Student’s Academic Transition Issues: Associate Degree to Baccalaureate Nursing

Health care requires increasing the number and quality of registered nurses to the baccalaureate level to address part of the critical nurse shortage problem and need for highly qualified professionals. Two major national initiatives examining the nursing workforce issue in the United States recommend decreasing barriers, refining academic pathways and facilitating nurses return to school for higher levels of education by streamlining nursing education between community colleges and baccalaureate programs. Nurses prepared at higher levels have demonstrated stronger patient outcomes and ability to provide safe and effective care. This study sought to define barriers, priorities and enhancement/motivational factors, as identified by students, during transition from associate degree to baccalaureate nursing degree completion programs. Additionally, demographic data was compared to barriers and enhancement factors to determine if any associations between these exist. Students were provided with an electronic survey tool that allowed easy access and return. The outcome data from this pilot study provides nursing educators and professional practice leaders a better understanding the barrier factors, allowing leaders to design programs, delivery models, advising, and address needed areas of additional support or elimination to promote student success. At the same time, identified enhancement factors can be increased, streamlined for students.


Introduction
The Institute of Medicine [1] and Carnegie Foundation for the Advancement of Teaching [2] recommend decreasing barriers by improving academic pathways to promote seamless progression from community colleges and baccalaureate programs to promote earlier, more efficient, access and cost-effective completion of a baccalaureate programs. In response to these key recommendations to the nursing profession, the authors designed a study to explore the transition issues as defined by the students, to guide nursing education and practice responses.

Background/Review of Literature
The Institute of Medicine's [1] Future of Nursing: Leading Change, Advancing Health outlines eight recommendations to improve health care in the United States (U.S.) via nursing changes. Recommendations for nursing address the need to increase the U.S. proportion of nurses with baccalaureate degree to 80 percent by 2020. The IOM report elaborates on the need to decrease barriers by defining academic pathways that promote seamless progression and access for nurses to higher levels of education; promotion and support (financial) by health care agencies; salary differential for employed nurses with higher degrees; expanding baccalaureate programs through increased funding, scholarships and loan programs; early and continuous intra-professional collaboration with other disciplines; and recruitment of diverse student populations [1]. The Carnegie Foundation for the Advancement of Teaching: Preparation for the Professions report Educating Nurses: A Call for Radical Transformation recommends an immediate need to streamline nursing education between community colleges and baccalaureate programs, "to allow for early completion of a baccalaureate program that are feasible, fair, and affordable for all nursing students" [2]. Health care practice requires increasing the quantity and quality of registered nurses to the baccalaureate level to address part of the critical nurse shortage problem and need for highly qualified professionals [1].
Experts on U.S. workforce issues predict a major shortage of nurses of up to million by 2020, related to the following factors: increased numbers of newly insured under the Affordable Health Care Act; increased numbers in the population; increased numbers of older individuals; an aging of the nursing workforce; and expanded areas of health care service [3]. The shortage is based on a supply-demand model that indicates a growing demand for nurses related to an increased general population, increase in those older than 65 years of age, and increase in the number of people gaining access to health care as a result of the Affordable Care Act [4]. The supply of nurses remains a challenge due to a high portion of nurses approaching retirement age and limitations on enrollment rate in schools of nursing due to the faculty shortage and clinical placements [5]. The current U.S. percentage of nurses prepared at the Associate Degree (ADN) level is 45.5% and Baccalaureate degree (BS/BSN) level is 33.7% [4].
The Institute of Medicine's report [1] states health care will need more nurses to address the predicted shortage. Additionally, these nurses should have higher levels of preparation to address improved patient outcomes. Evidence supports the IOM recommendation, indicating nurses with baccalaureate degrees are linked to lower rates of mortality [6,7]; are better prepared to provide safe and effective care than associate degree nurses [8]; and demonstrate better communication skills, knowledge, problem solving, patient-teaching and psychosocial skills [9]. More nurses will be needed with advanced education and skill to meet the demands of the future [1]. Meeting this need will require streamlining programs to produce increase the number nurses prepared at the baccalaureate, or higher level of education.
The U.S. Tri-Council for nursing [10] endorsed a position statement on the need to enhance the educational advancement of registered nurses. In response, many academic nursing programs continued to develop articulation partnerships spelling out the necessary coursework for degree transition from community college to baccalaureate education. Presently, students still find many challenges that influence their decision to pursue and attain advanced education. Researchers have explored personal characteristics, work attributes and work attitudes to predict if a nurse with an associate or bachelor's degree would enroll or complete a higher educational level [11], finding predictors of obtaining the BSN degree include: being black, living in a rural area, non-nursing work experience, higher work motivation, working in the intensive care units and working day shifts.
There is limited current data on barriers and enhancing factors related to transition from the associate to baccalaureate nursing degrees offered through Registered Nurse to Baccalaureate (RN-BS/ BSN) programs, although there is rich anecdotal data. Students report complicated admissions requirements, including pre-requisite nursing courses and liberal arts and sciences classes that vary from one institution to another; financial barriers; conflicting responsibilities of work or family; and lack of guidance [12]. Only two older qualitative studies [13,14] explored the transition issues, revealing several barrier themes, including: a variation of expectations, tentative beginnings, limited time, lack of confidence/fear, insufficient recognition for past educational and life experiences, insufficient differentiation in roles of different registered nurses (RNs) prepared at different educational levels, and lack of basic academic support. Students in these studies identified several factors (enhancement/motivational) that facilitated advancing their education, including: it was the right time and place in life to go to school, looking forward/continuing job opportunities, achieving a personal goal, and obtaining support and encouragement to return to school identification of cornerstone courses that led to significant change [13,14]. Nurse educators and clinical leaders have actively pursued measures to ease the transition in RN-BSN programs, including articulation models, joint enrollment projects, cohort admission programs with clinical agencies and various other measures. However, most of the measures are relatively new and have not been analyzed for impact. In order to best understand the issue and develop solutions, the current study explored students' perceptions of barriers and enhancement factors in academic transition in this decade.

