Registered nurses returning to school for a bachelors degree in nursing: Issues emerging from a meta-analysis of the research

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1 Copyright econtent Management Pty Ltd. Contemporary Nurse (2011) 39(2): Registered nurses returning to school for a bachelors degree in nursing: Issues emerging from a meta-analysis of the research TANYA K ALTMANN Division of Nursing, Sacramento State University, Sacramento, CA, USA ABSTRACT This literature review was conducted to determine what is known about nurses attitudes and perceptions about returning to school. There are four societal infl uences making nursing continuing education important: (1) Many nurses are still practicing with an Associate s degree or diploma and few continue their formal education; (2) Recent studies have indicated that there are improved patient outcomes in hospitals which employ higher educated nurses; (3) A poor economy during a nursing shortage means high demand and less incentive for nurses to return to school for higher education; and (4) The worsening faculty shortage means an increased need for nurses to advance their education. Understanding nurses attitudes and perceptions may help identify gaps in our knowledge, determine ways to foster positive attitudes toward education learning among nurses, and allow us to entice nurses to return to school. It may also identify crucial steps to ensure the provision of quality healthcare. Keywords: nursing; attitudes; continuing education; RN-BSN; post-registration education; literature review THE PROBLEM Healthcare is a fast paced, dynamic environment where providers of care should continually renew, update, and challenge their knowledge. The complexity of medical and surgical interventions undertaken in hospitals requires an even bigger and more sophisticated clinical workforce (Aiken, Clarke, & Sloane, 2002, p. 187). The idea that basic nursing education will prepare a nurse for a lifetime of practice is no longer reasonable given rapid technological and scientific advancements (Bahn, 2007; Gillies & Pettengill, 1993; Gould & Kelly, 2004). The American Nurses Association (2000) actively promotes the acceptance of lifelong learning and continued competency upgrading for nurses and many states mandate continuing education (CE) hours. Talk began more than four decades ago about making the Bachelor of Science in Nursing (BSN), or equivalent degree, the standard for entry-intopractice. While some countries have adopted this standard, there is still a vast discrepancy in education that includes practicing nurses who graduated with an Associate s degree (ADN) or diploma in nursing. Although this meta-analysis focuses 256

2 RNs returning to school: Issues from the research mainly on the U.S. with global research taken into account, the findings are useful internationally. In some countries nurses still graduate with an ADN or diploma in nursing. In the U.S., only about 20% of ADNs and 30% of diploma educated nurses continue their formal education to the baccalaureate level or beyond (Health Resources and Services Administration, 2006). Both the National Advisory Council on Nurse Education and Practice (1996) and the American Organization of Nurse Executives (2005) encouraged baccalaureate education and suggested that nursing should strive for a workforce comprised of two-thirds baccalaureate prepared nurses by This has not been achieved. A recent report on The Future of Nursing in the U.S. (Institute of Medicine [IOM], 2011) is recommending increasing the proportion of nurses with BSNs from 50 to 80% by To move closer to this goal worldwide, nurses educated below the baccalaureate level need to be encouraged to return to school for continued formal education. In fact, The Future of Nursing report (Institute of Medicine [IOM], 2011) also recommends that schools of nursing promote seamless transition for nurses to higher levels of education. One rational for the push for BSN nurses is because recent studies have indicated that there is decreased morbidity, mortality, and failure-torescue rates in hospitals that employ larger percentages of baccalaureate prepared nurses (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Aiken, Sochalski, & Lake, 1997; Clarke & Aiken, 2003; Curtin, 2003; Estabrooks, Midodzi, Cummings, Ricker, & Giovannetti, 2005; Friese, Lake, Aiken, Silber, & Sochalski, 2008; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002; Tourangeau, Giovannetti, Tu, & Wood, 2002). There are continual advancements in healthcare and increases in patient acuities. Even the public is aware of the need for nurses to have a baccalaureate degree. Mattson (2002, p. 72) reported that 76% of the public thinks nurses should have 4 years of education or more past high school to perform the duties of their job. There is a current nursing shortage expected to be critical by 2020 (Yordy, 2006). There is also a perception that ADN and diploma programs are shorter in academic semesters. Given this situation, it is unlikely that ADN or diploma programs will vanish any time soon. It also means there are fewer incentives for these nurses to return to school to secure or retain employment (Delaney & Piscopo, 2004). Another critical factor in the nursing shortage is lack of faculty. In 2008, the U.S. nurse faculty vacancy rate, for all levels of nursing education, was 7.6% (American Association of Colleges of Nursing, 2009). Predictions are that this vacancy rate will increase as the nursing shortage progresses (Yordy, 2006) which means that even the shorter programs will have faculty staffing problems. Of even more concern is that with an increased emphasis on higher education for nurses, there is increased need for faculty to teach in these programs. Due to nursing faculty shortages, U.S. nursing schools turned away 49,948 qualified applicants from BSN and graduate nursing programs in 2008 (American Association of Colleges of Nursing, 2009). One cause of the faculty shortage is a growing shortfall of RNs educationally prepared to transition into faculty roles (Cleary, Bevill, Lacey, & Nooney, 2007). Appropriate preparation for nursing faculty is currently the Master of Science in Nursing (MSN), although the trend in university settings is to require a doctorate (ONA Staff, 2006). Raising BSN program enrollment is the first step to addressing the nursing faculty shortage (American Association of Colleges of Nursing, 2005). If it is truly better to have a more educated workforce, and ADN and diploma programs continue to exist, more nurses need to be encouraged and assisted to return to school for the BSN. Attitudes determine the success of any program or plan (Bahn, 2007; Joyce & Cowman, 2007). Hence, there is a need to understand the attitudes of ADNs and diploma nurses toward returning to school to obtain the BSN. This information might lead to ways of fostering positive attitudes toward education among RNs, identifying solutions to perceived barriers, and suggest future research needs. 257

