ASSOCIATE DEGREE (ADN) programs in Virginia

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1 INSPIRATION FOR ASPIRATIONS: VIRGINIA NURSE INSIGHTS ABOUT BSN PROGRESSION AMY B. GILLESPIE, EDD, MSN, RN AND NANCY LANGSTON, PHD, MN, RN, FAAN, ANEF The Partnerships for Progression: Inspiration for Aspirations project was developed to create a culture of academic progression for nurses in Virginia. A survey was completed by 128 nurses who are currently enrolled in Registered Nurse to Bachelor of Science in Nursing programs throughout Virginia to learn why registered nurses pursue the bachelor of science degree (BSN) and to identify supports and obstacles that influence their experiences. Findings indicate that BSN progression is influenced by an interacting set of personal, work, and educational factors. Family support was cited as the most important facilitator for returning to school, yet time demands of balancing family, work, and school were seen as major obstacles to continuation. Internal motivation may differentiate nurses who return to school from those who do not. Determining ways to inspire nurses while implementing practical steps for enabling nurses to pursue a BSN and succeed once they enroll is the challenge for nursing service and educational organizations. (Index words: Nursing education; Institute of Medicine; RN-to-BSN student; Baccalaureate completion education) J Prof Nurs 30: , Elsevier Inc. All rights reserved. ASSOCIATE DEGREE (ADN) programs in Virginia meet vital health care workforce needs and are a strong source of diversity for the nursing workforce. ADN and diploma programs graduated 66% of new nurses in Virginia in 2011, and approximately, 36% of those new graduates self-reported as non-white or Hispanic (Healthcare Workforce Data Center, 2012). ADN programs provide access to nursing education for students in underserved rural and urban areas. Important opportunities for first generation college students and second career adults to enter the field of nursing are being provided by community colleges in Virginia. Creating a culture of progression that can pull associate and diploma-prepared nurses into continuing their academic progression is the challenge addressed by the Inspiration for Aspirations project. Recommendations from Institute of Medicine (IOM; 2010) have been taken seriously by nursing organizations in Virginia. Virginia was in the second wave of states to Virginia Commonwealth University School of Nursing, 1100 East Leigh Street, Richmond, VA. Address correspondence to Dr. Gillespie: Virginia Commonwealth University School of Nursing, 1100 East Leigh Street, Richmond, VA agillespie@rmhfoundation.org (A.B. Gillespie), nlangston@vcu.edu (N. Langston) become an action coalition state. The Education Committee of the Virginia Action Coalition has accepted as one of its goals the IOM recommendation of having 80% of the nurse workforce prepared at the bachelor's level or beyond by However, nurses in Virginia prepared at the ADN or diploma level return to school for a bachelor of science degree (BSN) at a rate of only approximately 30% within 10 years of graduation from their prelicensure program (Virginia Department of Health Professions, 2010). Virginia's BSN programs are graduating approximately 1,300 new nurses annually, but nurses who complete a prelicensure program at the associates or diploma level will need to return to school at record numbers for Virginia to even approach the 80% BSN goal. Hence, a project that arose from the 80% goal was to create a climate and develop practices that inspire students enrolled in associate and diploma programs to progress in their education. Funding to support development of the project Partnerships for Progression: Inspiration for Aspirations was provided through the Northwest Health Foundation National Partners Investing in Nursing's Future grant, with matching funds provided by the Richmond Memorial Health Foundation and the Medical College of Virginia Foundation. The project's mission was to enhance partnerships between and among educational institutions and facilitate a culture that will encourage Journal of Professional Nursing, Vol 30, No. 5 (September/October), 2014: pp Elsevier Inc. All rights reserved.