Purpose of the Study/Aim
The purpose of the study was twofold; 1) define barriers, priorities and enhancement/motivational factors perceived by students as they transition from associate (ADN) to baccalaureate (BS/BSN) nursing programs and 2) explore associations of barriers and enhancing factors with demographics to better understand student issues. Barriers were defined as factors that interfered or made pursuing education more difficult; whereas enhancement/motivating factors were identified as factors that helped facilitate or made pursuit of education easier. The study is designed to gather current data from nurses in this decade, knowledge that is missing from the literature.

Research Design:
The research was undertaken with an exploratory approach as there is limited current data noted in the literature related to academic transitions of the RN to BS/BSN student. A descriptive survey method, using an electronic Qualtrics survey tool was used (http:// www.qualtrics.com).

Research Questions
The research questions related to barriers, priorities and enhancement/motivation factors to obtaining a bachelor's degree and factors which assisted in pursuing this degree among students with an associate degree or diploma in nursing. In a descriptive survey, nursing students were given options/choices to select, and an openended "other" selection. Actual subset questions are listed in tables 1 and 2. The research questions were as follows: • What are the barriers in obtaining a BS/BSN degree? • What are the enhancement/motivating factors in obtaining a BS/BSN degree? • Is there a relationship between students' demographic factors and barriers and enhancement factors in obtaining a BS/BSN degree? • What priority factors are related to the selection of the RN-BS/BSN program? • What priority factors made going back to school for a BS/BSN degree easier?

Research Instrument:
The survey instrument was developed by the investigators based on research findings in qualitative studies of Kovner et al., [11], Delany &Piscopo [13], Megginson [14]. In addition, questions reflected anecdotal information and suggestions obtained from Deans/Directors who have worked with RN-BSN students in the state surveyed. Once developed, the instrument was peer-reviewed by a panel of ten Deans/ Directors for content validity and readability, then revised appropriately prior to use. The survey collected demographic data, 41 items multiple-choice selections for questions related to barriers, priorities and enhancement factors, and open-ended "other" area for comments.

