Transitioning Associate Degree in Nursing Students to the Bachelor of Science in Nursing and Beyond: A Mandate for Academic Partnerships

Transitioning Associate Degree in Nursing Students to the Bachelor of Science in Nursing and Beyond: A Mandate for Academic Partnerships

TRANSITIONING ASSOCIATE DEGREE IN NURSING STUDENTS TO THE BACHELOR OF SCIENCE IN NURSING AND BEYOND: A MANDATE FOR ACADEMIC PARTNERSHIPS SUSAN SPORTSM...

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TRANSITIONING ASSOCIATE DEGREE IN NURSING STUDENTS TO THE BACHELOR OF SCIENCE IN NURSING AND BEYOND: A MANDATE FOR ACADEMIC PARTNERSHIPS SUSAN SPORTSMAN, RN, PHD, ANEF⁎

AND

PATRICIA ALLEN, RN, EDD, CNE, ANEF†

The Institute of Medicine recommendation for 80% of nurses to achieve a baccalaureate degree in nursing by 2020 becomes a major challenge in Texas with only 37.3% of nurses holding this degree in 2010 (Institute of Medicine, 2011). The challenge requires a 42.7% increase in the percentage of baccalaureate-prepared nurses. Regionally, nurse educators together with nurse practice partners are seeking solutions to this challenge. One region in west Texas approached this challenge by first developing and launching a needs assessment for current associate degree nurses, nursing students, faculty, and nurse managers. The results of this needs assessment are presented in this article. Following institutional review board approval, three surveys were developed to capture the perceptions of students enrolled in Texas associate degree nursing (ADN) programs and their faculty regarding enrollment in a bachelor of science in nursing program. A similar survey was developed for chief nursing officers in acute care settings in west Texas. Respondents in all categories suggested that time, financial constraints, and perceived difficulty in completing needed prerequisite general education courses were barriers to RNs continuing their education. Because most of the respondents hoped to return to school within 5 years, recruiting ADN graduates who have been out of school 5 years or less seems to be where schools of nursing should invest their recruitment efforts. (Index words: Associate degree nurses; Facilitating education processes; Regional partnerships) J Prof Nurs 27:e20–e27, 2011. © 2011 Elsevier Inc. All rights reserved.

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URSING IS FACING what may be referred to as the “perfect storm.” A call for health care reform has collided with a call from the Institute of Medicine (IOM) to increase the numbers of baccalaureate, master's, and doctorally prepared nurses practicing today (IOM, 2011). Health care reform requires nurses to broaden their roles in primary care and in care coordination, informatics, and population health. These

⁎Director of Academic Consulting Services for Elsevier, Inc. †Professor and Director, Center for Innovation in Nursing Education, Texas Tech University Health Sciences Center, School of Nursing, Lubbock, TX. Address correspondence to Dr. Sportsman: 769 County Rd., 343 Forestburg, TX. E-mail: [email protected] 8755-7223/11/$ - see front matter e20 doi:10.1016/j.profnurs.2011.08.004

expanded roles ultimately require nurses to have additional education. In addition, the IOM Future of Nursing report recommends that 80% of nurses hold a bachelor of science in nursing (BSN) by 2020. To prepare nurses to meet both recommendations and to practice in the future health care, nurse educators must rethink old paradigms and create new educational strategies. A major challenge ahead for nursing education is to increase the baccalaureate nursing workforce through many creative, nontraditional education pathways. In Texas, this challenge may be especially difficult. Nationally, 50% of the nursing workforce holds a baccalaureate degree, whereas only 37.3% of Texas' nursing workforce is prepared at the baccalaureate level (Texas Center for Nursing Workforce Studies, 2010). Currently, 79 schools of nursing in Texas offer the

Journal of Professional Nursing, Vol 27, No. 6 (November–December), 2011: pp e20–e27 © 2011 Elsevier Inc. All rights reserved.

