Outcome Measures for Traditional and

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1 Nursing Education Perspectives Outcome Measures for Traditional and Accelerated Nursing Graduates: An Integrative Literature Review Leslie K. Payne and Patricia Mullen doi: / Abstract aim The purpose of this article is to examine research studies that compared outcome measures of students/graduates of traditional and accelerated BSN programs. background Accelerated postgraduate baccalaureate nursing programs are popular. It is important to compare outcome measures and explore equivalence between traditional and accelerated programs. method Peer-reviewed research articles published within the last six years were identified in ERIC, CINAHL, and MEDLINE. results Seven research studies involving 1,159 traditional students and 576 accelerated students were included in this review. conclusion Findings indicate that although there were some statistically significant differences in outcomes between groups, research methodologies used in several of the studies were not ideal. Future research needs to be geared toward practice pattern differences between the two groups as well as research exploring evaluation methods. Accelerated postgraduate bachelor of science in nursing (ABSN) programs for students who have obtained a bachelor s degree in another field have been in existence in the United States since Most ABSN programs require students to attend school full time and are typically between 12 and 18 months in duration (American Association of Colleges of Nursing, 2005; Beal, 2007). ABSN students complete the required BSN essentials in about half the time of their traditional counterparts. Therefore, ABSN programs are founded on the recognition that students with degrees can be successful in a demanding program and tend to be more motivated than their traditional counterparts (Mullen, 2007; Seldomridge & DiBartolo, 2005; Siler, DeBasio, & Roberts, 2008; Suliman, 2006). Predictors of successful completion of an accelerated program are well documented (Abbott, Schwartz, Hercinger, Miller, & Foyt, 2008; Carty, Moss, Al-Zayyer, Kowitlawakul, & Arietti, 2007; Stuenkel, Nelson, Malloy, & Cohen, 2011). Research geared toward learning strategies (Hegge & Larson, 2008; Mullen, 2007; Suliman, 2006) and preferred teaching methods of accelerated students (Kemsley, McCausland, Feigenbaum, & Riegle, 2011; Lekan, Corazzini, Gilliss, & Bailey, 2011; Walker et al., 2007) has also been published. However, a paucity of research focuses on differences in outcome measures between graduates of accelerated programs and traditional BSN graduates. As educational pedagogies in accelerated programs change based on research, it is important to examine differences in outcome measures and explore equivalence between traditional and accelerated programs. METHOD The articles for the current integrated literature review were identified through the electronic database search engines of CINAHL, ERIC, and MEDLINE. Peer-reviewed research articles published within the last six years were targeted. The key search terms were accelerated nursing program, accelerated baccalaureate, second-degree baccalaureate, and accelerated nursing graduates. This search resulted in 51 citations. The results from the search were further screened with inclusion and exclusion criteria. The inclusion criteria for this review were research studies comparing outcome measures, programs based in the United States, those that were peer-reviewed, were written in English, and were postgraduate BSN programs (not simply accelerated programs). The exclusion criteria were dissertations, demographic-only research (no outcome measures), studies outside the United Sates, and commentaries on research studies. Of the 51 articles, 30 were not outcomes-focused, 7 were duplicated citations, 4 did not deal with accelerated programs, 2 were descriptive 238 july/august 2014

2 Traditional/Accelerated Nursing Graduates studies of graduates (not comparisons of the two groups), and 1 study was based in Canada. The remaining seven studies met the inclusion and exclusion criteria. RESULTS A total of 1,159 traditional students and 576 accelerated students were included in this body of research (Table 1). For this article, the included studies were sorted according to the type or classification of outcome researched. Based on the results, the outcome measures were divided into four categories: a) academic achievement, b) transition to professional role, c) clinical competencies, and d) employment characteristics (Table 2). Academic Achievement Three of the seven articles included a comparison of academic achievement between groups (Aktan et al., 2009; Bentley, 2006; Korvick, Wisener, Loftis, & Williamson, 2008). These included a grade point average (GPA) score in the major, a National Council Licensure Examination (NCLEX ) pass rate, Health Education Systems Inc. (HESI) scores (both specialty and exit), specific course grades, and a nationally