Duke’s Nursing School Failed Them. They Say Their Race Played a Role.

Tension between Wen Sun and his instructor had been building for weeks. Then one day in June 2018, while the two worked at the Duke Birthing Center, the instructor snapped at him. “Do you think I want to be here?” she asked, and accused Wen of not appreciating her.

Wen had grown used to this. He appreciated her, he told her. Later that day, she held a door open for Wen, and chided him as she did it. “Your instructor is holding the door for you,” the instructor said, according to Wen. “Maybe you should say ‘thank you’ to her. This is the reason why you will not pass the class.”

Under the buzzing of the fluorescent hospital lights and with racing thoughts, Wen, a second-semester Chinese student in Duke University’s accelerated bachelor of science in nursing program, felt defeated once again. Not long after that moment, he flunked out.

He was not the only one. Two other students of Asian heritage who also failed the program told The Chronicle that instructors in Duke’s School of Nursing treated them unfairly in clinical-nursing courses, the period of their education spent working in hospitals around North Carolina. Wen and one other student were allowed back into the program after semester-long leaves of absence. A third did not re-enroll. The director of International House, a center for international students, recently told an investigator looking into a complaint Wen filed that the school appeared to have “issues with students of Asian heritage” in her experience, according to a Duke investigation.

When The Chronicle contacted the nursing school about these accusations, a spokesman responded by denying any pattern of bias. “The Duke University School of Nursing did not and does not discriminate against students based on their country of origin,” wrote Michael Evans, assistant dean of communications, marketing, and business development for the school, in an email to the Chronicle.

Evans also wrote that the nursing school had undertaken efforts to “support inclusion” in recent years, by creating a diversity office, providing racial-equity training for the faculty and staff, and helping establish a fellowship program for the nursing faculty that focuses on topics that relate to racial identity.

Two months ago, a Duke administrator stepped down from a program in the Duke School of Medicine — which is separate from the nursing school — when her email telling international students to speak English on campus was made public. The Office for Institutional Equity is still investigating that incident.

The nursing students’ allegations suggest that a racial-bias problem at Duke may extend beyond one program.

‘A Cultural Issue’

Wen started the three-semester-long clinical portion of his program in May 2018 at the birthing center, which is part of Duke Health, as the college’s medical system is called. In this portion, nursing students are assigned to work some days at North Carolina hospitals under the supervision of nurses Duke hires as clinical instructors. The clinical requirement is standard for nursing programs across the country and gives practical experience to students preparing to enter the field.

Wen said he was a solid student making high marks in all of his classes. His relationship with his clinical instructor, a registered nurse in North Carolina who led and evaluated six to eight students a term, was tense from the start. Early in the program, his instructor, who is not white, told a group of students that “a white girl stole” her scholarship when she was in school. That comment made Wen uncomfortable, he said, and he asked her not to make derogatory statements like that.

Clinical instructors are active nurses hired by the Duke nursing-school faculty who work in local hospitals, Evans wrote in an email. Duke, which has about 800 students in its nursing school, typically has 35 to 45 clinical instructors working with students each semester, and clinical instructors are supervised by a nursing-school faculty member, he said.

Wen had read an article before moving to the United States — on BuzzFeed, he recalled — that said Chinese people don’t say “thank you” and “sorry,” enough. So he said those words frequently until he was told he said them too much. He never found the balance his instructor desired, he said.

He tried to relate the world he knew, helping his mother in a restaurant in North Carolina, to what he was doing in the clinic. He made sure not to pester people or intrude on their privacy in the hospital.

That timidity, he said, was interpreted as rude indifference and a lack of engagement in his clinical course.

A month into his the course, Wen received a “learning improvement plan,” a remediation program for struggling students, from two Duke faculty members. It listed his failings point by point. Before he got the plan, his clinical instructor had said he wasn’t engaged enough, so he started asking questions. But the plan seemed to take issue with that, docking him for “incessant questioning” of a nurse.

His instructor had also told him early on to show more appreciation to the nurses he was shadowing as part of his program, so he’d sent an email to a nurse who’d helped him. “This is Wen,” he wrote in that email. “I was your student nurse today. It is really nice working with you. And thank you for all your teachings! I am working on my clinical reflection. If you can give me any kind of input, I would really appreciate it! Thank you. Best, Wen Sun.”

But the improvement plan counted that effort against him. Wen was not to contact nurses, and should formally apologize to the nurse he’d emailed, the plan said. (No mention of a no-contact standard exists in the program’s syllabus or student handbook.)

“They told me I should not email the nurse after working hours, and they think it is a cultural issue,” he said. “They said Americans don’t work after hours.”