3 Tanya K Altmann LITERATURE REVIEW: SEARCH PROCESS The literature, through June 2009, was electronically searched using Medline, the Cumulative Index of Nursing and Allied Health, and PubMed. Information was sought related to ADNs and diploma nurses attitudes towards continuing formal education. The terms used to describe the concept included: interest, attitudes, perceptions, influences, motives, and reasons. These terms were used as they were frequently interchanged to describe the concept of interest (see Appendix A for examples of definitions). In conjunction with the terms used for the concept, the terms used to search for articles related to returning to school for a BSN included: CE, RN-BSN, continued professional development (CPD), continued professional education (CPE), post-registration education, continuing formal education, and derivatives of these terms. Difficulty arose in evaluating the articles found as many authors included both degree seeking and non-degree seeking education and few provided definitions of terms. Only articles which obviously included continuing formal education to the baccalaureate degree and/or above were included in this meta-analysis. Sixty-nine articles were found and perused to determine their relevance. Nine studies, excluded from this meta-analysis, were conducted prior to 1990 and their findings were similar to the findings in a meta-analysis (which was included) by Waddell (1993). Another four studies were excluded as they did not appear to evaluate continuing formal nursing education. Twenty-eight research studies were found which included continuing formal education in some form; 11 studies were doctoral dissertations. Two articles (Davey & Murrells, 2002; Davey & Robinson, 2002) reported different findings from the same study. TYPE OF EDUCATION STUDIED Fifteen studies evaluated RNs attitudes, motives/ reasons, and perceptions of influences/incentive, constraints/barriers, and benefits of participation in continuing formal education (Carlson, 1992; Cavanaugh, 1990; Davey & Murrells, 2002; Davey & Robinson, 2002; Delaney & Piscopo, 2004; Dowswell, Hewison, & Hind, 1998; Ellerton & Curran-Smith, 2000; Joyce & Cowman, 2007; Martin, 1992; Megginson, 2008; Melusky, 1998; Reilley, 2003; Roche, 1990; Root, 1991; Zuzelo, 2001). The samples included prospective students and/or those enrolled in continuing formal education; sometimes the categories were not clearly identified. Eighteen studies were conducted in the U.S. Thirteen studies (Bahn, 2007; Beatty, 2000; Emerson, 1992; Harper, 2000; Hayajneh, 2009; Hughes, 2005; Jerdan, 1993; Jukkala, Henly, & Lindeke, 2008; Kersaitis, 1997; Kubsch, Hansen, & Huyser-Eatwell, 2008; Penz et al., 2007; Saunders, 1993; Small, 1995) and the meta-analysis by Waddell (1993) were found to clearly include evaluation of the variables of interest related to continuing formal education and CE in general. Only the results related to continuing formal education were useful for this meta-analysis. One article (Jukkala et al., 2008) examined not only the perceptions of nurses in two Midwestern states but also included the perceptions of rural physicians. SIMILARITY OF DESIGN/METHODS Among the 28 studies reviewed, there were a number of similarities (see Appendix B for summary of the studies). These similarities were in the areas of instrument used, sampling method and size, and type and size of location studied. The most common data collection instrument was the questionnaire (N = 24) analyzed statistically (N = 23). In three studies (Hughes, 2005; Melusky, 1998; Root, 1991) follow-up interviews, with a small sample of those who had completed a questionnaire, were conducted to validate findings. Seventeen of the questionnaires were researcher developed. The only published questionnaire used more than once was the Adult Attitudes toward Continuing Education Scale (Beatty, 2000; Carlson, 1992; Emerson, 1992) and it is not specifically designed to be used with nurses. Instruments were pilot tested in 12 studies 258

4 RNs returning to school: Issues from the research and reliability and/or validity were reported, and appeared satisfactory, in 16 articles. Another similarity of design was related to the sample. Although 38% of the quantitative studies used a form of random selection, because they used a questionnaire, the final sample was a convenience sample (those who chose to respond). Hence, all of the quantitative studies resulted in a convenience sample. For the qualitative studies, the sampling was purposive. Sample size for quantitative studies varied from a small size of 77 respondents to as many as 770 respondents (average = 293) with one notable exception. Penz et al. (2007) drew study data from a national study in Canada (N = 2838). Overall response rates ranged from 11 to 91% (average = 50.5%). In the qualitative studies, the sample sizes ranged from 6 to 35 participants except when questionnaires where used and then the sample size was significantly larger. Most of the studies (81.5%) were completed in small geographical locations. For example, six were conducted in one hospital, six in one state or province, and five in a region of one state (see Appendix B, last column). At least five studies specifically included nurses in Pennsylvania. Nine of the studies were conducted outside the U.S.; two in Canada, four in the United Kingdom (U.K.), and one in each of Ireland, Australia, and Jordan. This confirms interest and currency of the topic in many nations. PERSONAL CHARACTERISTICS OF THOSE WHO RETURN AND THOSE WHO DO NOT There were a number of personal characteristics discussed in the literature describing RNs and their decisions related to continuing their education. These can be categorized into age, gender, marital status, dependents, employment, and income. The most consistent finding in the literature is that the RN who either returns for the BSN, or plans to return, is young (Carlson, 1992; Delaney & Piscopo, 2004; Ellerton & Curran-Smith, 2000; Martin, 1992; Roche, 1990; Root, 1991). However, two studies found participation and interest increased with age (Bahn, 2007; Kersaitis, 1997) and one found no significant relationship (Jerdan, 1993). The RN who was likely to return for the BSN would also be a female ADN graduate (Beatty, 2000; Martin, 1992). This is not surprising since the majority of working RNs are female ADN graduates. In contrast, Davey and Robinson (2002) found that significantly more men than women were degree minded (meaning they were interested in continuing their formal education) but cautioned that the study had a small number of men so interpretation must be guarded. Martin (1992) found that those not returning were more likely to be married with children. More specifically, Roche (1990) found that RNs with more than two children were less likely to return to school. Davey and Robinson (2002) and Saunders (1993) both found that women with no children at home were more inclined to return to school for a degree than women with children. Kersaitis (1997) found that participation in continuing formal education increased as the age of the RNs children increased. These findings are consistent with it being either a younger (without children), or a much older (with grown children), RN who returns to school. It was also found that the RN who returns to school has been employed as a nurse for fewer years (Carlson, 1992; Martin, 1992; Roche, 1990; Root, 1991). Consistent with being employed longer, it was also reported that fewer nurses in management positions (Root, 1991) returned to school. Interestingly, although it was the RN with fewer years of employment who returned, it was also the RN with a higher income (Delaney & Piscopo, 2004; Root, 1991). This might be explained by a younger married (thus a two incomes) RN who has less financial obligations who advances their education. MOTIVATIONAL FACTORS FOR PURSUIT OF EDUCATIONAL ADVANCEMENT The literature is replete with reasons RNs return to school for the BSN. In additional to personal characteristics, the research addressed the motivational factors related to participating in continued 259