2 NURSE INSIGHTS ABOUT BSN PROGRESSION 419 Virginia student nurses to pursue progression from their diploma or associate programs to the baccalaureate. In order to determine where to focus efforts to facilitate seamless progression, a survey was created to ask nurses currently enrolled in registered nurse (RN)- BSN programs about their actual experiences of returning to school. The purpose of the survey was to learn more about why nurses with the diploma or ADNs pursue the bachelor's degree and identify supports and obstacles that influence their experience. Data from this survey were compared with the reported results of previous studies that were focused more broadly and included nurses not enrolled and those enrolled in BSN programs. This comparison to previous studies provided insights about internal and external factors that impact academic progression for nurses. In addition, the comparison addressed a subtle question: Are nurses who choose to return to school inherently different from those who choose not to return? Finally, results from the survey were used to develop recommendations for service and academic organizations based on factors RN-BSN students identified as important to facilitating academic progression. Review of the Literature Community hospital nurses, both RNs and licensed practical nurses, were surveyed in southwest Florida to assess their interest in continuing education and to determine perceived barriers to advanced study. Nurses who responded to the survey included nurses who were already enrolled in an education program and those who were not. Results of the open-ended survey questions indicated that barriers to returning to school included financial concerns, time constraints (balancing family, work, and school demands), and limited workplace incentives (increased pay or change in role or responsibilities). Nurses who were enrolled in a program or were considering enrolling cited career enhancement opportunities and their personal value on advanced education as the strongest reasons for returning to school (Morrison & McNulty, 2012). Supports and barriers to educational progression for students who were already near completion of an RN- BSN program were explored at one Hispanic-serving college in the southwest. Students preassigned to focus groups based on self-identified ethnicity reflected on factors that influenced their decisions to return to school, as well as the challenges and facilitators they experienced while enrolled. These nurses cited factors within the specific academic program such as flexibility and strong individual advising as being essential to their success in the program. Facilitators external to the academic program included family support and personal attributes such as their desires to succeed. Financial resources and employer factors such as tuition support and a potential to apply what they were learning also contributed to their success (Robbins & Hoke, 2013). When attempting to identify predictors of success in pursuing advanced nursing education, Kovner et al. completed a series of surveys of RNs from across the United States. The sample included nurses prepared at all levels of prelicensure education. Nurses who had an ADN were found to be more likely to enroll in a BSN program if they were younger, Black, not married, reside in a rural setting, have previous work experience in a nonhealth care setting, work in an intensive care unit or step down unit, and work during the day shift (p. 336). Nurses who did not plan to return to school cited concerns about advanced age and the lack of desire to change jobs, so they did not see a need to advance their education (p. 341). Consistent with other studies, the three most frequent responses to an open-ended question about barriers to returning to school were cost, family/child care, and lack of time (p 338). These studies indicate that practicing nurses are concerned about balancing personal responsibilities, time, and money. Such issues factor heavily in their decisions about whether to enroll and then continue their education (Robbins & Hoke, 2013; Kovner, Brewer, Katigbak, Djukic, & Fatehi, 2012; Megginson, 2008; Lillibridge & Fox, 2005). What may differentiate nurses who do return to school from those who do not are their internal motivators and approaches to facing the challenges they experience. Methodology The Partnerships for Progression: Inspiration for Aspirations RN-BSN Student Survey was conducted on-line in 2012 with a group of nursing students currently enrolled in 12 BSN progression programs throughout Virginia. The survey was developed within a framework structured around three categories of factors that correlate with themes found by Morrison and McNulty (2012) and those found by Megginson (2008). Using this previous work, we explored three categories of factors with this survey; personal, work, and educational program. The survey was organized into three sections; factors affecting the personal decision to pursue the degree; importance of supports, for example, tuition reimbursement, mentoring, and support of family in decision to enroll; and the importance of the support in allowing continuance in the program. Each item of the sections was rated on a 5-point Likert scale with 1 being not important to 5 being extremely important. Internal Review Board (IRB) approval was granted, and the survey link was distributed to deans and directors of RN-BSN programs who were asked to forward the link to students enrolled in their programs. There were 128 student respondents from 19 regions in the state. Of the 128 respondents, 77% were employed full time (Figure 1), primarily in a hospital setting (Figure 2.), the average age was 38, and 95% were female. The Decision to Return to School The decision to return to school is multifactorial. The primary motivator cited by respondents to the survey (mean rating of 4.31) was the opportunity to pursue a graduate degree. Seventy-eight percent of the respondents reported intent to pursue degrees in nursing