Procedure/Sample/Data Collection/Analysis:
After receiving institutional review board approval for the study, an electronic letter was sent to ten Nursing Deans/Directors of national nursing accredited programs in the selected state with RN-BS/BSN programs introducing the leaders to the survey. The letter discussed the survey, shared the institutional review board (IRB) approval and explained that informed consent would be documented by willingness to participate in survey. The Dean/Director was then asked to forward an attachment letter with a link to the survey to their RN-BS/BSN students. The letter to the students also included the information on IRB approval and the assumed consent by participation explanation. Based upon an estimated number of 520 RN-BS/BSN students enrolled in the state programs in 2014, the return rate was approximately 10% (N=52).
Data was analyzed using frequency, distributions and correlations using the Statistical Package for Social Sciences [15] (with a significance level of p<0.05). Since written comments were limited, all were included in the findings. All demographic data was reported in aggregate format and grouped into meaningful categories, then reanalyzed and determined to meet normalcy distribution of data.

Demographic Findings
Respondents were 100% female; primarily white/Caucasian (96%), with 18% (20-29 years old), 32% (30-39 years old), 32% (40-49 years old) and 28% greater than 50 years old. Most of the subjects were married (71%), with 16% separated or divorced, 10% single and 4% with domestic partners. A small percentage (12%) were not working, while 6% were working part time between 12-25 hours, and 82% were working 25 or more hours a week. Although the RN-BS/BSN programs were located in one state, 44% (n= 23) of the students were from other states as a result of the distance offerings. Students were from a variety of regional locations; with 35% from rural and 65% from urban areas. Although this demographic data is close to the demographic data of the state surveyed, the gender and race demographics of the U.S. are more diverse.
The students had completed previous degrees, primarily at ADN (92%), and 8% Diploma graduates and 65% with bachelor's degrees in another field. The students had completed all their previous degrees at various ages, with 48% completing by age 30; 38% by age 40, and 14% after the age of 40. Most (81%) completed their previous nursing degree/diploma in less than four years. The number of years between completing the previous degree and starting the RN-BSN program varied, with 20% starting within the first year, 12% from year 1-3, with equal number (8%) between 3-5 years, 5-7 years, 7-9 years, 9-11 years, and 11-13 years, 2% at 13-15 years and 27% completing after 15 or more years. When asked how long they thought the RN-BSN program would take them to complete, 10% reported less than a year, 45% reported 1-2 years, 35% 2-3 years and 10% thought it would take more than 3 years. Most respondents calculated it would take them at least two years to complete the nursing courses (79%), as well as taking them two years to complete the non-nursing requirements (93%).

Barriers for Students Pursuing a RN-BS/BSN Degree
Respondents identified barriers they faced while pursuing additional education at the BS/BSN level (Table 1). Major barriers included issues with educational and work issues, family and personal responsibilities and financial restraints. In the area of "other", participants entered free text noting such factors as additional lack of/ cost of childcare, professional employment dedication, work responsibilities, learning disability and time constraints were added.

Barriers for Students Pursuing a RN-BSN degree N Percentage
Cost (tuition and fees) 40 82% Family responsibilities 25 51% Obtaining pre-requisite coursework for admissions 10 20% Lack of employer support 9 18% Lack of motivation 8 16%

Enhancements/Motivational Factors for Students Pursuing a RN to BS/BSN Degree
Factors that motivated students to return to school for their BS/BSN degree completions (Table 2) included internally motivating factors such as desire for continued education/professional development and support of one's family and significant others. External factors included financial and family/employer support, and increased opportunities at the baccalaureate degree level. Educational incentives included having a choice of a number of programs, ease of completing pre-requisite courses and a short acceptance time for admissions. However, employer mandates were a very low motivating factor. When describing the "other" factors, individual nurses wrote that multiple factors encouraged them including the desire to pursue graduate school, scholarship and tuition support, availability of online programs, limitations for opportunity at the ADN level, promotion options and being a role model for one's own children.