5 Tanya K Altmann formal education. Motivators, often described in terms of benefits, can be personal/internal or professional and oriented in the past/present or future. According to Dowswell et al. (1998), individuals with a past/present orientation tended to relate negative attitudes whereas those with future orientations tended to be positive about change. Motivators can be either real, such as in a lack of transportation or funding, perceived, such as an attitude or belief, or a combination of both. In addition to the identified personal motivational factors (see Table 1), lack of confidence was cited as a reason why RNs do not return to school (Carlson, 1992). In Waddell s (1993) meta-analysis of 22 studies, motivational orientations explained 46% of the variation in RN participation or nonparticipation in continuing nursing education. In addition to the professional reasons for returning to school identified in the literature (see Table 2), Emerson (1992) found that RNs failed to recognize that acquisition of skill and knowledge was intrinsic to professional development. Megginson (2008) summarized what motivates RNs to pursue an advanced degree. These reasons were being able to: 1) access programs at the right time in life, 2) work with various options, 3) achieve a personal goal, 4) acquire a credible professional identity (through BSN status), 5) receive encouragement from colleagues, and 6) access user-friendly RN-BSN programs. TABLE 1: PERSONAL MOTIVATIONAL FACTORS Personal motivational factor Personal achievement or satisfaction Positive attitude regarding BSN education Improved self-esteem Future career plans Authors who identified this concept Bahn (2007); Cavanaugh (1990); Delaney and Piscopo (2004); Martin (1992); Reilley (2003) Carlson (1992); Emerson (1992); Jerdan (1993); Roche (1990) Dowswell et al. (1998); Martin (1992); Root (1991) Davey and Murrells (2002); Reilley (2003); Zuzelo (2001) DISINCENTIVES FOR PURSUIT OF EDUCATIONAL ADVANCEMENT A barrier is something that bars advancement or access (Abate, 1999). In the context of this metaanalysis, barriers include those factors that interfere with a RN s enrollment and achievement in a BSN program (Martin, 1992). Penz et al. (2007) found that the nurses reporting the greatest number of barriers were between 30 and 59 years of age, single (either never married, divorced, or widowed), had dependents (children or other relative), and worked in full-time or permanent positions (limiting their opportunities and employer support). This is consistent with other research findings (Davey & Robinson, 2002; Kersaitis, 1997). Reasons not to return were personal, professional/employer, and academic. Although personal reasons (see Table 3) create some barriers, Cavanaugh (1990) found that no groups identified personal responsibilities as TABLE 2: PROFESSIONAL MOTIVATIONAL FACTORS Professional motivational factor Pressure from employers and the profession Authors who identified this concept Dowswell et al. (1998) Career advancement Davey and Murrells (2002); Delaney and Piscopo (2004); Martin (1992); Reilley (2003); Root (1991) Career mobility and options Professional enhancement Increased professional values Recognition and job security Need for the BSN in the life of their career Improved clinical judgment Cavanaugh (1990); Davey and Murrells (2002) Bahn (2007); Saunders (1993) Kubsch et al. (2008) Bahn (2007); Dowswell et al. (1998); Zuzelo (2001) Carlson (1992) Davey and Murrells (2002); Davey and Robinson (2002); Joyce and Cowman (2007) Increased knowledge Hughes (2005) 260

6 RNs returning to school: Issues from the research TABLE 3: PERSONAL DISINCENTIVES Personal disincentives Family Time away from family Having multiple roles or other responsibilities Lack of selfconfidence and fear Authors who identified this concept Bahn (2007); Carlson (1992); Davey and Robinson (2002); Ellerton and Curran-Smith (2000); Hughes (2005); Kersaitis (1997); Reilley (2003) Carlson (1992); Ellerton and Curran-Smith (2000); Hughes (2005); Reilley (2003) Delaney and Piscopo (2004); Martin (1992); Zuzelo (2001) Carlson (1992); Megginson (2008) prohibitive. Attitude had a stronger influence. A dispositional barrier to education is the student s attitudes towards learning and perceptions of herself as a learner that interfere with her ability to complete her education (Reilley, 2003, p. 8). According to Melusky (1998), more positive attitudes towards education lead to lower perceived barriers and increased intent to register. Having a negative ADN or diploma school experience (Megginson, 2008) or a negative attitude about BSN education and believing there was no need for it (therefore placing it as a low personal priority; Carlson, 1992), were barriers to enrolling in BSN education. Although the majority of studies did not inquire about the RNs attitudes toward learning in general and themselves as a learner, Emerson (1992) found there was a positive correlation between hours of education accumulated and attitude with (a) enjoyment of learning, (b) importance of adult education, and (c) intrinsic value of adult education. Other barriers identified included lower self-esteem and lack of study skills (Carlson, 1992). Kersaitis (1997) found that there was a significant positive association between employer assistance and participation in continuing formal education. With regards to professional disincentives (see Table 4), there was a lack of employer TABLE 4: PROFESSIONAL DISINCENTIVES Professional disincentives No increase in salary or different treatment at work Would not enhance clinical skills Lack of support (financial or emotional) or recognition Work schedules/ conflicts/constraints; shift work Authors who identified this concept Bahn (2007); Davey and Robinson (2002); Ellerton and Curran-Smith (2000); Hughes (2005); Megginson (2008) Carlson (1992); Davey and Robinson (2002) Bahn (2007); Carlson (1992); Dowswell et al. (1998); Ellerton and Curran-Smith (2000); Hughes (2005) Bahn (2007); Beatty (2000); Ellerton and Curran-Smith (2000); Hughes (2005); Martin (1992); Megginson (2008); Reilley (2003) support for change and the implementation of new learning. In addition to class scheduling, Hughes (2005) reported finding that shift work caused increased fatigue and decreased motivation thereby influencing the RNs decisions enrolling in a BSN program. Academic barriers (see Table 5) mainly fell into the category of curricular issues. However, Cavanaugh (1990) found that curricular issues were not significant in identifying group differences between those RNs who returned to school, planned to return, or did not intend to return to school for the BSN. Root (1991) found that RNs pursuing the BSN listed program or school related barriers while RNs not pursuing the BSN listed personal barriers. Perhaps this is because the RN pursuing a degree has looked more closely into programs thereby identifying academic barriers. Regardless, this suggests perspective or attitude plays an important role in decision making. One barrier, cost, was listed in nine of the reports (Bahn, 2007; Beatty, 2000; Carlson, 1992; Delaney & Piscopo, 2004; Ellerton & Curran- Smith, 2000; Kersaitis, 1997; Martin, 1992; Reilley, 2003; Root, 1991; Zuzelo, 2001). Cost can be viewed as either a personal, professional, 261