TRANSITIONING ADN STUDENTS TO THE BSN AND BEYOND

associate degree in nursing, and 1 school offers the diploma in nursing. Twenty-five programs are baccalaureate or master's-as-entry nursing programs. In Texas, about 10,000 nurses graduate each year and currently is one of the largest producers of nurses in the United States. In fact, new data reveal that one in three of the nation's nurses are produced by six states—Texas, California, New York, Florida, Ohio, and Illinois (Bargagliotti, 2009). Because only 37.3% of Texas nurses hold a BSN, it will be a major challenge to meet the IOM recommendation for 80% of nurses to achieve a baccalaureate degree in nursing by 2020 (IOM, 2010). The challenge requires a 42.7% increase in the percentage of baccalaureate-prepared nurses despite the fact that more than three fourths of the nursing programs in the state are associate degree programs. Nurse educators and their practice partners in west Texas have begun to address this challenge through a variety of creative solutions. As a first step, a needs assessment for current associate degree nursing (ADN) students, faculty, and nurse managers was developed and launched to determine facilitators and barriers for RNs to return to school for a BSN or master of science in nursing (MSN). Recognition of these barriers and facilitators will be useful in building innovative strategies to improve nurses' education in west Texas. The results of this needs assessment are presented in this article.

Background and Literature Education for RN-to-BSN students has a long history. Initially, students in RN-to-BSN programs were educated in curricula with traditional students. Recognizing flaws in this program design allowed RNs to gain access to BSN completion programs created specifically for the RN returning to school. This realization of the need for a curriculum designed for the RN student began in the 1980s and was fully in operation by the mid-1990s in many universities across the nation. Despite articulation agreements between community colleges and universities, statewide articulation plans, and employer funding designated specifically for RN education, many RNs across the country fail to move on to achieve the BSN. Aiken (2011) indicates that 60% of all RNs have an associate's degree and predicts based on past trends that of the 72,000 associate degree graduates in the United States in 2010, only 4,000 are likely to receive a master's degree or higher. At a time of a nursing faculty shortage and a shortage of nurse practitioners needed for implementation of the Affordable Care Act, the concern is increasing not only the BSN nurse percentage for previously demonstrated safety assurance in practice but also the shortage of nurses to prepare for advance practice roles (Aiken, 2011). Aiken (2011) suggests that the nursing profession will not be able to meet the targets for advanced nurses (MSN or doctoral) by relying on RN-to-BSN education because her research suggests that most RNs complete only one degree beyond their entry-level degree. However, in states such as Texas, where geographic disparity and

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strong community support of community colleges exist, nurse leaders must develop attractive ways to move ADNprepared students to higher educational levels. Robertson, Canary, Orr, Herberg, and Rutledge (2010) investigated what facilitates and/or hinders RN students' completion of a BSN education and identified the need for awareness of the prolonged timeline for completion of many RN students seeking their BSN. The need to identify the learning needs of the ADN-prepared RNs also supported the survey under discussion. Investigators have called for better statewide articulation agreements, hybrid and online formats, environments promoting progression, and reevaluation of needed prerequisite courses and nursing curriculum revisions (Davidson, Metzger, & Lindgren, 2011; Spencer, 2008; Smith, 2010). All of the investigators called for reform through the lens of the faculty, with the exception of one recent study, which was from the student's perspective. Maneval and Teeter (2010) surveyed associate degree and diploma nursing students in Pennsylvania to elicit their future educational plans and opinions. The survey revealed that if money were not an obstacle for students to advance their education, 95.8% would pursue a baccalaureate or higher degree. Overwhelmingly, associate degree nurses plan to pursue BSN; however, money appeared to be the greatest obstacle. In addition, a qualitative investigation from the students' perspective revealed that barriers to BSN completion were “(1) time; (2) fear; (3) lack of recognition for past educational and life accomplishments; (4) equal treatment of BSN, ASN and diploma RNs; and (5) negative ASN or diploma school experience” (Megginson, 2008, p. 47). The literature revealed a variety of barriers for RNs in achieving a BSN. A lack of seamless education through state articulation agreements, online or hybrid formats for learning, funding, and time, as well as previous negative educational experience, fear, inconsistent prerequisite courses, and online or hybrid formats for the adult learner are all identified as barriers to achieving a BSN. In short, what appears to be needed is a curriculum that is designed specifically for practicing RNs.

The Texas Experience The work of nurse leaders in the west Texas region was implemented through the prism of nursing education and practice in a large, sparsely populated region. Seven cities are in the region, the largest of which has a population of 264,418, and the smallest, a population of 88,439. Although these cities serve as medical hubs in their areas, there are many smaller communities with rural hospitals and/or clinics scattered throughout the 71 counties in the region. To support the goals of the Team Texas strategic plan and the objectives of the IOM report, in September 2010, the regional leaders instituted a survey to identify barriers and facilitators to continuing the education of associate degree nurses from the perspective of ADN students and nursing faculty across

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the state of Texas, as well as nurse administrators in the west Texas region.

