quotes derived from the data were identified as exemplars of the themes. The PI also reviewed the literature during data analysis, which resulted in no additional findings.

All participants agreed to engage in member checking to provide feedback on the findings. As such, available participants confirmed the findings' dependability through member checking by the PI via telephone contact (Lincoln & Guba, 1985; Polit & Beck, 2017). Lastly, personal record keeping by the PI throughout the data collection and analysis process was part of an audit trail (Colaizzi, 1978; Lincoln & Guba, 1985; Polit & Beck, 2017).

RESULTS

Four overarching themes emerged from the data: pursuing the dream, finding support, figuring it out, and advocating for others. Each theme was described extensively by participants within the interviews.

Pursuing the Dream

Pursuing the dream was not limited to careers in nursing. Instead, participants described a dream of being valued as people and respected as individuals. The professional accomplishment was a means to that end. Mya described professional accomplishment as a means of pursuing the dream of being valued when she said, "As a DACA recipient, I feel like my humanity is always being questioned. But as a nurse, I feel fortunate that I'm able to make therapeutic connections with my patients and that we're able to see humanity in that."

Some described a longtime dream to become nurses. For example, Samantha knew she was going to be a nurse before high school. However, many began their professional pursuit by declaring majors in other respected professions, including medicine, law, business, science, and education. However, once they witnessed the value of humanity and respect for individuals evident in nursing, their dreams changed. Nursing became the only profession they wanted to pursue. To quote Josue, "I don't really have a Plan B because this is what I want to do for the rest of my life. I want to work as a nurse."

Receiving DACA was a pivotal step. Participants often spoke of pursuing their dreams and how being a recipient made the dream of a nursing career possible. Mia verbally illustrated challenges before DACA: "I felt like I was stuck[horizontal ellipsis]it felt like my wings were cut off[horizontal ellipsis]I wanted to do so much, and I knew my potential, but I was unable to do it because of a piece of paper." Gabriella resonated with other participants about the difference after DACA: "I was able to go back to school[horizontal ellipsis]I could still have a chance to fulfill[horizontal ellipsis]my dream of being a nurse." Participants also acknowledged the privilege of becoming DACA recipients and US nursing program graduates. As Jose noted, "Being a registered nurse now in the US is just a huge privilege because it's always been my dream to help others, and DACA has really helped clear that path for me."

Finding Support

Participants identified support as both emotional and financial. Emotional support helped participants combat feelings of fear, discouragement, defeat, and uncertainty to pursue their dream to become a nurse. In addition to personal support systems made up of family and friends, participants described emotional support in the form of encouragement from faculty. Brittany recalled the emotional support offered by a particuclar faculty member: "She would check in with me, asking how I was doing, how my grades were, and she would cheer me up at all times."

Guidance by nursing faculty also pertained to financial support. Mia recalled a time when she almost left nursing school: "The professor was always telling us to reach out and look for resources. Always use all your resources." Participants shared how financial support was critical as DACA recipients are exempt from receiving federal aid to fund their nursing education. Additional means of financial support were found within accelerated bachelor of science in nursing programs, community colleges, and private universities because of lower costs or no out-of-state tuition for DACA recipients. For example, Lola commented, "The state school was three times more [expensive][horizontal ellipsis]and private schools have more scholarships for me." Josh shared, "I was able to get all four years covered through scholarships." Payment plans were also available within private universities. Alba Jean recalled how payment plans helped provide support "because they knew that I was struggling and I had to pay in full every semester."

Support also came from organizations outside higher education and included nursing associations, advocacy groups, and health care systems. Mya described the support she received: "It [organization] provides mentors and scholarships for people that are immigrants and want to become health care providers of some sort or health care workers in the communities that they're from[horizontal ellipsis]and[horizontal ellipsis]set aside money for my NCLEX." Samantha recalled, "I paid[horizontal ellipsis]for my school out of my own pocket and with the help of my hospital." Natalie shared how a health care system offered tuition assistance: "[The system] is great because they offer tuition reimbursement."