7 Tanya K Altmann TABLE 5: ACADEMIC DISINCENTIVES Academic disincentives Insufficient credit for pre-licensure coursework and experience Unnecessary classes; no duplication of classes; impractical classes Travel distance to a university; location of classes Inconvenient/inflexible class schedules Enrollment procedures Length of time to complete the program; programs too long Poor or no academic advising Authors who identified this concept Carlson (1992); Megginson (2008); Root (1991); Zuzelo (2001) Delaney and Piscopo (2004); Zuzelo (2001) Beatty (2000); Delaney and Piscopo (2004); Jukkala et al. (2008); Penz et al. (2007); Reilley (2003) Delaney and Piscopo (2004); Reilley (2003); Zuzelo (2001) Delaney and Piscopo (2004); Melusky (1998) Martin (1992); Root (1991) Carlson (1992); Delaney and Piscopo (2004); Reilley (2003); Zuzelo (2001) and/or academic barrier. However, in contrast to salary arguments, Seago and Spetz (2002) found that ADNs general earn less and have different annual increases than BSNs. Recent research on decreases in patient morbidity, mortality, and failure-to-rescue rates in institutions with higher numbers of BSN prepared graduates contradicts opinions that a BSN would not enhance clinical skills. Perhaps it is difficult for those who have not returned to school and enhanced their knowledge and skills to see the benefits. WHAT RETURNING STUDENTS NEED/ WANT FROM THE EDUCATIONAL SYSTEM Research has revealed a number of areas in which academia could improve so that returning to school is more appealing to RNs. These can be divided into four broad categories: curriculum changes, financial advising, academic advising, and access to programs. Primarily, RNs want their concerns (see Table 5) addressed and to be accepted and treated as professionals (Zuzelo, 2001). Regarding the curriculum in RN-BSN programs, RNs want a curriculum developed for their particular needs (Carlson, 1992; Reilley, 2003; Zuzelo, 2001). They also want a program separate from the generic students (Ellerton and Curran-Smith, 2000; Zuzelo, 2001). Seago and Spetz (2002) conducted an indepth analysis of nursing education in California to determine why/how students choose their pre-licensure program. Many of the characteristics identified are similar to RNs motivators for continuing formal education. Generally, students choose their academic program based on geography, time commitment, and financial resources The time commitment for education was found to have a significant impact on the lifetime value of that education as each additional year of time in school reduces expected lifetime earnings by approximately $40,000 (Seago & Spetz, 2002, p. 116). This supports the aforementioned identified need for shorter RN-BSN programs. Regarding the cost of returning to school, nurses request funding such as financial aid, scholarships, forgivable loans, or tuition reimbursement (Delaney & Piscopo, 2004; Reilley, 2003; Zuzelo, 2001). Mostly they wanted employer funding or tuition reimbursement. Nurses have also identified the need for improved academic advising and mentorship (Megginson, 2008) and a more simplified process of enrollment and progression. Together these indicate that returning to school was viewed as complicated and troublesome. Nurses want easy access to classes; flexible hours, locations nearer to their home or employer, home study, and/or online courses (Delaney & Piscopo, 2004). These may be becoming a null issue as more classes are already accessible online and in asynchronous formats. In fact, academic barriers were listed less often in the more recent literature except in relation to the participation of rural healthcare professionals (Jukkala et al., 2008; Penz et al., 2007), where professional isolation continued to rank 262

8 RNs returning to school: Issues from the research high. Professional isolation included physical distance, separation from learning environments, or detachment from a peer support network (Jukkala et al., 2008). Partnerships between academia and employers might limit this issue and allow for more flexible scheduling to accommodate RNs needs (Delaney & Piscopo, 2004). WHAT RETURNING STUDENTS NEED/ WANT FROM THE EMPLOYERS Similar to their needs from the educational system, RNs identify a number of ways in which their employer could support, thus encourage them, to continue their formal education. These include, but are not limited to, recognition/rewards, and emotional and financial support. RNs expressed the need to be recognized for their achievement (Reilley, 2003), and have the value of the BSN education recognized (Delaney & Piscopo, 2004). Nurses wanted managers with leadership styles that encourage reflective practice and the application of new learning (Beatty, 2000: Hughes, 2005), mentors who motivate advanced educational endeavors (Megginson, 2008), and flexible work schedules (Davey & Robinson, 2002). Nurses wanted their efforts rewarded (Delaney & Piscopo, 2004) specifically with increased salaries (Bahn, 2007; Joyce & Cowman, 2007; Megginson, 2008). It should be noted that being motivated by salary does not necessarily diminish a nurse s altruism or professionalism (Chitty, 2011). Roche (1990) found that 76% of RNs received some type of reimbursement for tuition and books while the most recent National Sample Survey (Health Resources and Services Administration, 2006) concluded that only about 8.2% of RNs attending school used employer tuition and reimbursement plans. This suggests that RNs may not be aware of employer reimbursement or that there are restrictions on qualifying for reimbursement. Thus, it is reasonable to consider that RNs might need information on how to obtain financial aid and/or employer is funding. Cheung and Aiken (2006) published a case review of six hospitals that demonstrated the kinds of initiatives employers are sponsoring to support and encourage RNs to continue their formal education. In all six cases, the hospitals partnered with local universities and/or colleges to facilitate enrollment of their RNs. In five cases, classes were provided at the hospital. Two hospitals provided around $5000 in tuition reimbursement and two others provided either a stipend or scholarship to RNs demonstrating progress towards a degree. In all cases, the support resulted in increased numbers of RNs participating in continuing formal education programs. LIMITATIONS Limitations on the research reviewed include that fact that most researchers did not define their variables and used questionnaires with small convenience samples from small geographical locations. The result is that the generalizability of findings is limited. Additionally, many of the studies were old and although the studies described attitudes and perceptions, they did not correlate these to actions. In order for there to be generalizations and learning from research, there needs to be clear definition of terms. Few studies were found which defined attitude or motives. This created difficulties in summarizing the literature. There were also identified inconsistent uses of terms such as CE, CPD, and post-registration education. Most authors who used these terms did not provide their definition and in many cases it was unclear as to whether the authors incorporate formal education and/or returning to school for the BSN. For example, Harper (2000, p. 164) studied voluntary CE which was described as any activities that are not mandated to maintain licensure or employment. By contrast, Joyce and Cowman (2007), surveyed nurses in primary degree to higher diplomas and master s programs but referred to these educational programs as CPD. The majority of the studies (85.7%) used questionnaires which have several advantages: cost efficiency, convenience, and can be used with large sample sizes. Questionnaires also have limitations, the main ones being that they tend to have low 263