Development of Surveys Three surveys were developed to capture the perceptions of students enrolled in Texas ADN programs and their faculty regarding enrollment in a BSN program. A similar survey was developed for chief nursing officers (CNOs) in acute care settings in west Texas. Each of the surveys requested information regarding respondents' gender, age, and ethnicity. ADN students were asked if they had a previous degree. ADN nurse educators and nurse administrators documented their educational background and the length of time they had been practicing nursing. Table 1 compares the survey questions regarding BSN education to which the three groups responded.

Implementation of the Survey After receiving permission from a university institutional review board, the three surveys were placed on Survey Monkey. E-mail addresses for program directors of all Texas associate degree programs were obtained from the President of the Texas Organization of Association Degree Nursing Programs. In September 2010, an e-mail was sent to each program director requesting they send the appropriate link on Survey Monkey to each of their faculty and currently enrolled students and request they complete the survey posted. Respondents included 416 students in ADN programs across the state and 61 ADN faculty. As part of the effort to encourage collaboration among all nursing education programs in west Texas, the authors were working with the west Texas Area Health Education Center (AHEC). The AHEC provided e-mail

Table 1. Survey Questions for Each Respondent Group ADN student questions Are you currently pursuing a bachelor's degree in nursing?

Are you planning to pursue a bachelor's degree in dursing? Do you agree with the statement, “Having a BSN will not add anything to my career path?” What barriers to pursuing the BSN do you see? Please check multiple boxes if these apply Rate the importance of having a BSN (extremely important, important, somewhat important, not important) to you Does your employer provide tuition assistance?

Does your employer allow you a flexible work schedule while attending school? Do you think being automatically admitted to a BSN program after you reach a certain point in your ADN curriculum would encourage you to continue your education immediately after graduating with an ADN? Are you interested in an online BSN program or a traditional classroom approach to BSN education? How do you think we can encourage RNs to complete the BSN? (a text box allowed individual responses) Would you prefer to enroll in a RN-to-MSN program rather than an RN-to-BSN program?

ADN faculty questions Do you regularly encourage your students to pursue a BSN following completion of the ADN or diploma program?

CNO questions Do you regularly encourage your nurses to pursue a BSN following completion of the ADN or diploma program?

Do you agree with the following statement? “Having a BSN will not add anything to my students' career path” What barriers to pursuing the BSN do you see for your students? Please check multiple boxes if these apply A BSN is important to my students (extremely important, important, somewhat important, not important)

Do you agree with the following statement? “Having a BSN will not add anything to a nurse's career path” What barriers to pursuing the BSN do you see for your staff nurses? Please check multiple boxes if these apply A BSN is important to my staff nurses (extremely important, important, somewhat important, not important) Do you provide tuition reimbursement for nurses employed at your institution pursuing a BSN, MSN, or doctoral degree?

Do you think being automatically admitted to a BSN program after reaching a certain point in the ADN curriculum would encourage students to continue their education immediately after graduating with an ADN? Do you think your students are more interested in an online BSN program or a traditional classroom approach to BSN education? How do you think we can encourage RNs to complete the BSN or the RN-to-MSN option? (a text box allowed individual responses) Would you prefer to encourage your students to enroll in a RN-to-MSN program rather than an RN-to-BSN program?

Do you think your staff nurses are more interested in an online BSN program or a traditional classroom approach to BSN education? How do you think we can encourage RNs to complete the BSN or the RN-to-MSN option? A text box allowed individual responses) Would you prefer to encourage your staff nurses to enroll in a RN-to-MSN program rather than an RN-to-BSN program?

TRANSITIONING ADN STUDENTS TO THE BSN AND BEYOND

addresses for CNOs in acute care hospitals that were a part of their database. E-mails were sent to these nursing administrators, requesting that they complete the appropriate survey. Twenty-six nurse administrators in west Texas participated. A limitation of this survey was that AHEC had e-mail addresses primarily for CNOs from acute care hospitals in west Texas. When their responses are compared with the students and faculty from across the state, not only were the number of responses smaller, but they may not necessarily have represented responses of their colleagues in other parts of the state or in clinical sites other than acute care. In addition, the authors did not ask the CNOs to share the request for participation with nurse managers or others who may have had a different view of the needs of ADN-prepared nurses.