Relationship of Demographic Data and Barriers and Enhancement Factors
Analysis of age and family/significant other support was found to be statistically significant (0.005). Analysis between age and incentives (employer mandate to keep my job) demonstrated a statistically significant relationship (0.005).
An association between partner status and a variety of barriers were noted to be statistically significant, including: the relationship between partner status and barriers (tuition and fees) (0.01); the relationship between partner status and the barrier of family responsibilities (0.05); the relationship between partner status and the barriers of family responsibilities (0.05) and partner status and lack of family/significant others support (0.011); and the relationship between partner status and lack of RN to BSN programs in my area (0.016). However, partner status and motivational factors for returning for the RN -BS/BSN degree were not found to be statistically significant.

Priority Factors Related to Selection of RN-BSN Program
Analysis of factors related to selection of RN-BS/BSN program revealed participants reported receiving their initial information about the RN-BS/BSN program from a website (58%), program advisors (44%) and from College Network (15%), with some indicating more than one source. Information about non-nursing required courses was received from the similar sources and most (94%) believed the information was easy to understand and helped motivate them to move forward with their educational program. The majority (73%) of students received individual advising prior to admission and most (84%) only applied to one program. All of the RN-BS/BSN programs that these students attended were either totally online or hybrid programs. Participants were asked to rank the most important priority factors in selection of an RN-BS/BSN program (Table 3). In addition to the responses provided, individual nursing students identified the following factors in the "other" selection: A quick enrollment and admissions process; accredited program; ability to self-pace; discounts provided through employer; assistance with disability; and desiring a program with graduate programs.

Positive Impact Factors the BSN Would have on Nursing Career
When reporting positive impact factors they felt the BSN would have on their nursing career, the students rank ordered: • Increase opportunity to pursue graduate education • Increase my career mobility

• Provide additional knowledge and skills as closely related impacts
In the open-ended section that included "other" option, one student nurse wrote the BSN degree would increase respect from my colleagues and another individual wrote the BSN would qualify them to teach at a community college.

Factors Delaying Progression in the RN-BSN Program
Major factors identified as delaying progression in the RN-BSN were costs and life events. Some of the nurses (24%) expected to work in the same area following graduation, but others (76%) saw future opportunities as possibilities. Over half (67%) of the survey respondents expected to attend graduate school within the next five years. In response to "other" option, two students indicated some concern with general education and pre-requisite courses taken as part of the ADN programs that did not translate into accepted credits at the BSN level. Several of the nurses found it difficult to arrange their own clinical experiences as required by their program. One non-clinical nurse also found assignments directly relating to clinical/service learning activities difficult to complete. In addition, one student reported academic advising was not available to them prior to admission to the RN-BS/BSN program, which set up barriers of additional coursework that could have been avoided. Another student wrote the costs and current economic instability made a difficult and unpredictable time to assume student loans. Lastly, three students were disappointed that the nursing profession has not focused more attention on the baccalaureate level of education until now.

Discussion
This study provided new preliminary findings on RN-BSN educational issues and confirmed some existing, but limited data in the literature. The findings confirm some commonly held beliefs based on anecdotal information about this student population that had not been previously identified in research. On a positive side, personal motivation was rated by most as the greatest incentive to return for the BS/BSN, including opportunities for continued education, professional development and future employment choices. This finding was not reported in the previous literature and reflects a change in enhancement/motivating factors. In addition, new educational factors that helped motivate students included short acceptance time into a program. Family and employer support was found in earlier studies and continues to be a strong motivational factor. A new finding revealed age and employer incentives were demonstrated to have a statistically significant relationship, indicating the influence the employer can have on individuals pursuing higher education at different stages of their career. Additionally, as health care agencies attain/maintain Magnet status, increased BS/BSN leaders will help advance the initiative. Nurses who are early or mid-career are finding the longevity need for a BS/BSN more predominant than their predecessors. The clear message for higher education is being better delivered through both education and practice leaders.
Priorities for education have shifted, reflected in the top two priorities for program selection being the online/distance delivery model and reputation of the school. These are new findings and reflect the current student's need for flexibility and quality through distance education, shifting away from onsite/local education demands. Students identified pre-requisite and non-nursing course requirements as a lower priority, which did not confirm the anecdotal data supplied by students and some deans/directors in the study's region.
Multiple barriers associated with the RN-BS/BSN academic transition are identified. Supporting the existing literature, costs and financial issues and family responsibilities remain highly ranked issues, while new data reflected the barriers of obtaining pre-requisite coursework and support of employers and family were added to the list of primary barriers to pursuing a BS/BSN degree. It is clear that employers and family support can be both a positive and negative factor in continuing one's education, Lack of educational opportunities is clearly not an issue for most students completing this study, which may or may not differ from the general population of students.
The students indicated that online and hybrid programs as their number one priority, reflecting need for flexibility and choice. The widespread access to distance education programs helped the students deal with juggling the demands of work and family responsibilities; however these responsibilities continue to serve as major barriers. Working full time and/or carrying for others left little time for focus and study in school. Concurrently, students' reported employer support with both encouragement and tuition assistance as an enhancement to success.