9 Tanya K Altmann response rates, high rates of missing data, inability to rectify respondents misunderstandings, inability to adapt questions inability to probe complex issues in depth (Waltz, Strickland, & Lenz, 2005, p. 264). Only three of the questionnaire studies used follow-up qualitative data to clarify and probe further (Hughes, 2005; Melusky, 1998; Root, 1991). Fourteen of the 18 quantitative studies did consider issues of reliability and validity (see Appendix B). However, not all necessary information was reported and, in a few cases, the reliability and validity of the original instrument was reported rather than for the study conducted. Even when an instrument has evidence of reliability and validity in a previous study or a pretest, it should still be monitored each time the instrument is employed (Waltz et al., 2005). In the literature reviewed, sample size and selection were also identified as issues. Sample size varied greatly but, with the exception of one Canadian study (Penz et al., 2007), never reached a large enough scale to approach what is needed for generalization. When compared to the estimated number of ADNs and diploma nurses practicing within the full population for each study, the majority of sample sizes should be considered small. In all cases, the resulting sample selection was either purposive or convenience. Convenience samples raise the question of why people participated and sample validity; whether there is representativeness. Representativeness is the degree to which the key characteristics of the sample resemble the characteristics of the total population. Fifteen of the 28 studies were conducted in the southern and eastern U.S. with at least five including the state of Pennsylvania. Six were conducted in one hospital, six in one state or province, and five in a region of one state. Using small geographical locations makes for a manageable sample size and repeating the same location allows for verification of results. However, they also limit generalizability which is the inference that the findings represent phenomena in the population beyond the study sample. In general, a timeline for a review is to go back in the literature at least 3 years, but preferably 5 years (LoBiondo-Wood & Haber, 2006) so that the literature is relevant to the current situation in practice. Since only eight studies were found that were less than 5 years old, articles were included dating back to As almost half (44.8%) of the research reviewed was over 10 years old and 73% was over 5 years old, the findings should be interpreted cautiously. Younger age and fewer years of practicing as a nurse appear to be dominant features in the profile of RNs in both categories (those returning and those planning to return to school). What was not identified was the correlation between these factors and the decision to return to school the how and why. While it was suggested that recruitment into RN-BSN programs start younger, there was no clear delineation as to what point in time RNs change their perceptions that they can or should return to school. Neither internal nor external factors alone appear to cause an individual to return to school. No study attempted to address how attitude affects behavior or whether particular attitudes have a greater impact on action. Few studies clearly defined what specific attitudes were related to higher participation in RN-BSN education. Motivational orientations were found to explain almost half of RNs variation in participation but what still needs to be determined is how internal factors move one to action and how positive attitudes are fostered. IMPLICATIONS Educators In response to the identified students needs, educators should consider RN-BSN curriculum which is need specific, gives credit for work and life experiences, is practical, and accessible. Additionally, educators should enhance student advising and support mentorships and articulation agreements between ADN or diploma programs and BSN programs. Programs should be mainly marketed toward the young RN but should also try to be more conducive and convenient for the RN with dependents. Marketing should not exclude the experienced RN as it was shown that interest renews with age. Additionally, it is the older RN 264

10 RNs returning to school: Issues from the research with experience who might want to continue their education beyond the BSN and become faculty. Educators teaching in ADN and diploma programs also need to become more involved in fostering lifelong learning and, specifically, continued formal education. They should ensure, to the best of their abilities, positive schools experiences occur and foster forward thinking, educational mobility, and the understanding that the students basic education is only the beginning of a process of lifelong learning. Hospital management Managers and administrators in healthcare institutions also have a role in fostering the educational mobility of RNs and developing policies which provide support to the RNs. They should provide nurses with recognition and rewards for educational accomplishments, flexible scheduling, emotional and financial support and information on how to access this support. Increased salaries may be accomplished by the instigation of clinical ladders for retention and promotion. At minimum, nurse managers and administrators should actively listen to their nursing employees needs and goals (Megginson, 2008) as this will help them better encourage and support the returning RN. There is also evidence that partnerships between hospitals and teaching institutions can also be successful (Cheung & Aiken, 2006). Future research Analysis of the literature shows that there is a need to define and understand what ADN and diploma nurses think about furthering their education to the BSN level, their motivations, and their attitude toward advancing their education. These studies need to be conducted with larger, thus more representative, samples in diverse geographical locations using different methodologies. There is also a need to review RN-BSN curriculum and to evaluate the perception and effectiveness of obtaining a BSN post registration. This meta-analysis supports the need for further research with nurses who continue their formal education (Waddell, 1993; Zuzelo, 2001). Specifically, there is a need for further research into ADN and diploma nurses attitudes toward RN-BSN education (Delaney & Piscopo, 2004; Hughes, 2005; Joyce & Cowman, 2007). Hughes (2005, p. 43), who studied nurses in England, found that the literature fails to indicate the reasons why nurses undertake study despite the barriers that have been identified. Research needs to be conducted with nurses who are not enrolled or enrolling in continuing formal educational programs. Findings from this type of study might demonstrate ways to entice nurses to continue their education. After an extensive literature review, Delaney and Piscopo (2004) concluded that few studies examined RNs thoughts about returning to school to complete their BSN and that most studies were conducted with RNs who had already returned to school. Studies need to be conducted with larger more representative samples in diverse locations. Since at least 54% of the studies were conducted in small regions of the southeastern U.S., it is difficult to generalize the findings to the U.S. at large or other countries. Joyce and Cowman (2007) also concluded there was continued need for research into reasons nurses participate in continuing formal education using much larger samples of RNs. In addition to larger and diverse samples, studies also need to be conducted using a variety of different methodologies including mixed methodologies. Since 86% of the studies used questionnaires, which have limitations as mentioned earlier, and the majority of the studies reviewed used researcher developed questionnaires, it is difficult to synthesize the information and make generalizations. In keeping with a suggestion by Megginson (2008), there is a need for research investigating national RN-BSN curriculum and program characteristics. Since there is no international standard for nursing education curriculum, this would be relevant for individual countries. This research might help in understanding what students are learning, identify missing content and needs, streamline programs for consistency, and ensure that programs 265