Results of the Survey Responses From Students Of the 416 student respondents, 81.5% was enrolled in a generic associate degree program; 8.5% were enrolled in licensed vocational nurse (LVN) to associate degree nurse transition programs. Most (90.1%) of the students in the LVN-to-ADN transition programs had practiced as an LVN for 5 years or less. Slightly less than one third of the students held an additional academic degree. Eightyseven percent of the students were female; 13% were male. Most of the students (63.8%) were less than 35 years of age, and most (71.4%) were White. Table 2 provides an analysis of the demographics of the student respondents. Most (89.8%) of the students planned to enroll in a BSN some time in their career. Thirty respondents (7.3%) were currently enrolled in prerequisites, and another 159 (38.6%) planned to attend a BSN program immediately after completing their current program. Only 42 (10.2%) of the respondents did not plan to ever enroll in a BSN program. When asked if they planned to enroll in a BSN program within 5 years, 6 (1.5%) of the students indicated that they were currently enrolled in a BSN program (as compared with 30 who were completing their prerequisites). One hundred seventy (41.7%) stated Table 2. Demographics of Student Respondents Age of Age by Ethnicity of respondents total and respondents (N = 414) percentage (n = 412) 20–24 23.7% (98) Hispanic or Latino 25–29 21.3% (88) Black or African American 30–34 18.8% (78) Asian 35–39 14.3% (59) Native Hawaiian or Other Pacific Islander 40–44 7.0% (29) American Indian or Alaska Native 45–49 8.0% (33) White 50–54 5.3% (22)

Ethnicity by total and percentage 12.9% (53) 11.9% (49) 3.4% (14) 0.5% (2)

0.0% (0) 71.4% (294)

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they would enroll within the next 2 years, and 151 (37%) said they would enroll within the next 5 years. Although 67 respondents did not answer the question pertaining to their current employers, 248 (71.1%) of the students said that their current employers did not provide tuition assistance. Two hundred twenty-eight (67.1%) indicated that their current employer allowed them a flexible work schedule. The survey did not explore whether current employers were in the health care industry. When students were asked, “Do you think being automatically admitted to a BSN program after you reach a certain point in your ADN curriculum would encourage you to continue your education immediately after graduating with a ADN?” most (n = 347, 84.4%) indicated that it would. An additional 50 students (12.2%) were not sure. Only 14 students (3.4%) indicated that it would make no difference. Students demonstrated interest in alternative methods of education, likely as a strategy to meet other obligations while enrolled in school. One hundred seventy-nine (43.2%) were interested in online instruction, and 155 (37.4%) were interested in a hybrid approach. Sixty-three students (15.2%) were interested in learning in a classroom environment. For this question, 17 students (4.1%) responded that they were not interested in pursuing a BSN. Students were asked to choose from a list, the barriers which were most likely to prevent them from enrolling in an RN-to-BSN program. Although 20 students did not respond to this question, greater than 50% of those responding identified lack of time, family obligations, and availability of financial aid as barriers. Table 3 identifies the barriers given as choices and the number and percentage of students responding to each. The survey delved more deeply into students' views about barriers to continuing their education by asking the question, “How do you think we can encourage RNs to complete the BSN?” Two hundred sixty-nine students answered this question in a text box in a variety of ways, many providing multiple suggestions. However, most of the responses could be categorized into four general areas, including (a) lack of knowledge of benefits and opportunities associated with the BSN degree, (b) need for financial assistance, (c) barriers to the admission process, and (d) need for work flexibility and incentives.

Benefits Associated With Achieving the BSN Ninety percent of respondents who addressed the issues of benefits associated with the BSN either suggested that most ADN graduates did not know of the advantages of the BSN or, more likely, did not believe there were any advantages. For example, one respondent said: Why should I get an extra degree in my field? I would rather complete a bachelors' in management so that I can either change career fields when/if I burn out or pursue a management job in case I get injured…Honestly, I feel putting more pressure on people to pursue the BSN belittles the ADN degree.