To succeed in his clinical course, Wen had been grasping at the only professional experience he had: helping his mother, a waitress. That comparison, which he’d made to his clinical instructor, offended her, according to the learning plan, and was counted in the document against Wen.

Wen felt discouraged, depressed, and anxious. He was asked to sign the plan but did not, he said, because he felt attacked and confused about where he went wrong.

The learning plan required that he see a counselor at Duke’s International House. He felt forced to go but also wanted to improve. There, Wen spoke with Lisa Giragosian, the director, according to a report produced by Duke’s Office for Institutional Equity in response to a complaint Wen ultimately filed. She was kind and honest with him, he said.

“Director indicated that it appeared to her that the SON,” or School of Nursing, “had issues with students of Asian heritage,” the report said. “Director indicated that it appeared that the SON referred more students of Asian heritage to the IH than other schools at Duke.”

Giragosian remembered two other Asian students who had been referred to the International House, and that both had expressed “academic concerns,” according to the report.

In Wen’s private meeting, he said, Giragosian suggested he consider transferring to another university because of his problems at the nursing school.

Giragosian did not respond to multiple requests for comment.

Not long after Wen went to the International House, he grew more anxious and depressed. On June 11, 2018, according to the complaint he later filed with the Office for Institutional Equity, he attended the clinical session in which his instructor complained to him about his lack of appreciation. She later followed him out of the room of a patient who had been responsive to his work, he said. “No patient wants you,” she said, walking behind him. “No nurse wants you.”

He was perplexed. The stress, depression, anxiety — the weight of all of it — was too much. He fainted after leaving the clinical session, voluntarily sought help from Duke’s counseling service, and was hospitalized for three days for a stress-induced mental breakdown.

Ten days later, in June 2018, he failed the clinical course and was required to take a leave of absence for a semester, he said. The experience pushed back his graduation, forcing Wen to take out a private loan for living expenses.

That’s when Wen filed his complaint with Duke’s equity office. While he waited for a response, he reached out to Asian students who had graduated from the program. Noel Magtoto, a Filipino student who graduated from the program in December 2017, responded.

Magtoto, now staff nurse at a hospital in San Diego, told The Chronicle he had been hesitant about enrolling at Duke at first — moving from California to a conservative state as an openly gay Asian man. But he had no problems until one day early in the clinical portion of the program.

A professor asked him loudly, in front of his cohort, to take out the stud earring he was wearing, saying it was against nursing policy. Magtoto had read in that year’s student handbook that studs were permitted, so he asked her to clarify. Instead she made an announcement. “She said, ‘It is not OK for guys to wear earrings,’” Magtoto said. “There were only seven guys at the time, and I was the only one wearing earrings, so everyone knew that was directed toward me.”

He was annoyed, he said. Nursing faculty members had told him they wanted to “respect their patient population,” and “avoid preconceived notions.” He said he knew they were trying to stick to conservative ideals, and his earring did not fit that mission.

Magtoto said the professor admitted to having made a mistake about the earring, so he tried to move on. But his relationship with Duke faculty members never recovered. His professor would greet every student around him, he said, giving him the “cold shoulder.” The Duke faculty constantly pushed the importance of confidentiality, but his professor had no problem sharing Magtoto’s hospitalization for a torn muscle without his permission, he said.

Now more than three years removed from his Duke experience, Magtoto said the combination of his sexuality and his race made a student the School of Nursing did not care to understand or cater to. “They try to portray inclusivity in regards to their marketing,” Magtoto said. “In reality, it is much less inclusive and diverse than what they are trying to show.”

In January, Wen got a response to his complaint: “There is not sufficient evidence to establish that” the clinical instructor had “discriminated against” Wen “because of his race, gender, or any other protected class,” according to the report.

Sticking it out through the semester-long leave of absence and re-entering the program was Wen’s only option, he said. He’d made it to Duke, and no matter how he was treated, he was going to leave as a nurse.

‘Lacks Confidence’

An Asian-American woman who attended Duke from 2014 to January 2017 in the school’s nurse-anesthesia master’s program, told The Chronicle a similar story.

The woman, who requested anonymity because she is now applying to other nursing schools and doesn’t want to be perceived as weak, said her grade-point average never dipped below a 3.9 before she entered the Duke clinical portion. Initially, she aimed to be the assertive and confident student the university wanted her to be, but a year into her clinical course, a poor evaluation, obtained by The Chronicle, called her “a bit arrogant.”

Months later, another evaluation included in documents provided to The Chronicle carried the opposite message. It read, “Lacks confidence.” “Lacks confidence and assertiveness.” “Isn’t assertive enough.”

Month after month, she said, she felt thrown in different directions — confused by who she thought her instructors wanted her to be.