11 Tanya K Altmann are meeting the needs of the students, consumers, and the healthcare delivery system. Research should also be conducted in the area of the educational level of RNs and its relationship to quality outcomes (Davey & Robinson, 2002; Megginson, 2008). Specifically, this type of research needs to look at the quality of care provided by RNs who do advance their education to the BSN level to determine the impact of education on clinical practice. This would help confirm or dismiss the perception amongst nurses that there is no clinical benefit to obtaining a BSN post registration. This is especially significant since there is accumulating evidence of a relationship between higher BSN staffing and improved patient outcomes. CONCLUSION As identified in the problem section, the public believe nurses need more education and the research demonstrates more positive patient outcomes with BSN education. Currently the world is facing a nursing shortage which is predicted to get worse due, in part, to an increasing faculty shortage (qualified applicants are being turned away from nursing school because of faculty shortages). As a result of the current job market, RNs are not motivated to return to school to secure or retain employment. Associate degree and diploma programs are helping to meet the need for nurses and are adequately preparing nurses for basic entry into practice. However, there remains a dearth of BSN prepared nurses. Reports in the literature demonstrate that barriers and motivators to continuing formal education can be classified as personal, professional, and academic. Motivators include increased self- confidence, autonomy, quality patient care, improved clinical judgment, career advancement, and personal growth. Barriers include cost, lack of support, and curricular issues. These suggest a role for nurses, employers, and educators in attracting and supporting RN-BSN students. Attitudes were rarely evaluated but thought to strongly influence actions and outcomes with respect to educational endeavors. Based on the findings in the literature, it is primarily the younger RN, perhaps one still pre-licensure, who should be motivated to continue their education. Limitations of the current research include the use of small sample sizes, convenience or purposive sampling, few studies specifically addressing continuing formal education, restricted geographical regions studied, and use of questionnaires. Overall, the literature supports the need for further research to: 1) define and understand what associate degree and diploma nurses think about furthering their education to the BSN level, their motivations, and their attitude toward advancing their education, 2) evaluate RN-BSN program curriculum and characteristics, and 3) identify the effects of RN-BSN education on patient outcomes. Future research needs to use larger randomized samples, diverse populations, and alternate methodologies to fill in the gaps in our understanding of this issue. It is believed that there is renewed interest amongst researchers in nurses returning to school for CE even though only eight of the 29 articles reviewed were published since This renewed interest might be, in part, because the economics of nursing and health care has changed dramatically in the last 5 years. It also might be because recently published research suggests a strong link between nurses educational level and patient outcomes and The Future of Nursing report (Institute of Medicine [IOM], 2011) recommends increasing the number of BSN graduates by promoting seamless access for nurses to higher levels of education. Information gathered in future research might lead to way to foster an attitude of lifelong learning among nurses, motivate more ADN and diploma nurses to return to school for the BSN or higher degree, help create curriculum which meets the needs of practicing ADN and diploma nurses, and prepare a workforce with the knowledge and skill ready to meet the challenges and changes occurring in healthcare today. As RNs become engaged in the educational system, hopefully some will be motivated to continue to graduate education and into faculty positions. 266

12 RNs returning to school: Issues from the research References Abate, F. R. (Ed.) (1999). The Oxford American dictionary of current English. New York: Oxford University Press. Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association, 290, Aiken, L. H., Clarke, S. P., & Sloane, D. M. (2002). Hospital staffing, organization, and quality of care: Cross-national findings. Nursing Outlook, 50, Aiken, L. H., Sochalski, J., & Lake, E. T. (1997). Studying outcomes of organizational change in health services. Medical Care, 35(11 Suppl), NS6 NS18. American Association of Colleges of Nursing. (2005). New data confirms shortage of nursing school faculty hinders efforts to address the nation s nursing shortage. Retrieved July 24, 2009, from NewsReleases/2005/enrollments05.htm American Association of Colleges of Nursing. (2009). Nursing faculty shortage fact sheet. Retrieved August 6, 2009, from nche.edu/media/pdf/facultyshortagefs.pdf American Nurses Association. (2000). Scope and standards of practice for nursing professional development. Washington, DC: American Nurses Association. American Organization of Nurse Executives. (2005). Practice and education partnership for the future. Washington, DC: American Organization of Nurse Executives. Bahn, D. (2007). Orientation of nurses towards formal and informal learning: Motives and perceptions. Nurse Education Today, 27, Beatty, R. M. (2000). Rural nurses attitudes toward participation in continuing professional education. Unpublished doctoral dissertation, Pennsylvania State University, University Park, TX. Carlson, D. S. (1992). Psychosocial deterrents related to nonparticipation of registered nurses in baccalaureate nursing degree programs. Unpublished doctoral dissertation, Pennsylvania State University, University Park, TX. Cavanaugh, B. M. (1990). Factors infl uencing educational mobility for associate degree nurses. Unpublished doctoral dissertation, University of Denver, Denver, CO. Cheung, R., & Aiken, L. H. (2006). Hospital initiatives to support a better-educated workforce. Journal of Nursing Administration, 36(7/8), Chitty, K. K. (2011). Nursing s pathway to professionalism. In B. P. Black & K. K. Chitty (Eds.), Professional nursing concepts & challenges (6th ed.; p. 67). St Louis, MO: Saunders. Clarke, S. P., & Aiken, L. H. (2003). Failure to rescue. Needless deaths are prime examples of the need for more nurses at the bedside. American Journals of Nursing, 103, Cleary, B., Bevill, J. W., Lacey, L. M., & Nooney, J. G. (2007). Evidence and root cause of an inadequate pipeline for nursing faculty. Nursing Administration Quarterly, 31(2), Curtin, L. L. (2003). An integrated analysis of nurse staffing and related variables: Effects on patient outcomes. Online Journal of Issues in Nursing. Accessed July, , from ANAMarketplace/ANAPeriodicals/OJIN/ TableofContents/Volume82003/No3Sept2003/ StaffingandVariablesAnalysis.aspx Davey, B., & Murrells, T. (2002). To get a better job or do the job better: Motivations of registered general nurses to participate in post-registration degrees. Learning in Health and Social Care, 1(3), Davey, B., & Robinson, S. (2002). Taking a degree after qualifying as a registered general nurses: Constraints and effects. Nurse Education Today, 22, Delaney, C., & Piscopo, B. (2004). RN-BSN programs: Associate degree and diploma nurses perceptions of the benefits and barriers to returning to school. Journal of Nursing Education, 20, Dowswell, T., Hewison, J., & Hind, M. (1998). Motivational forces affecting participation in post-registration degree courses and effects on home and work life: A qualitative study. Journal of Advanced Nursing, 28(6), Ellerton, M. L., & Curran-Smith, J. (2000). Postdiploma nursing education: After the year The Journal of Continuing Education in Nursing, 31,