normed examination. Aktan et al. used an outcomes model of program evaluation to compare outcomes of 33 traditional and 43 accelerated graduates of a single institution between 1991 and Although the outcomes had been incorporated into the institution s yearly evaluation, no comparison was made between the two programs. The students completed a survey that was used to compare self-reported NCLEX pass results, the number of times needed to pass, and major GPA score. Various professionalism outcomes (committee service, certifications, membership in professional organizations, and graduate study) pertaining to the transition to the professional role were also compared. The researchers found no statistical difference in professional outcomes or the self-reported NCLEX examination information; however, the accelerated group had a significantly higher reported GPA in the major when compared with the traditional students (t = 242, p = 0.00) (Aktan et al.). Although the authors suppose that major intrainstitutional differences between accelerated and traditional programs are not evident, they do not attempt to explain the difference in GPAs. Korvick et al. (2008) wanted to directly compare accelerated and traditional students to determine whether any academic differences were present. They compared the academic performances of 32 traditional and 29 accelerated students enrolled in an identical course within the same semester. The researchers compared total points earned on five examinations and clinical applications (quizzes reflecting laboratory skills) between the groups. The average of total points earned was 86 percent (SD = 3.7) for the traditional group and 91 percent (SD = 3.1) for the accelerated group. Results demonstrated that the accelerated students performed statistically better than their traditional counterparts (t = 4.95, p = <.05) (Korvick et al.). Although the researchers looked at the GPAs of prenursing students and found no statistical differences, this study may have been strengthened by comparing the actual GPAs in nursing courses between the two groups. To explore faculty perceptions, Bentley (2006) developed a retrospective correlational study to determine whether a difference was present between traditional and accelerated students in select academic variables and NCLEX performances. Although the faculty at their institution anecdotally believed that the accelerated students were academically superior, research did not validate this belief, and no significant difference (no statistical values given) in science GPAs was seen between the two cohorts. A convenience sample of 224 student (172 traditional and 52 accelerated) graduates between the years 2000 and 2004 was used in this study. Although this study explored science GPA as a factor or predictor of educational success, the educational outcome variables were the number of C, D, and F grades in nursing courses, HESI specialty assessment examination scores (administered after individual courses), and the HESI exit examination (administered at the end of the program). This study also explored predictors of success on the NCLEX examination; however, an individualized model was not created for each program (traditional/accelerated); rather, the models created combined both programs. Concerning outcome variables, the Bentley (2006) study found that the accelerated students performed significantly better on the psychiatric (t = 3.394, p <.001), pediatric (F 1,219 = 20.16, p =.000), and exit HESI (F 1,219 = 9.589, p =.002) tests. The accelerated students also had significantly fewer Cs in courses (t = , p = <.001). Although the accelerated students did have a higher NCLEX pass rate, it was not statistically significant (χ 2 = 0.346, p =.388). Scores on all of the HESI examinations (maternity [r = 0.205, p =.005], medical-surgical [r = 0.211, p =.007], psychiatric [r = 0.181, p =.017], pediatric [r = 0.205, p =.005], and exit [r = 0.274, p =.006]) were correlated with passing the NCLEX in the traditional group; by contrast, only the exit (r = 0.419, p =.002) and medical-surgical (r = 0.292, p =.036) specialty HESI tests were correlated with a NCLEX pass rate among students in the accelerated group. Bentley (2006) created a model to test the effect of the exit HESI, number of Cs, and science GPA on the NCLEX pass rate; scores on specialty HESI examinations were subgroups of the exit examination and were intentionally omitted from the model. The model, with three variables, resulted in an R 2 of (F = 8.947, p =.000); only the exit HESI significantly contributed toward the prediction of success on the NCLEX. To explore predictors that could be influenced throughout the course of study (the exit examination was administered at the end of the program), a second, more restrictive model was created with only the number of C s and the science GPA. It resulted in an R 2 change of and an F change of Both the number of C s (t , p = 0.12) and the science GPA (t 2.158, p = 0.32) were found to be significant predictors of passing the NCLEX. The Bentley (2006) study could have been strengthened by providing the GPAs on nursing courses as well as the science GPAs (prerequisite) as it was stated that the Volume 35 Number 4 239