3 420 GILLESPIE AND LANGSTON Yes, Part Time 11% beyond the BSN. Open-ended comments included I went back to obtain my BSN because I want to apply for the NP program next fall and I personally wanted to obtain my BSN because I have been in nursing for many years, and I had the opportunity to do this program, and hope to pursue graduate degree. This finding differs from results obtained in the southwest Florida study and may be an indication that nurses who go back to school have different long-term career goals than nurses in the general population. The second most highly rated factor (mean rating of 3.98) was the ability to pursue a clinical position requiring a BSN. Because the majority of the nurses who responded to the survey are employed by hospitals (77%; Figure 2), this finding may be indicative of the policy changes made by institutions seeking to achieve an 80% BSN nursing workforce as recommended by the IOM (2010). The job market is so competitive and you must have a BSN or graduate degree in order to achieve the job that you are seeking or applying for. It is becoming more and more necessary to have a BSN as more hospitals upgrade requirements for bedside nurses. I graduated from an associate's program in late 2009 and was unable to find employment due to my lack of experience. I had intended to go back to school to earn a Bachelor's and at the time this was my only option. I am glad I returned to school and hope this will give me a competitive edge over other Public Health 2% Other 12% Long Term Care 5% Clinic or Office 8% Employment No 12% Yes, Full Time 77% Figure 1. Are you currently employed as a nurse? Setting of Current Employment Hospital 73% Figure 2. In what setting is your most current or recent job as a nurse? applicants. The third most highly rated factor was the opportunity for higher pay. Personal love of learning received a mean rating of 3.8 and ranked fourth (of the seven factors) lower than the more tangible outcomes of career opportunities and pay. The RN-BSN students were strongly influenced by the more internal motivator of a desire to learn. opportunity to enhance the things I had learned during my Associate program and expand on those things. I had a thirst for learning prior to starting the program, but that has been magnified since starting. Personal accomplishment of a long time goal. continuing education to provide the best care and to be an example to my daughter. Importance of Initial Supports for Pursuing the BSN Encouragement and support from family was cited as the most important factor in the initial decision to pursue a BSN with a mean rating of Balancing the commitments of family, work, and school were frequently cited as stressors in past studies (Morrison & McNulty, 2012), so having the support of family prior to making the decision to enroll was key for the nurses. The average age of RN- BSN student respondents in this survey was 38 years, and 95% of them were women. It is likely that many respondents are currently raising children and need to factor those responsibilities into any decision. Family support is mandatory. If there is no support the whole project fails. Employment factors such as tuition reimbursement (mean rating 3.59) and the availability of scholarships (mean rating 3.46) address the financial concerns that constrain many nurses from pursuing additional education. Knowing that the monies were available provided an added support that encouraged these nurses to enroll in school (Figure 3). Academic advising from the BSN programs was also ranked highly as a factor that facilitates the initial decision to return to school with a mean rating of The array of prerequisites and admission requirements for BSN programs can be confusing hence the importance of academic advising at the time the nurse is considering returning to further education. The median length of time between completion of their prelicensure program and enrollment in a BSN program for survey respondents was 8 years, with a range of 0 35 years (Spencer, 2008). The ready availability and openness of advising from the BSN program became important because the nurses became more removed from their original educational setting. Respondents reported that local community colleges helped them with the transition with advising and support to complete prerequisite and general education courses. My academic advising from was wonderful, helpful and essential. These findings and comments indicate the importance of the community college/ university relationships and agreements in supporting these nurses with their educational goals.