Figuring It Out

Figuring it out was characterized by participants as the unknown process by which some states allow DACA recipients to become licensed as RNs. Robert recalled, "It's just very different depending on the state by state." Lola offered: "Many states[horizontal ellipsis] are not inclusive to DACA recipients although we have a work authorization number and a Social Security that allows us to work in the United States legally." Similarly, Alba Jean shared, "I think there are only 10 states where they allow [DACA] nurses to really get a license as a nurse."

Because of the lack of clarity regarding the licensure process, participants had to be proactive. Lola described how "all the information that I have gathered is because I have been actively[horizontal ellipsis]pursuing [licensure] answers." Participants described trying to locate individuals who could answer general questions about the licensure process but concluded that reliable sources were limited. As Mau explained, "The challenge of it all is that there's no one else that you can really ask for[horizontal ellipsis]guidance or advice." Brittany likened the experience to being "thrown in the water and learning how to swim," as she said, "I didn't really have anyone to help me out throughout that whole process." Consequently, as noted by Jose, several participants consulted legal counsel to assist in the process of applying for their nursing license: "There's not much information out there about DACA recipients in the nursing workforce[horizontal ellipsis]I have to go to a legal representative and ask them."

Participants agreed that nurse educators did not provide clarity regarding the licensure process for DACA recipients. As a result, participants were misinformed by nursing faculty that their DACA status disqualified them from applying for RN licensure. Even after her successful licensure, Mia recalled, "They still advise students that they can't become licensed. I have met a couple, and[horizontal ellipsis]I was like no, that's not true. You are able to get licensed." Lola commented that, "with your faculty, as your counselors, their responsibility is to help you out in these situations. Unfortunately, they don't know these things, and we have to come up with the information."

Several participants described how fellow DACA recipients who were licensed nurses helped them figure out the licensure process via social media. For instance, Josue reported how being "part of a group on Facebook, of DACA recipients that want to pursue nursing as a career" helped him with the licensure process. Mia, who read a post on Facebook by a DACA recipient who received licensure, recalled how critical this type of information is: "Because many students are out there looking for answers. They're just waiting to hear about somebody who went and did it so they can continue with theirs [licensure]."

Advocating for Others

Advocating for others was characterized as advocating for other DACA recipients who are US nursing program graduates on their licensure pathway. Samantha described this as, "I'm not a US citizen, I am a female, and I am Mexican - I'm Hispanic a minority[horizontal ellipsis]and I can still achieve things and reach my goals[horizontal ellipsis]. So I can say that if I can do it, you can do it too." Furthermore, Javier explained, "Advocacy kind of went hand in hand with being undocumented and taking care of people; it was a skill that definitely helped and continues to help. Especially being bilingual, you are able to kind of bridge the gap." JP felt an obligation to advocate for others as "it was incumbent on me to do that[horizontal ellipsis]. Because it's not clear cut. Even for the savviest of us."

Advocating for others was also described by participants as writing letters, speaking with legislators, and being interviewed. For example, Lola shared, "Just being involved in my community with different immigrant organizations[horizontal ellipsis]my love for advocacy with the immigrant community, and I've been able to talk to representatives in the legislature[horizontal ellipsis]and share my story." Dulce included advocacy in states where DACA recipients are not eligible to sit for licensure as "the next thing to work on[horizontal ellipsis]and get people to advocate and say yeah, you have a work permit and a Social Security number, you should be able to sit for NCLEX and continue to care for patients in the community."

DISCUSSION

The lived experiences of DACA recipients of US nursing programs and their pathways to professional licensure highlight their ability to pursue their dreams, find support, figure out solutions, and advocate for others. The findings also suggest inequities that require resilience on the part of DACA recipients and indicate that nursing faculty are uninformed regarding the struggles of DACA recipients to become licensed RNs. As such, additional means of support for DACA recipients within higher education and nursing education are necessary as discussed pertaining to each theme.