3 Nursing Education Perspectives Table 1: Summary of Literature Review Findings Article Method N Outcomes Significant Results Tool Limitations Aktan et al. (2009) Descriptive 33 traditional 40 accelerated NCLEX pass rate GPA Hours worked per week Serves on committee Professional certification Role transition Higher GPAs in accelerated Self-designed 20-question survey Self-report Bentley (2006) Retrospective correlational 172 traditional 52 accelerated HESI specialty scores HESI exit exams Clinical course grades NCLEX pass rates Number of C, D, F grades in nursing courses Psychiatric, pediatric and exit HESI Fewer Cs in accelerated No specific number of Cs presented Brewer et al. (2009) Cross-sectional 691 traditional 309 accelerated Attitudes toward work Intent to stay in job Income Searching for job Job title Job title Higher yearly income and hours worked in accelerated Longitudinal panel design Response bias No tool validation presented Korvick et al. (2008) Retrospective quasiexperimental 32 traditional 29 accelerated Class examinations Higher exam scores in accelerated Accelerated students had stiffer requirements for admission Oermann, Alvarez et al. (2010) Descriptive study 28 traditional 11 accelerated Performance Confidence Job satisfaction None Web-based survey Likert scale Self-report No Cronbach s alpha Oermann, Poole- Dawkins et al. (2010) Focus groups 96 traditional 42 accelerated Confidence Adequacy of educational preparation Readiness to practice Clinical skills Focus groups Small sample size One institution Rafferty & Lindell (2011) Surveyed managers 107 traditional 93 accelerated Leadership Critical care Teaching/collabora-tion Planning/evaluation Communication Professional development Schwirian s Six-Dimension Scale of Nursing Performance, modified Anonymous survey Note. GPA = grade point average. study was interested in differences in academic achievement in nursing schools. The removal of HESI specialty examinations in the predictive model was seen as a weakness. Although all of the specialty examinations were correlated to NCLEX success in the traditional students, this was not true in the accelerated student group. It may also have been beneficial for the authors to complete the predictive models for each cohort in addition to the combination of the two programs to provide insights on potential differences in predictors. Transition to Professional Role Oermann, Poole-Dawkins, Alvarez, Foster, and O Sullivan (2010) were interested in exploring the difference in the transitions of traditional and accelerated students into the professional nursing role. Specifically, the researchers were interested in the perceptions of managers about new graduates readiness to practice, transition to the professional role, and progression through orientation within one hospital system. The system had hired 240 july/august 2014

4 Traditional/Accelerated Nursing Graduates 96 traditional and 42 accelerated graduates within the last 18 months. The researchers queried nurse managers through focus groups about the readiness of these graduates to begin practice. The managers in this study perceived that new graduates, of either a traditional or accelerated program, lacked the clinical education for adequate independent patient care. They also implied that students in an accelerated program lacked the essential amount of time to process clinical experiences and develop the art of nursing. The authors suggested that including more simulation during their educational experience might help counteract this deficit. According to these focus groups (Oermann, Poole-Dawkins et al., 2010), students in the accelerated programs tended to transition into the new role more quickly than their traditional counterparts. However, both traditional and accelerated graduates were similarly acclimated to the new role by the end of the first year. Differences, if any, were thought to be due to generational differences. In summary, this qualitative study found that both the traditional and accelerated graduates were not educationally prepared for practice, and that accelerated students transitioned to their new role more readily, and both groups progressed similarly through their first year of clinical practice. The researchers acknowledge that this study was limited due to the research design (focus groups) and the fact that each focus group met only once. In addition, several managers chose to not participate. Oermann, Alvarez, O Sullivan, and Foster (2010) explored differences between accelerated and traditional graduates in performance, job satisfaction, and transition into their new professional role. This descriptive study surveyed 28 traditional and 11 accelerated new graduates, orienting within a specific health care system, about