4 NURSE INSIGHTS ABOUT BSN PROGRESSION 421 Importance of Initial Supports for Pursuing the BSN Figure 3. How important were each of the following supports in your initial decision to pursue the BSN? Community college and university programs working together to provide on-site educational progression planning by counselors from the university program at the community college will model for students an active commitment to them and to the importance of advancing their education. In addition, programs can work together to create policies and practices that enhance access, such as on-line and hybrid program offerings or onsite classes in the employment setting. Offering guaranteed admission for students who meet specific criteria can only serve to facilitate the progression of motivated students. Furthermore, removing institutional barriers by such initiatives as articulation agreements will address some of the issues that students who chose to enroll in RN-to-BSN programs experienced. Importance of Continuing Supports for Pursuing the BSN Nurses found that they needed the ongoing support of their families in order to continue in school, once the enrollment hurdle was cleared. Encouragement and support of family was rated (mean of 4.11) as the most important factor to continuing education. I am fortunate enough to have a family that truly believes in my education.this has been the one saving grace, my wonderfully patient and understanding family especially my husband. My husband is a saint, and pitched in to do lots of things around the house to allow me time to study and read, read, read, and do papers and projects. My extended family was very accommodating and gave me a "free pass" on holidays. Employers also factor heavily in nurses' ability to stay in school. Ongoing tuition support is essential with tuition reimbursement ranked second with a mean rating of 3.71 and the availability of scholarships and financial aid ranked third at I couldnothavestayedinthe program without tuition reimbursement from my employer. Responses to open-ended questions indicated that flexibility of work hours, availability of parttime options, and flexible time away from work became increasingly important as the nurses moved along in their programs of study. Nurses responded that flexibility from work to allow specific days off and to allow cutting back number of hours each week were essential elements in their ability to continue with their programs (Figure 4). Obstacles to BSN Progression The most frequently cited obstacle to the pursuit of a BSN was managing family responsibilities and school with a mean of Difficulty finding time to study or complete coursework came in second with a mean rating of These nurses are trying to juggle school, work, and home responsibilities, so time is a major barrier they must address to meet their goals. Balancing work, school, and family have been very difficult since I am the only one working in my family with my husband and daughter relying on me to keep a roof over our heads. I have adapted my schedule to be able to study on my days off and when there is down time at work. My children have crazy schedules as well as my husband, so I plan week to week and schedule my study time around everyone else's schedules. I have found myself up late at night when my children are asleep to be a good time to work on papers that are due. The ability to manage a family, full-time job and complete the program in less than two years post pre-requisite completion [is an obstacle] (Figure 5). The topic of prerequisites as an obstacle to progression was mentioned in open-ended responses in terms of the availability of the courses and, in some cases, the number

5 422 GILLESPIE AND LANGSTON Importance of Continuing Supports for Pursuing the BSN Figure 4. How important were each of the following supports in allowing you to continue attending school for the BSN? required. I am finding that this balance is very difficult as the bridge program requirements are very extensive when managing career and family simultaneously. Many RN- BSN programs have adapted their course schedules to meet the needs of working, adult students, but limited options still serve as a barrier for some nurses in some academic settings. In addition, even when nursing programs have adopted an on-line format for the nursing courses, frequently, the general education and nursing prerequisite courses required for the program are not online and, hence, continue to create a barrier to access. Schedule of courses [is an obstacle]. I have to wait a full year before I can graduate. I only have three classes left to take to graduate and I must take one each semester for three semesters in order to graduate. Limited availability from one semester to the next for needed classes. [BSN program] did not offer other needed classes online, or evening or weekend had to go outside of campus to get non nursing classes to fit my schedule (Figure 5). Summary Observations Although the findings from this survey indicate that the actual obstacles experienced by nurses enrolled in BSN completion programs are similar to the anticipated barriers cited by nurses who have not yet chosen to continue their education, there are some differences between these populations of nurses. The nurses who are enrolled in academic programs place a high value on Obstacles to BSN Progression Figure 5. How much of an obstacle has each of the following been to your pursuit of the BSN?