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Table 3. Barriers to Enrolling in BSN by ADN Students (n = 396) Chosen by respondents, n (%)

Barrier No. of prerequisite courses needed to pursue BSN Availability of financial aid Time Family obligations Job responsibilities BSN program access Lack of tuition reimbursement

128 (32.3) 204 265 218 102 102 115

(51.5) (66.9) (55.1) (25.8) (25.8) (20)

With such a shortage of nurses right now, we need all the help we can get. Another respondent said: I recently found out that there is no difference in pay for an ADN and a BSN nurse, so there is really no incentive to getting a BSN degree, other than you can work as a supervisor with a BSN. Another said: You can encourage RNs to complete the BSN by getting their current employers to encourage it. The policies of the organization where I work do not indicate that there is an advantage to getting a BSN. These responses suggest that for some students, there is no recognition of the impact the additional preparation that BSN nursing courses (leadership/management, community health, research, and courses in professional issues) have upon the practice of nursing, particularly in direct care in an acute setting. There was some awareness of the trend for employers to prefer to hire new BSN graduates rather than an ADN graduate. For example, one respondent said: Tell them that employers NOW prefer new BSN graduates rather than ADN graduates, despite the fact that their clinical experience is identical. Being an ADN-prepared RN does no good if you can't get a job. Respondents to this survey were ADN students from across the state of Texas; some were enrolled in schools in urban areas where employers with sufficient applicants do give BSN-prepared new graduates preferential treatment. This is not true in more rural areas, where the nursing shortage is still acute. Despite the recognition that in some circumstances the BSN candidate was preferred, this respondent did not recognize any difference in the clinical preparation of the BSN and the ADN graduate.

Financial Assistance Twenty-four percent of the respondents spoke to the need for some type of financial assistance to continue for the BSN degree. Scholarships, tuition reimbursements, loan forgiveness programs, and raises upon achieving the degree were all mentioned as possible options. One of the respondents stated:

For me, the biggest obstacle is financial aid. An immediate financial benefit (such as an automatic scholarship for enrolling in the BSN program within 6 months of graduation from the ADN program) would be helpful. However, one respondent noted: Tuition for schools that offer BSN degrees typically are much higher than community college rates. Even if your employer offers tuition reimbursement, you still have to come up with $1,500 or more at the beginning of the semester. You are not reimbursed until the end of the semester.

Barriers to Admission to a BSN Program At least 25% of the written responses identified barriers related to university admission processes. For most, the diversity of required courses and/or the lack of clarity of the admission process resulted in barriers to enrollment in RN-to-BSN programs. The responses identified a number of strategies to reduce these barriers. The most common was to develop streamlined processes, such as dual admission to both the ADN and BSN programs, which would facilitate immediate enrollment in the university before or at completion of the ADN curriculum. Some respondents had the impression that because of the shortage of nurse faculty, there were limited slots in RN-to-BSN programs across the state (an impression that may not be true). Other suggestions included increasing the flexibility of transferring prerequisites or reducing the number of prerequisites required to move to the university level. One respondent suggested: The state should have one Web site that clearly lists current prerequisite for each RN-to-BSN program, as well as indicating the transferability of general education courses offered at community colleges. A respondent noted that some programs required at least 1 year of clinical practice as an RN before application could be made to a BSN program. Although this also may not currently be true, the concern expressed about this perceived barrier is as follows: I really want to continue my education right after finishing my ADN degree, but I am not sure if I would be accepted, since I have no working experience yet. Lack of convenience and flexibility of the classes once students are admitted to BSN programs were also identified as stumbling blocks to degree completion. Most respondents recognized that convenience and flexibility were necessary for the successful completion of students who were also working and who have families or other types of responsibilities. Two responses which addressed this issue said: I believe more RNs would continue their education if the curriculum was adjustable to their work schedule. and

TRANSITIONING ADN STUDENTS TO THE BSN AND BEYOND

Being able to work with a student around their family and job hours is extremely important and gives encouragement to the student that he or she can do all of these things. Online classes were identified as an important component of making the degree possible. Some respondents felt that being able to use work hours as part of their clinical experience would also be helpful. The authors' experience suggested that ADN-prepared nurses are more interested in pursuing a master's degree in nursing than a BSN. To validate this perception, the student survey asked the question, “Would you prefer to enroll in an RN-to-MSN, rather than a RN-to-BSN program?” Seventy-two students (17.3%) indicated no interest in an RN-to-MSN program, 149 (35.9%) students were undecided, and 194 (46.7%) were interested. This interest was also expressed in the qualitative responses. For example: If I am going to pursue further nursing education, then it will be for the MSN so that I may have more autonomy. I am not in favor of “wasting” an extra year of time in order to pursue a degree which will leave me in the job I am already in. and I would prefer to go through an RN-to-MSN program, rather than having to go through a BSN program first.