their perceptions of their own job performance, confidence, and satisfaction. The 39 participants completed an online survey developed by the researchers following orientation and then again after one year of employment. Table 2: Outcome Categories Category Academic Achievement The surveys were composed on a Likert scale and consisted of three sections: leadership, job satisfaction, and work demographics. Although the study found that graduates did not see themselves as competent when they entered the work force, no statistical difference was found between the accelerated and traditional cohorts. Similarly, graduates of both cohorts improved throughout the year, again with no statistical difference between the two groups. The Oermann, Alvarez et al. (2010) study has many limitations. Methodologically, it is unclear where the data about the beginning perceptions were Empiric Source GPA in major Aktan et al. (2009) Korvick et al. (2008) NCLEX pass rates Aktan et al. (2009) Bentley (2006) Course performance Korvick et al. (2008) HESI scores Bentley (2006) Clinical Competencies Critical care Teaching/collaboration Planning/evaluation Interpersonal relations/communications Rafferty & Lindell (2011) Transition to Professional Role Transition time Oermann, Poole-Dawkins et al. (2010) Progression through orientation Oermann, Poole-Dawkins et al. (2010) Readiness to practice Oermann, Poole-Dawkins et al. (2010) Service on committees Aktan et al. (2009) Professional certifications Aktan et al. (2009) Employment Characteristics Job satisfaction Yearly income/hours worked weekly Title Work setting Patient load Union membership Work schedule/shift Overtime Brewer et al. (2009) obtained. It must be assumed that the participants rated themselves at the beginning and at the end of the first year on the same survey and at the same time. The study would have been strengthened had the researchers administered the survey at the beginning of employment and then again after the first year. Although the researchers report that the survey reliability was established through an expert panel review, no Cronbach s alphas were given and there was no mention about validity. No statistical numbers were given to establish the lack of significance between the groups. Volume 35 Number 4 241

5 Nursing Education Perspectives Clinical Competencies Rafferty and Lindell (2011) wanted to determine whether nurse managers had different perceptions of the clinical skills between traditional and ABSN graduates. They used an adapted version of Schwirian s Six Dimensional Scale of Nursing Performance to compare managers perceptions of the clinical competencies of 107 traditional and 93 accelerated graduates. The researchers provided managers with the validated scale at a conference and instructed these managers to evaluate a typical accelerated or traditional graduate in their first year of performance. This Likert-type tool measured leadership, critical care, teaching/collaboration, planning/evaluation, interpersonal relations/communications, and professional development. The Rafferty and Lindell (2011) study found no statistical difference between the managers perceptions of graduates on any of the variables. The study also has acknowledged limitations, including methodologic weakness (anonymous questionnaire), sampling (convenience), and the fact that it relied on the memory of conference participants to rate a typical graduate. Employment Characteristics Brewer et al. (2009) utilized a cross-sectionally designed study to explore outcomes in newly licensed registered nurses (5-18 months) from 60 geographic regions in 35 states. The stated purpose of the study was to compare outcomes between graduates of traditional BSN programs with graduates of ABSN programs. The authors queried 691 traditional and 309 accelerated graduates with a 16-page survey. The questions were divided into four areas: a) demographics, b) work environment and type of setting, c) attitudes about work, and d) perceived job opportunities. The outcome variables explored included income, hours and/ or overtime worked, number of jobs since graduating, length of time intending to stay at the person s first job, patient load, job title, union membership, type of shift, work schedule, paid time off, and medical insurance provided. The only statistical differences found were in the number of hours worked, yearly income, length of time intending to stay in position, and job title. The study found that accelerated students had higher incomes (t 940 = 2.05, p =.04), worked fewer hours (t 951 = -2.55, p =.004), intended to stay longer in their current job (t 5 = 13.00, p =.02), and held the title of manager more frequently (t 2 = 10.09, p =.007) than their traditional counterparts (Brewer et al.). DISCUSSION Students enrolled in accelerated programs in this integrative review were found to have significantly higher GPAs (Aktan et al., 2009; Bentley, 2006), superior academic performance (Korvick et al., 2008), and higher