6 NURSE INSIGHTS ABOUT BSN PROGRESSION 423 education and learning. A majority of these students state an intention to continue their education beyond the BSN despite the very real stressors that they are currently experiencing (Figure 6). Therefore, in promoting inspiration for progression, it may be important to talk with nurses not just about the bachelor of science (BS) program but their potential for graduate education their ultimate goal. This internal motivation may be the factor wielding the greatest impact on the decision to enroll in a program and perseverance in continuing. Policy Implications for Academic Programs and Employers Certainly, employers and academic programs have no control over the personal factors cited by nurses as the most important sources of support and the biggest obstacles to success time and family. Knowing the value and impact of these factors can allow institutions to develop policies and practices that account for these influences and enhance the likelihood that nurses will decide to go back to school and then succeed once they enroll. Giving nurses who are in school time to study and complete assignments may greatly enhance the likelihood that they will be able to succeed and remain employed full time in their current positions. Comments on the surveys indicated that nurses often felt that they must leave their current positions or make other drastic changes in their work situations in order to remain in school. I have had to quit my part time job. I have changed jobs. I found it difficult to complete coursework and studying due to working 4 10hr shifts. My employer is currently unwilling to manipulate scheduling. I had to change jobs to be able to have flexibility to have specific days off for classes and to cut back hours for school. The possibility of flexible scheduling or part-time employment with full or prorated benefit options may be an integral part of any policy initiative to encourage academic progression (Delaney & Piscopo, 2004). My employer was fantastic and supported me 100%. I was able to do my clinical rotation at a participating clinic owned by the Hospital where I work, and my employer Level of Education Hope to Achieve PHD 13% Other 6% MSN 65% BSN 16% Figure 6. What level of nursing education do you ultimately intend to achieve? allowed me to flex my schedule to work on weekends to stay current in my work flow and not burn up all my time off. Flexibility from work to allow specific days off and to allow cutting back number of hours each week [were support systems]. Flexibility in educational offerings is also important. Although on-line options were cited as vital for some nurses, others felt that they needed face-to-face learning opportunities, either because of their individual learning styles or because of lack of comfort with technology. Difficulty learning in an on-line environment: I withdrew from both classes my first semester and took ONE non-nursing online class the following spring and summer. Other respondents stated, First and foremost I could never have done any of this without the classes being online, it made all the difference. Availability of classes being a balance of online and on ground coursework. Providing a variety of formats for coursework and not requiring all nurses to adjust to the same teaching modalities are imperative if academic progression is to be made available to all nurses. In addition, options for part-time study must be presented as acceptable progression models rather than exceptions to expectations and hence creating the perception that parttime students are less desirable or of lower quality than full-time students. In addition to creating a climate that supports flexibility in progression, schools of nursing may wish to develop initiatives that address the importance of family support. Providing opportunities for the significant others to attend orientation and advising sessions may help family members support the prospective student in the decision to return to school. Hosting annual meetings for family members in which the program is discussed and the student and family are celebrated for their success may assist in creating sustained support by the family. Regardless of the initiatives, the development of activities that address the importance of family in a student continuing to completion needs to be addressed. Nurses in this survey worked a median time of 8 years prior to returning to school for the BSN. Because of this gap, the academic advising relationships of greatest import for these nurses are with the BSN program (mean rating 3.37) rather than the prelicensure program (mean rating 2.40). However, open-ended responses cited community colleges as essential for assistance with required prerequisites and general education courses, however. Therefore, these findings highlight the importance of the development of strong partnerships between community colleges and universities. Because prerequisites and general education courses are required for all RN-BSN programs, an examination of the impact of these on the ability of nurses to advance their education is worthwhile. General education courses required by colleges and universities to meet graduation eligibility vary widely. The individual governing boards of each institution determine much of the nonnursing curriculum and so creating a completely unified set of pre- and co-requisites for nursing students across the