Nurse Educators and Administrator Responses Of the 61 Texas ADN nurse educator respondents, 91% were female, 76.6% were master's prepared, 67% were older than 50 years, and 83.1% were White. A small minority graduated from a diploma nursing program. The ADN degree was the entry-level degree of 42.6% of the faculty respondents; an additional 42.6% of the educators entered nursing through a BSN degree. Sixty-two percent of the faculty has been practicing for more than 25 years. Almost all (98.4%) reported that they encouraged their students to continue their education after graduating from an ADN program. Twenty-six nursing administrators in the west Texas area responded to the survey. Similar to the nurse educators, 90% were female and 46% were more than 55 years of age. Most (88.5%) were White, although 11.5% were Hispanic. There were no other ethnic groups represented in the nurse administrator group. Fifty-two percent of the administrators began their careers as an ADN-prepared nurse, 24% as a diploma-prepared nurse, and 24% as a BSN-prepared nurse. Fifty percent of the nurse administrators remain at the ADN level. Three (13.6%) held a BSN and two (9.1%) an MSN, and one each (4.5%) hold a master of business administration, a master of hospital administration, or a doctor of education. In addition, four respondents (18.2%) were currently in an educational program. Most (57.7%) of this group had also been practicing longer than 25 years.

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Eighty-eight percent of the administrators reported they encouraged RN employees to continue their education. Educators and administrators shared the overall view of the student respondents regarding barriers to returning to school. The differences were in the priority each group gave to each barrier. As previously noted, students viewed time constraints as the most important barrier, followed by family obligations and availability of financial aid. The educators and administrators prioritized these barriers in the reverse order (family obligations followed by time constraints). When nurse educators were asked the type(s) of delivery methods they believed their students preferred, their responses were similar to the responses of the students. The perception of relative attractiveness of an RN-toBSN or an RN-to-MSN program seems to be diverse among student, educator, and administrator respondents. As previously noted, 46.7% of the students were interested in an RN-to-MSN program; yet, 35.9% were unsure if this would encourage them to return to school. When nurse administrators and educators were asked, “Would you prefer to encourage RNs to enroll in an RNto-MSN rather than an RN-to-BSN program?” their answers were wide-ranging as well. Table 4 provides specific information about these responses. One might hypothesize that administrators are concerned about RNs obtaining MSN degrees, which might remove them from the bedside. However, it is not clear why most of the educators responded “no” or “undecided.” Some student responses were much different from those of the nurse educators or administrators. For example, 40% of the student respondents viewed obtaining a BSN as “very important” to their careers; 42.3% of the nurse administrators and 50% of the nurse educators indicated that students viewed obtaining a BSN as “somewhat important.” Although most of the students indicated that their employer provided no tuition reimbursement, 46.2% of the administrators indicated they offered tuition reimbursement, 42.3% did not, and 11.5% were not sure. Again, this finding may be irrelevant because it was not clear that they were necessarily working in health care. The difference among the three groups regarding their support of dual admission was even more striking. Most of the students supported dual admission (84.4%), whereas the support was much more mixed among the educators and administrators. Table 5 illustrates these differences in opinion.

Conclusions/Recommendations This survey of students, faculty, and administrators in Texas validated many of the findings previously cited in Table 4. Response to Question regarding Preference for RN-toMSN

Administrators Educators

Yes

No

34.6% (9) 39.3% (24)

46.2% (12) 39.3% (24)

Undecided 19.2% (5) 21.3% (13)

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Table 5. Summary of Dual Admission Responses

Supports Do not support

ADN students (%)

ADN educators (%)

Nurse administrators (%)