13 Tanya K Altmann Emerson, M. S. (1992). Mandatory continuing education: An analysis of registered nurses attitudes and infl uence on employment state choice. Unpublished doctoral dissertation, Kansas State University, Manhattan, NY. Estabrooks, C. A., Midodzi, W. K., Cummings, G. G., Ricker, K. L., & Giovannetti, P. (2005). The impact of hospital nursing characteristics on 30-day mortality. Nursing Research, 54, Friese, C. R., Lake, E. T., Aiken, L. H., Silber, J. H., & Sochalski, J. (2008). Hospital nurse practice: Environments and outcomes for surgical oncology patients. Health Services Research, 43(4), Gillies, D. A., & Pettengill, M. (1993). Retention of continuing education participants. The Journal of Continuing Education in Nursing, 24, Gould, D., & Kelly, D. (2004). Training needs analysis: An evaluation framework. Nursing Standard, 18(20), Harper, J. P. (2000). Nurses attitudes and practices regarding voluntary continuing education. Journal for Nurses in Staff Development, 16(4), Hayajneh, F. (2009). Attitudes of professional Jordanian nurses toward continuing education. The Journal of Continuing Education in Nursing, 40(1), Health Resources and Services Administration. (2006). The registered nurse population: National sample survey of registered nurses March 2004: Preliminary findings. Merrifield, VA: U.S. Department of Health and Human Services, Bureau of Health Professions, Division of Nursing. Hughes, E. (2005). Nurses perceptions of continuing professional development. Nursing Standards, 19, Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academy Press. Jerdan, F. L. (1993). The relationship of attitude and subjective norms to intention to attend non-mandatory continuing education programs among registered professional staff nurses. Unpublished doctoral dissertation, Adelphi University, Garden City, NY. Joyce, P., & Cowman, S. (2007). Continuing professional development: Investment or expectation? Journal of Nursing Management, 15, Jukkala, A. M., Henly, S. J., & Lindeke, L. L. (2008). Rural perceptions of continuing professional education. The Journal of Continuing Education in Nursing, 39(12), Kersaitis, C. (1997). Attitudes and participation of registered nurses in continuing education in New South Wales, Australia. Journal of Continuing Education in Nursing, 28, Kubsch, S., Hansen, G., & Huyser-Eatwell, V. (2008). Professional values: The case for RN-BSN completion education. The Journal of Continuing Education in Nursing, 39(8), LoBiondo-Wood, G., & Haber, J. (2006). Nursing research methods and critical appraisal for evidence-based practice (6th ed.). St Louis, MO: Mosby Elsevier. Martin, J. E. S. (1992). A comparison between registered nurses who are enrolled and those not enrolled in a BSN degree program. Unpublished doctoral dissertation, Indiana University, Bloomington, IN. Mattson, S. (2002). Nursing at a crossroads: Exploring the need for advanced nursing education. AWHONN Lifelines, 5(6), Megginson, L. A. (2008). RN-BSN education: 21st century barriers and incentives. Journal of Nursing Management, 16, Melusky, K. M. (1998). Knowledge, attitude and perceived barriers as predictors of intention to register for independent study courses by registered nurse students at the Pennsylvania State University. Unpublished doctoral dissertation, Pennsylvania State University, University Park, TX. National Advisory Council on Nurse Education and Practice. (1996). Report to the Secretary of the Department of Health and Human Services on the basic registered nurse workforce. Washington, DC: U.S. Department of Health and Human Services, Health Resources and Service Administration, Bureau of Health Professions, Division of Nursing. Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine, 346, ONA Staff. (2006). Nursing shortage stresses need for educators. Ohio Nurses Review, 81,

14 RNs returning to school: Issues from the research Penz, K., D Arcy, C., Stewart, N., Kosteniuk, J., Morgan, D., & Smith, B. (2007). Barriers to participation in continuing education activities among rural and remote nurses. The Journal of Continuing Education in Nursing, 38(2), Reilley, J. L. (2003). The educational participation of the female registered nurse baccalaureate student: Motivation, barriers, and persistence to complete the degree. Unpublished doctoral dissertation, Widener University, Wilmington, NC. Roche, E. M. (1990). The relationship of attitude toward BSN education, self-esteem, life events and RN s decision to return to school to earn a BSN. Unpublished doctoral dissertation, Widener University, Chester, UK. Root, S. M. (1991). Registered nurses who do and who do not pursue the baccalaureate degree in nursing. Unpublished doctoral dissertation, Virginia Polytechnic Institute and State University, Blacksburg, VA. Saunders, M. J. M. (1993). Attitudes about continuing education and program participation among Kansas long-term care registered nurses. Unpublished doctoral dissertation, Kansas State University, Manhattan, NY. Seago, J. A., & Spetz, J. (2002). Registered nurse pre-licensure education in California. Nursing Economic$, 20(3), , 125. Small, B. (1995). Perioperative nurses attitudes toward continuing education. AORN Journal, 61, Tourangeau, A. E., Giovannetti, P., Tu, J. V., & Wood, M. (2002). Nursing-related determinants of 30-day mortality for hospitalized patients. Canadian Journal of Nursing Research, 33, Waddell, D. L. (1993). Why do nurses participate in continuing education? A meta-analysis. The Journal of Continuing Education in Nursing, 24, Waltz, C. F., Strickland, O. L., & Lenz, E. R. (2005). Measurement in nursing research (3rd ed.; p. 264). New York: Springer. Yordy, K. D. (2006). The nursing faculty shortage: A crisis for health care. Retrieved August 6, 2009, from other/nursingfacultyshortage pdf Zuzelo, P. R. (2001). Describing the RN-BSN learner perspective: Concerns, priorities, and practice influences. Journal of Professional Nursing, 17(1), Received 16 June 2010 Accepted 11 July 2011 APPENDIX A DEFINITIONS OF SEARCH TERMS USED FOR THE CONCEPT OF INTEREST Abate (1999) Attitude: a settled opinion and behavior reflecting this (p. 44). Motive: a factor or circumstance that induces a person to act in a particular way (p. 516). Perception: an instance of the faculty of perceiving where to perceive is to apprehend or understand (p. 583). Reason: a motive, cause, or justification, and the intellectual faculty by which conclusions are drawn from premises (p. 664). Carlson (1992) Attitude: a motivational disposition that implies the likelihood of some specific behavior at least, moving toward or away from the something (p. 11). Martin (1992) Attitude toward life: the way an individual chooses to relate to their inner and outer world (p. 17). Roche (1990) Attitude: an acquired predisposition toward an evaluative response which is potentially bipolar, varies in its intensity, and mediates evaluative behavior (p. 19). Melusky (1998) Attitude: a combination of a perception with a judgment that often results in an emotion that influences behavior (p. 13). 269