7 424 GILLESPIE AND LANGSTON Commonwealth is difficult if not impossible. The argument could also be made that a lockstep approach to educating nurses would eliminate valuable diversity in perspectives that nurses from different educational world views bring to the workplace. In addition, community colleges in Virginia do not all have the same general education requirements, so matching the courses completed with the courses required for a nurse with an ADN seeking to complete a BSN can be laborious and confusing. Facilitating opportunities for community colleges and universities to work together on partnerships that promote seamless progression, including an ongoing examination of general education courses is a key to overcoming this potential obstacle. For nurses in this study, workplace incentives have a role in the motivational piece of educational progression. While nurses cited the requirement of a BSN or higher for their current or desired roles as a push for returning, they also stated that a lack of incentives such as increased pay or changed/enhanced responsibilities after obtaining the BSN was discouraging. The cost of on-line BSN programs is extremely high and there is no financial incentive to obtain my BSN. This finding aligns with reasons given by nurses in other studies for not returning to school (Morrison & McNulty, 2012). Differentiation in nursing roles within the clinical setting and clear financial incentives for advanced education may help encourage nurses who are on the fence about enrolling. Inspiration Policies and procedures in the workplace or academia will not be able to directly address the one factor that seems from this study to help differentiate nurses who return to school from those who do not. Placing a strong personal value on learning cannot be mandated. The mean score for having an opportunity to pursue a graduate degree was higher than that of greater pay or the opportunity for clinical advancement (Figure 7). Creating a culture that encourages academic progression requires an acknowledgement that education is not the same as just getting a degree. Tangible incentives from employers such as higher pay or opportunities for advancement combined with builtin support systems such as strong academic advising, mentoring, and cohort education can provide an atmosphere where lifelong learning becomes the norm. Encouragement and participation of other coworkers in same classes was a strong support mechanism. Hospital cohort was extremely important. My academic advising from was wonderful, helpful and essential. Information is not the same as inspiration. Nurses who express concern about being too old to return to school can benefit from mentoring with older nurses who were successful at completing an advanced degree. It was a lifelong goal and I have been able to finish now that kids are grown. Nurses who question the value of more education should hear stories from nurses who find that they do deliver better care as a result of new knowledge and insights. Returning to school is stressful and difficult. Without internal motivation or inspiration, many nurses will not be able to overcome the very real obstacles they face. Summary Nurses currently enrolled in BSN progression programs are an important source of insight for facilitating advanced education for nurses. BSN progression is influenced by an interacting set of personal factors, factors in the work environment, and factors in the educational environment. Academic programs and Factors in Personal Motivation to Pursue the BSN Degree Figure 7. How important were each of the following factors in your personal decision to pursue the BSN degree?

8 NURSE INSIGHTS ABOUT BSN PROGRESSION 425 employers can each take practical steps for enabling nurses to pursue a BSN and succeed once they enroll. Partnerships between associate and baccalaureate programs and between service and academic institutions can establish a platform from which to create the climate and culture that makes visible the value of education, to the individual and to the patients for whom they care. This creation of a positive climate and culture can have a significant impact on stimulating internal motivation of the nursing students or the practicing nurses to continue their educational progression to their highest possible capability. It will take the focused work of institutions in partnership to create a climate and culture that engenders internal motivation for individuals to desire to advance their education. And it will take the focused work of institutions to provide the system supports that will diminish the external forces that dampen the will and limit the opportunities for motivated students to continue to their highest possible level of academic achievement. Acknowledgments The authors would like to acknowledge Community Health Solutions of Richmond, VA, for their work as evaluators for the Partnerships for Progression: Inspiration for Aspirations grant with special recognition for the excellent work provided by Stephen Horan, PhD, and Terry Gardner Cyr, MS, in the development of the graphics and editing for this subproject. Thank you to the other members of the grant steering committee Jeffrey S. Cribbs, MC, co-chair; Deborah Ulmer, PhD, PhD, RN; Deb Zimmermann, DNP, RN, NEA-B; and Becky Bowers-Lanier, PhD, MSN, RN, for their guidance of the grant activities. References Delaney, C., & Piscopo, B. (2004). RN-BSN programs: Associate and diploma nurses' perceptions of the benefits and barriers to returning to school. Journal for Nurses in Staff Development, 20, Healthcare Workforce Data Center. (2012). Virginia Nursing Education Programs: Academic Year. vahwdc.tumblr.com. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington DC: National Academic Press. Kovner, C. T., Brewer, C., Katigbak, C., Djukic, M., & Fatehi, F (2012). Charting the course for nurses' achievement of higher education levels. Journal of Professional Nursing, 28, Lillibridge, J., & Fox, S. D. (2005). RN to BSN education: What do nurses' think? Nurse Educator, 30, Megginson, L. A. (2008). RN-BSN education: 21 st century barriers and incentives. Journal of Nursing Management, 16, Morrison, T. L., & McNulty, D. M. (2012). Response from Southwest Florida nursing community supporting the future of nursing. The Journal of Nursing Administration, 42, Robbins, L. K., & Hoke, M. M. (2013). RN-BSN culture of success model: Promoting student achievement at a Hispanic serving institution. Journal of Professional Nursing, 29, Spencer, J. (2008). Increasing RN-BSN enrollments: Facilitating articulation through curriculum reform. The Journal of Continuing Education in Nursing, 39, Virginia Department of Health Professions. (2010, Nov). A comparison of the Virginia Licensed Nursing Workforce Survey and the National Sample of Survey of Registered Nurses.