HESI pediatric, psychiatric, and exit scores (Bentley). No difference was found in NCLEX pass rate between the two groups; however, the data were self-reported and more objective assessment is warranted. There was a correlation between HESI specialty and exit examinations, exit examination performance, and NCLEX pass rates in the traditional group. Only the exit and medical surgical HESI examinations were correlated with the NCLEX pass rates in the accelerated group (Bentley). No difference was found in clinical competence, transition to a professional role, and NCLEX pass rate. There were some differences seen in employment characteristics between the two groups, with accelerated students having higher job satisfaction, yearly income, and quicker advancement to an elevated clinical nursing role. The accelerated group also worked fewer hours per week than their traditional counterparts (Brewer et al., 2009). In the study by Bentley (2006), all the HESI specialty tests were correlated with the NCLEX pass rate in the traditional group; however, in the accelerated group, only the medical surgical specialty HESI examination results were correlated with the NCLEX pass rate. This result implies that administering other individual HESI examinations may not be helpful in predicting success in an accelerated program. Hence, it would have been beneficial for Bentley to create a model that included these specialty examinations. Ongoing research, including curriculum review of traditional and accelerated tracks, should be performed at all institutions to provide evidence that specialty assessment tests can predict both accelerated and traditional student performance on the NCLEX. Tools or grading schemes that have been validated as predictors or measures of success in a traditional program may not prove to be valid in an accelerated program. Perhaps modified versions of nationally normed specialty examinations should be developed for use by accelerated programs. Although age was not associated with academic performance in either group in the Korvick et al. (2008) study, the managers in the Oermann, Poole-Dawkins et al. (2010) study found that differences between students were more dependent on age than educational preparation. Lack of competency in informatics was a concern expressed in relation to older graduates. Because students enrolled in accelerated programs have conventionally been older than their traditional counterparts (Walker et al., 2007), it may be beneficial for accelerated programs, which have significantly older students, to explore the possibility of including more informatics content (Korvick et al., 2008; Oermann, Poole-Dawkins et al.). Further research exploring the first year of practice of traditional and accelerated students is also needed. Simply relying on the perceptions of managers through focus groups or through surveys is insufficient (Rafferty & Lindell, 2011), and more rigorous research is required. Perhaps reviewing and comparing performance evaluations throughout the first year may provide more sound data regarding potential differences between graduates of the two programs. Practice patterns of accelerated students should also be explored. Future research questions may include whether accelerated students leave their initial jobs sooner than traditional students or whether institutions have any reservations about hiring accelerated students. Previous studies have shown that nursing students with higher GPAs have higher passing rates on the NCLEX (Collins, 2002; 242 july/august 2014

6 Traditional/Accelerated Nursing Graduates Roncoli, Lisanti, & Falcone, 2000). Therefore, one would have assumed that the accelerated students in the study by Aktan et al. (2009) would have performed statistically better on the NCLEX than their counterparts because they had statistically higher GPAs. This may imply that an evaluation difference exists between the traditional and accelerated programs at their institution (Aktan et al.). As admittance to graduate programs becomes more competitive, it is imperative to determine whether differences in GPAs between programs are an actual measure of superior performance, simply due to evaluation methods, or even grade inflation. Further research should also try to answer the question about whether graduate schools should use the same GPA requirements for admittance for both traditional and ABSN students. CONCLUSION ABSN programs are recognized as a successful method of educating nurses. Because most nursing programs change to meet the needs of nursing graduates due to an ever-changing health care system, it is imperative to evaluate educational and professional outcomes between the traditional and accelerated programs to ensure equivalence and ongoing success. However, rigorous research should include both evaluation methods used in ABSN programs and practice patterns. ABOUT THE AUTHORS Leslie K. Payne, PhD, RN, ACNP, FNP, is assistant professor, Baylor University Louise Herrington School of