84.4 12.2

39.3 46.2

34.6 39.3

the literature. Time, financial constraints, and perceived difficulty in completing needed prerequisite general education courses were primary reasons that RNs did not return to school. However, one finding revealed in this survey and previously noted by others (Maneval & Teeter, 2010) was surprising to the researchers. Texas associate degree students are not always aware of the opportunities available for RN-to-BSN education within this state. Prior to the survey, the authors believed that RN-to-BSN programs were well marketed in Texas, but the survey revealed students are not aware of the available options. Several of those surveyed had misconceptions/ misinformation about programs. It is possible this information was obtained from those with whom they work with rather than the schools offering these programs. One recommendation for Texas schools of nursing is for more widespread marketing of programs offering the pathway to BSN education. It would also be most helpful to students if information about all state RNto-BSN/MSN programs were available on an easily accessible Web site. Another interesting response from associate degree students' related to the RN-to-MSN pathway option. Thirty-five percent of the students were not sure that having an MSN option would positively influence their return to school. As a result, offering an RN-to-MSN-only program might be a deterrent for this group of students to return to school. Therefore, having an option for the RNto-MSN student to “opt out” of such a program by receiving a BSN would be very helpful in ensuring success for students seeking additional education. Texas is ranked 43rd in the nation for number of residents with a bachelor's degree: therefore, degree completion is a very high priority for this state (Kolowich, 2011). Because most of the respondents hoped to return to school within 5 years, recruiting ADN graduates who have been out of school 5 years or less seems to be where schools of nursing should invest their recruitment efforts. The further away from school the RNs are, the less likely they are to return to school; therefore, as a result, dual admission and other strategies to target the new or recent graduate should be implemented. The variety of general education prerequisites among various colleges and university and the lack of institutional flexibility in accepting transfer makes moving to a BSN difficult. Consensus about prerequisite general education would enhance articulation and seamless education for RNs in Texas. Texas Nurses Association Education Committee is currently surveying nursing faculty in both ADN and BSN programs to identify what nurses believe is critical foundational coursework for the

success as a professional nurse. This survey should reveal some interesting findings on general educational requirements core to nursing education, which may lead to changes in required prerequisites. The discrepancy between what students and administrators reported regarding tuition reimbursement was puzzling, if students who responded that their employer did not offer tuition assistance worked in health care. In these challenging economic times, some hospitals may not offer such assistance. However, this discrepancy may also result from the fact that many hospitals only provide reimbursement after the student has completed the course. Students surveyed saw this as a major barrier to educational pursuit. If the student has shown success in prerequisite completion and program admission, hospitals may want to provide “upfront” reimbursement for coursework. This gesture on the part of the employer would be a positive acknowledgement of the employee's success to this point and confidence in the nurse's ability to complete the RN-toBSN program. In conclusion, Aiken (2011) supports entry into practice at the BSN level as the most efficient way to increase the numbers needed for nursing practice. However, in Texas, given the number of associate degree programs in the state, the geographic diversity, and the state commitment to community colleges, promotion of ADN to BSN will be the strategy to increase BSNs in Texas. Texas Schools of Nursing will continue to encourage prospective nursing students to choose university education if possible. However, we must also facilitate the educational processes for associate degree RNs to continue their education. Only through both approaches will we be able to meet the need for sufficient RNs throughout our state and the goal of BSN education for 80% of the nurses.

References Aiken, L. (2011). The future of nursing. The New England Journal of Medicine, 364, 3 January 20, 2011, p. 196–198. Retrieved from nejm.org on February 8, 2011. Bargagliotti, L. (2009). State funding for higher education and RN replacement rates by state: A case for nursing by the numbers in state legislatures. Nursing Outlook, 57, 274–280. Davidson, S. C., Metzger, R., & Lindgren, K. S. (2011). A hybrid classroom–online curriculum format for RN–BSN students: Cohort support and curriculum structure improve graduation rates. Journal of Continuing Education in Nursing, 10, 1–10. Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Kolowich, S. (2011). The ten thousand dollar question, Inside Higher Ed. Retrieved February 14, 2011, from http://www. insidehighered.com/news/2011/02/14/texas_governor_calls_ for_cheaper_ bachelor_s_degree_programs. Maneval, R., & Teeter, M. (2010). The student perspective on RN-Plus-10 legislation: A survey of associate degree and diploma nursing program students. Nursing Education Perspectives, 31, 358–361.

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Megginson, L. (2008). RN–BSN education: 21st century barriers and incentives. Journal of Nursing Management, 16, 47–55. Robertson, S., Canary, C. W., Orr, M., Herberg, P., & Rutledge, D. N. (2010). Factors related to progression and graduation rates for RN-to-bachelor of science in nursing programs: Searching for realistic benchmark. Journal of Professional Nursing, 26, 99–107.

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Smith, A. (2010). Learning styles of registered nurses enrolled in an online nursing program. Journal of Professional Nursing, 26, 49–53. Spencer, J. (2008). Increasing RN–BSN enrollments: Facilitating articulation through curriculum reform. Journal of Continuing Education in Nursing, 39, 307–313. Texas Center for Nursing Workforce Studies. (2010). Nursing Workforce in Texas-2009: Demographics and Trends.