Limitations and Strengths of Study
As a pilot study, the findings are limited due to the small number of participants, regional limitations and response rate. A reminder notice was sent out for a second response opportunity, but generated little additional participation. However, the procedural and study findings help guide broader national or international study that can be helpful in guiding education and practice. In addition the pilot study helped identify changes/shifts in the priorities and issues students perceive related to advancing their education.

Conclusion
In addressing the purpose of the study, the barriers, priorities and enhancement/motivational factors associated with RN-BS/BSN academic transition were well defined. The primary enhancement/ motivator finding that most students are self-motivated to advance their education needs to be capitalized by employers and educators, expanding awareness of opportunities higher education can provide, support students in their educational process through resources (e.g., financial, time), and providing quality online academic experiences. The barriers identified indicate individuals pursuing additional education sometimes have barriers outside of their control: cost, time, family responsibilities, work demands and time constraints; therefore development and implementation of flexible educational programs, with online delivery methods are overwhelming preferred and allow nurses prepared at the associate degree level pursue their baccalaureate degree. Even with the online method, educators and employers need to continue to demonstrate flexibility with scheduling in both the work place and academic arenas. For education, this may mean the development of adaptable course delivery models, schedules and academic advising. For employers, this may mean the development of work schedules that plan for school participation.
To address the barriers to seamless education and costs, educators need to adequately guide students to obtain correct non-nursing courses and pre-requisites and prevent unnecessary duplication of nursing courses to help defer additional costs. The pre-requisite coursework requirements were not identified as a priority by students, yet they were listed as barriers. Further investigation is needed in this area, as it also has an impact on cost and time. Early advising and degree audits in the associate degree programs can aid in this issue, but due to the variety of BS/BSN programs available it is not always easy to predict where a student will chose to attend. Nursing educators have a clear impact on streamlining pre-requisite (non-nursing) courses required and improving communication with associate degree programs; however, less control exists in non-nursing college/ university requirements for graduation and the school students choose to attend. In addition, educational institutions need to continue to provide online education programs and pursue scholarships and grants for students, and share funding opportunities with students at all stages of their academic careers. Since choice of programs was identified as an incentive, advisors at the associate degree level will need to become more versed in BS/BSN programs available and requirements.
The identification of support by family and significant others as both a barrier and enhancement factor was interesting. This leads the researchers to extrapolate that the level of support identified by the student may be a key to how it was viewed by the student. Returning to school puts a stress on time, money, childcare, eldercare responsibilities and work commitments for the students; therefore, program advisors and practice partners to support the student with stress management and time management skills. The use of "step-out options" for students that do not result in significant delay in their plan of study should also be considered. Both partners need to focus on connecting school with work, and perhaps, even connecting family with school by including the family in the orientation process. Students in the study indicated a desire to serve as a role model for their children in pursuit of higher education; therefore, involving the family could be a positive factor.
By better understanding the barriers factors influencing academic transition, decision-makers can begin to design programs, delivery models, advising and other areas of support to help decrease or eliminate these distractions from success, while strengthening motivational factors. Understandably, there may be regional differences in barriers to students and this study provided information on the experience of nurses from one region, unique student profiles may exist in various regions of the U.S. and globally. This study supports existing findings and provides new knowledge related to barriers and enhancing factors to nurses pursuing an RN-BS/BSN degree. A partnership between educators, practice leaders, families/ significant others and students is essential for the success of the student goals.