Nursing, Dallas, Texas. Patricia Mullen, PhD, RN, is assistant professor, Loretto Heights School of Nursing Rueckert Hartman School for Health Professions, Regis University, Denver, Colorado. For more information, contact Dr. Payne at Leslie_Payne@baylor.edu. KEY WORDS Educational Outcomes Accelerated Bachelor of Science in Nursing Programs Nursing Education References Abbott, A. A., Schwartz, M. M., Hercinger, M., Miller, C. L., & Foyt, M. E. (2008). Predictors of success on national council licensure examination for registered nurses for accelerated baccalaureate nursing graduates. Nurse Educator, 33(1), 5-6. Aktan, N. M., Bareford, C. G., Bliss, J. B., Connolly, K., DeYoung, S., Sullivan, K. L., & Tracy, J. (2009). Comparison of outcomes in a traditional versus accelerated nursing curriculum. International Journal of Nursing Education Scholarship, 6(1), 1. doi: / x.1639 American Association of Colleges of Nursing (2005). Accelerated programs: The fast track to careers in nursing. Retrieved from nche.edu/publications/issue-bulletin-accelerated-programs Beal, J. A. (2007). Accelerated baccalaureate programs: What we know and what we need to know Setting a research agenda. Journal of Nursing Education, 46, Bentley, R. (2006). Comparison of traditional and accelerated baccalaureate nursing graduates. Nurse Educator, 31(2), Brewer, C. S., Kovner, C. T., Poornima, S., Fairchild, S., Kim, H., & Djukic, M. (2009). A comparison of second-degree baccalaureate and traditionalbaccalaureate new graduate RNs: Implications for the workforce. Journal of Professional Nursing, 25(1), doi: /j.profnurs Carty, R. M., Moss, M. M., Al-Zayyer, W., Kowitlawakul, Y., & Arietti, L. (2007). Predictors of success for Saudi Arabian students enrolled in an accelerated baccalaureate degree program in nursing in the United States. Journal of Professional Nursing, 23(5), Collins, P. (2002). Predicting a passing outcome on the national council licensure examination for registered nurses by associate degree graduates (Doctoral dissertation, Western Michigan University). Available from ProQuest Dissertations and Theses database. (UMI No ) Hegge, M., & Larson, V. (2008). Stressors and coping strategies of students in accelerated baccalaureate nursing programs. Nurse Educator, 33(1), Kemsley, M., McCausland, L., Feigenbaum, J., & Riegle, E. (2011). Analysis of graduates perceptions of an accelerated bachelor of science program in nursing. Journal of Professional Nursing, 27(1), doi: /j. profnurs Korvick, L. M., Wisener, L. K., Loftis, L. A., & Williamson, M. L. (2008). Comparing the academic performance of students in traditional and second-degree baccalaureate programs. Journal of Nursing Education, 47(3), Lekan, D. A., Corazzini, K. N., Gilliss, C. L., & Bailey, D. E. (2011). Clinical leadership development in accelerated baccalaureate nursing students: An education innovation. Journal of Professional Nursing, 27(4), doi: /j.profnurs Mullen, P. A. (2007). Use of self-regulating learning strategies by students in the second and third trimesters of an accelerated second-degree baccalaureate nursing program. Journal of Nursing Education, 46(9), Oermann, M. H., Alvarez, M. T., O Sullivan, R., & Foster, B. B. (2010). Performance, satisfaction, and transition into practice of graduates of accelerated nursing programs. Journal for Nurses in Staff Development, 26(5), doi: /nnd.0b013e31819b5c3a Oermann, M. H., Poole-Dawkins, K., Alvarez, M. T., Foster, B. B., & O Sullivan, R. (2010). Managers perspectives of new graduates of accelerated nursing programs: How do they compare with other graduates? Journal of Continuing Education in Nursing, 41(9), doi: / Rafferty, M., & Lindell, D. (2011). How nurse managers rate the clinical competencies of accelerated (second-degree) nursing graduates. Journal of Nursing Education, 50(6), doi: / Roncoli, M., Lisanti, P., & Falcone, A. (2000). Characteristics of baccalaureate graduates and NCLEX-RN performance. Journal of the New York State Nurses Association, 31(1), Seldomridge, L. A., & DiBartolo, M. C. (2005). A profile of accelerated second bachelor s degree nursing students. Nurse Educator, 30(2), Siler, B., DeBasio, N., & Roberts, K. (2008). Profile of non-nurse college graduates enrolled in accelerated baccalaureate curricula: Results of a national study. Nursing Education Perspectives, 29(6), Stuenkel, D., Nelson, D., Malloy, S., & Cohen, J. (2011). Challenges, changes, and collaboration: Evaluation of an accelerated BSN program. Nurse Educator, 36(2), doi: /nne.ob013e31820c7cf7 Suliman, W. A. (2006). Critical thinking and learning styles of students in conventional and accelerated programs. International Nursing Review, 53(1), Walker, J. T., Martin, T. M., Haynie, L., Norwood, A., White, J., & Grant, L. (2007). Preferences for teaching methods in a baccalaureate nursing program: How second-degree and traditional students differ. Nursing Education Perspectives, 28(5), Volume 35 Number 4 243

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