15 Tanya K Altmann APPENDIX B SUMMARY OF STUDIES IN REVIEW Author(s) Sample size and response rate (RR) Study purpose Instrument type, reliability and validity Study location and population size Mixed method (quantitative and qualitative) studies Hughes (2005) 84 RNs (eight interviews), RR = 42% Perceptions of the value, influences, and barriers to CPD Researcher developed questionnaire (pilot tested N = 20) with follow-up interviews (semi-structured) U.K. (two NHS trusts and 13 nursing homes) Joyce and Cowman (2007) 243 RNs, RR = 46.7% Reasons for participation in post-registration education (primary degree and higher) Questionnaire One institution in Ireland Melusky (1998)* 249 RN-BSN students (six interviews), RR = 33% Knowledge, attitudes, barriers, and intention to register in independent university courses Researcher developed registered nurse questionnaire (pilot tested; α = 0.86) then series of focus group interviews One university, Pennsylvania (N = 773) Penz et al. (2007) 2838 questionnaires and 2547 qualitative responses, RR = 49% Barriers to participation in CE Data from national survey Rural Canada (N = 28,328) Root (1991)* 102 RNs (53 enrolled and 49 not enrolled; eight interviews), RR = 91 and 59% Motivations, locus-of-control, and perceived barriers of RNs who do and who do not pursue a BSN Modified Education Participation Scale (pilot tested; α = 0.88) and modified barriers-toeducation section (pilot tested) then follow-up interviews Virginia (N = 1390) Qualitative studies Bahn (2007) 20 RNs, RR = 47.6% Orientation of RNs toward CE and lifelong learning Semi-structured one to one interviews U.K. (N = 162) Delaney and Piscopo (2004) 101 ADNs and diploma nurses Perceptions of benefits and barriers to RN-BSN programs Researcher developed survey Connecticut Dowswell et al. (1998) 29 RNs, midwives, allied professional staff in PT degree courses, RR = 83% Motivations affecting participation in postregistration degree courses Semi-structured interviews U.K. (Continued) 270

16 RNs returning to school: Issues from the research APPENDIX B: CONTINED Author(s) Sample size and response rate (RR) Study purpose Instrument type, reliability and validity Study location and population size Megginson (2008) Six RN-BSN students Incentives and barriers to RN-BSN education Focus group interviews Southeastern university, U.S. Zuzelo (2001) 35 RN enrolled as parttime students Concerns and priorities of female RNs in RN-BSN programs Focus groups Five private institutions in large metropolitan region, U.S. Quantitative studies Beatty (2000)* 199 RNs, RR = 32% Attitudes of rural RNs toward CPE and reasons for participation Structured interviews followed by Adult Attitudes toward Continuing Education Scale (α for each factor ranged ) and Participation Reasons Scale (α for each factor ranged ) Seven Pennsylvania counties (N = 3076) Carlson (1992)* 460 ADNs and diploma nurses, RR = 74% Non-participation in higher education programs leading to a BSN Adult Attitudes toward Continuing Education Scale + Deterrents to Participation Scale One hospital Northwestern Pennsylvania Cavanaugh (1990)* 308 ADNs (both enrolled and not enrolled), RR = 49% Issues identified by ADNs as influential in decision to pursue or not pursue a BSN Researcher developed survey; panel of experts (N = 5); factor analysis; α = 0.86 Colorado (10 of 12 schools provided student lists) Davey and Murrells (2002) 620 RNs, (8 years post qualification) RR = 49% Motivations for postregistration degree education Questionnaire; pilot tested; α given for three items in tool but not for tool itself U.K. Davey and Robinson (2002) 620 RNs, RR = 49% Views and experiences with respect to choices and constrains in obtaining degrees Questionnaire; pilot tested U.K. Ellerton and Curran-Smith (2000) 770 (714 RNs with diplomas and 56 nurse managers), RR = 41 and 60% Assessed need for post diploma nursing education Researcher developed structured questionnaire; content validity by panel of seven experts Nova Scotia, Canada (N = 5950) 271

17 Tanya K Altmann Emerson (1992)* 190 RNs, RR = 63% Mandatory continuing education Adult Attitudes toward Continuing Education Scale; pilot tested (N = 30); r = 0.90 Kansas and Missouri (N = 3492) Harper (2000) 159 RNs, RR = 50% Attitudes and practices regarding voluntary CE Researcher developed survey; panel of experts and pilot tested (N = 4); no reliability testing 210-bed Suburban hospital Mid-Atlantic US state Hayajneh (2009) 472 RNs, RR = 52% Attitude toward CE in nursing Researcher developed questionnaire; pilot tested (N = 25); panel of experts; α = 0.86 Four teaching hospitals in Amman, Jordan Jerdan (1993)* 77 RNs, RR = 11% Relationship of attitude and subjective norms to intention to attend non-mandatory CE Questionnaire; panel of experts; pilot tested (N = 23) α = 0.89; panel of experts One hospital on Long Island, NY (N = 700) Jukkala et al. (2008) 224 (165 RNs and 59 Physicians), RR = 32% Perceptions of CE Five questions + demographics and background; panel of experts (content validity) Two Midwestern US states (N = 706) Kersaitis (1997) 347 RNs, RR = 69% Attitude and participation in CPE Cross-sectional, researcher developed survey New South Wales, Australia Kubsch et al. (2008) 198 RNs, RR = 31% Perception of professional values according to level of nursing education Researcher developed Professional Values Survey; panel of experts; α = Mid-sized U.S. hospital (N = 720) Martin (1992)* 132 non-bsns (61 enrolled and 71 not enrolled), RR = 54% Factors with influence RNs to return to school Researcher developed survey; panel of experts (N = 7); pilot tested; benefits scale α = 0.90 and barriers scale α = 0.67 Indiana Reilley (2003)* 215 Female RNs, RR = 58% Explore RN s students reasons and barriers returning to schools for BSN Educational participation socio-demographic questionnaire (panel of experts N = 3; pilot tested) and women s role strain inventory (validity index = 0.91; α = 0.92) Pennsylvania, NJ, Delaware Roche (1990)* 201 RNs, RR = 31% Attitudes toward BSN education and decision to return to school or not Researcher developed Attitudes toward BSN Education; panel of experts (N = 6); factor analysis; pilot study; α = 0.94 Five Pennsylvania Nurses Association districts (N = 2683) Saunders (1993)* 323 Long-term care RNs, RR = 28% Attitudes about CE and program participation Researcher developed four part questionnaire; α by part ranged Kansas Small (1995) 79 (16 certified and 63 non-certified perioperative RNs), RR = 79% Perioperative nurses attitudes toward CE Researcher developed Attitudes Scale; panel of experts (N = 11); ex-post-facto reliability r = One hospital, Texas *Dissertation research 272