She wished she had been more assertive. She said it might have helped her stay in the program, but as a first-generation college student raised by Asian parents, overconfidence wasn’t a personality trait that came naturally.

The learning-improvement plans and complaints kept coming, despite her efforts to improve. She watched as her classmates were given chance after chance for doing the same things that she did or worse, while she was forced to have multiple sit-down meetings with disappointed faculty members and staff, she said.

Already unsure of herself, stressed, and exhausted, she headed to her last rotation in November 2016 at a clinical site on a North Carolina military base. The base police ran a background check and her name — a common name for Asian women — came up with an arrest warrant, she said.

She was taken into custody at the county jail, she said, where she frantically called and texted Duke staff members. They never answered, and she was released 45 minutes after being processed. She found out later that Duke had never contacted the coordinators of the clinical site where she was supposed to work, she said.

She felt ignored, alone, and abandoned. But she pushed on, working 16-hour days without complaint because she didn’t want to make more trouble for herself, as she was still under the careful eye of several supervisors.

Faculty members had given her recommendations as part of her evaluations. She’d followed them. They’d told her to visit the campus counseling center. She did that, too. Eventually, her efforts weren’t enough to satisfy her instructors’ expectations. She was told she’d fail the course if she stayed or withdrew. She appealed the decision. Her appeal was declined through an email.

Facing the leaders of the nursing program, she sat exhausted, juggling the decision of whether to withdraw or take a leave of absence from the university. She never signed the withdrawal form the school presented her, but the school nonetheless counts her as having withdrawn, she says.

She was experiencing serious fatigue as a result of the stress. In the meantime, she’s sitting on an unfinished anaesthesia degree and works as a nurse in a local hospital.

‘I Want to Be a Nurse’

Eric Guo enrolled in Duke’s accelerated bachelor of science in nursing program in January 2018. At first, most of his classes were a breeze. He earned nothing lower than an 89, he said.

Then, in his second semester, in July 2018, he began his clinical course, and everything changed.

Guo’s clinical instructor constantly chided him about his accent, despite his best efforts to become more proficient in English. An evaluation from July 13, 2018, said the language barrier caused frustration for the instructor and Guo, but Guo says he didn’t feel the same way. He wasn’t frustrated.

Guo said his instructor said “too much about” his communication “limitations” and seemed bothered by his questions in his clinical courses.

He expressed concerns about his clinical instructor to faculty members, and he said they “jumped to their conclusions” that he was the one in the wrong. There were communication issues from the start, he said, and faculty and staff members did not like his accent. “My English is not very fluent,” he said, “but no other faculty complained about my communication.”

He said his instructors’ lack of patience put unnecessary stress on him. That anxiety tore into his home life.

In mid-July, he received a learning improvement plan and was sent to the International House, just as Wen had been. On July 23, 2018, he learned that he had failed the course with only two clinical sessions left to go.

He assumed the course was over. But he was notified later that his professor and clinical instructor were waiting for his final evaluation, a report similar to a final exam at the end of a course. He rushed through the two hours he was given, starting the moment he received the email.

At the end of those two hours, his failing status was finalized despite the false hope he’d had as he rushed through his last assignment. He was forced to take a semester-long leave of absence in August, which, like Wen, required him to take out another loan. In early January, he filed a complaint with the Office for Institutional Equity that requested the university investigate whether Chinese students’ failure rate was higher than that of other students in the Duke School of Nursing. Guo has been told an investigation found no basis for a determination that he’d been discriminated against, he says.

Guo returned to the program after his leave of absence and has received high marks from a new clinical instructor evaluating his hospital work, according to documents provided to The Chronicle. The two evaluations make no mention of communication lapses.

Today, Guo is trying to overlook backhanded comments directed at his speech as he continues through the program.

Wen is trying to get past the disheartening response he received in the investigation.

The student who requested anonymity still wants to get the degree and certification she worked for but wasn’t able to finish.

“I want to be a nurse,” Wen said, “and what they say about me and how they feel about me is far from how I am. I want to learn.”

Follow Lily Jackson on Twitter at @lilygjack, or email her at lily.jackson@chronicle.com.

Correction and clarification (3/27/2019, 11:07 a.m.): A previous version of this article stated that Guo had passed an English-fluency test required for admission to Duke. He did not take such a test; his program does not require one. After this article was published, Guo contacted The Chronicle to say that Duke investigators had told him they had found no basis for a finding of discrimination in his case. He had previously said investigators told him there was not enough evidence to merit an investigation. This has been added to the article.

Correction (3/26/2019, 10:25 a.m.): Wen Sun had helped his mother wait tables; he was not employed as a waiter. This article has been updated to reflect that.