Pursuing the Dream

The participants' pursuit of professional goals as a means of becoming valued as people and respected as individuals align with Parse's (2014) human becoming paradigm. Thus, despite ambiguity and opposition, goal achievement was transformational. This transformational process was inspired by the value of humanity and respect for others witnessed in nursing.

Finding Support

Veltri (2020) pointed to how DACA recipients have difficulty accessing higher education because of the lack of financial aid and the requirement that they pay out-of-state tuition. For nursing faculty to advocate for in-state tuition may be one element to assist DACA recipients in US nursing programs (Blozen, 2017; US Department of Education, 2015). In addition, designated safe spaces within institutions are necessary so that DACA recipients can feel comfortable self-disclosing immigrant status when seeking out means of support (Johnson et al., 2020; US Department of Education, 2015).

Figuring It Out

Uncertainty remains regarding which states license DACA recipients as RNs (Pimienta et al., 2020; Sofer, 2019; Zegers & Cuellar, 2019). According to Pimienta et al. (2020), 15 states have enacted legislation to allow the professional licensing of DACA recipients, but not all of these policies include the nursing profession. If better informed, nurse educators could identify states where DACA recipients can become licensed as RNs.

Advocating for Others

It is not enough to advise DACA recipients of their ability to take a licensure exam in individual states (Zegers & Cuellar, 2019). Rather, nurse faculty must advocate for legislation to allow DACA graduates of US nursing programs to qualify for professional licensure in every state (Sofer, 2019; Zegers & Cuellar, 2019). The ability for all DACA recipients who are US nursing program graduates to qualify for professional licensure in every state is a matter of social justice (Zegers & Cuellar, 2019). Such advocacy of nurse educators could contribute to a diverse nursing workforce and a diverse nursing faculty workforce.

Limitations

Certain limitations are inherent in any qualitative study, such as human recollection's fallibility (Munhall, 2012; Polit & Beck, 2017). Another limitation of the findings is that both researchers were Caucasian US citizens by birth, and the co-creation of meaning may be undermined by incongruent cultural perspectives. Although the sample was recruited from a national setting, it is unlikely that the data were sufficient to address each state's legislation's impact on the experience. The necessity to protect the identities of a potentially vulnerable sample also limited the methods of information sharing. Because a telephone number was the only traceable contact information, the anonymization of demographic data prevented follow-up with specific participants to clarify individual experiences. Another consequence of limited contact information was that results could not be shared via post or email. Therefore, member checking consisted of telephone discussions about aggregate findings with those who desired to validate the research.

Future Study and Implications

Since the DACA program began in 2012, estimates of DACA recipient physicians' impact on diversity in urban and rural health care settings exist (O'Reilly, 2017; Redford, 2019). However, the extent to which DACA recipients contribute to diversity in the nursing workforce remains unknown. By disaggregating nurses' data from other health care professions, nurse researchers can quantify DACA recipient nurses' contributions and estimate their impact on nursing workforce diversity (Capps et al., 2017; Smiley et al., 2018).

Policies related to nursing licensure for DACA recipients are not well defined in individual states (Gonzales et al., 2019; Jauregui & Morse, 2017; NCSBN, 2017, 2018, 2019, 2020; Pimienta et al., 2020; Zegers & Cuellar, 2019). Further transparency identifying states in which DACA recipients may practice is essential for nurse educators to share with nursing students who are DACA recipients. Additional research may also include the postlicensure experience of DACA recipients who were US nursing program graduates, especially those who may have become nurse educators.

CONCLUSION

The findings of this study underscore the need to understand the lived experiences of DACA recipients who are US nursing program graduates and their professional licensure pathway. DACA recipient nurses can contribute to diversity in both the nursing workforce and the nursing faculty workforce. However, barriers remain because DACA offers no lawful permanent residence in the United States, and individual states' policies exclude DACA recipients from obtaining professional licenses. Such barriers impact the ability of DACA recipients to become nurses. To advance national and state policies that contribute to nursing workforce diversity, it is critical to inform nurse educators about DACA recipients who are US nursing program graduates and their professional licensure pathways.

REFERENCES