Holistic Academic Progression for Nurses: An Interprofessional Model

This article highlights a holistic approach to supporting academic progression for nurses in an online RN to BSN program. Academic progression for RN to BSN students is supported by an interprofessional team composed of an Outreach Coordinator, Admission Counselor, Academic Advisor and Faculty Director. The interprofessional model is a specific set of strategies used by one program to support the student from the initial point of contact with the College through successful completion of the BSN degree. An emphasis is placed on understanding the unique needs and goals of the students in the program which is designed for nurses who are currently working in a variety of practice settings. Specific team member responsibilities and collaborative strategies that are integrated across the student’s experience are discussed. Student feedback serves as a primary source for evaluating the program. A sampling of student feedback is included in the article that demonstrates a high level of satisfaction with the holistic approach including (a) the availability of their advisors, (b) individualized degree planning, and (c) a supportive presence provided by their advisor during the program.


Introduction
In 2010, the Institute of Medicine (IOM) [1], now known as the National Academy of Medicine, issued key recommendations for the nursing workforce amidst a rapidly changing and complex healthcare environment. To meet current challenges and improve healthcare outcomes, the IOM urged academic nurse leaders to work together to increase the proportion of nurses with a bachelor-of-science in nursing (BSN) degree from 50 to 80 percent by the year 2020 and charged that "nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression" (p. 4).
In 2016, the National Academy of Medicine renewed their recommendations to support nurses in attaining higher levels of nursing education and specifically called for increasing the number of nurses with a doctorate degree. To move in that direction, the BSN is now the preferred degree for practice in many health care settings and organizations, including hospitals with Magnet Recognition, academic healthcare organizations and community-based and public health organizations [2]. Academic nurse leaders have responded by increasing access to BSN completion programs for registered nurses. The purpose of this article is to discuss a holistic approach to supporting academic progression for nurses in one online RN to BSN program.

Trends in RN to BSN Education
The accessibility of online programs has presented nurses with flexible, efficient and cost-effective ways to access higher education to advance their degree while they continue to work in their local communities and balance family responsibilities. Due to the emphasis placed on the BSN in the workforce, nurses are now strongly encouraged to advance their education to overcome limitations they may experience when progressing to certain positions within the profession. The number of nurses enrolled in RN to BSN programs increased by 69 percent between 2010 and 2014 [3]. Despite the increase, the number of nurses with a BSN or higher still falls behind the national goal of 80 percent by 2020. Between 2012 and 2016, the percent of Oregon RNs that held a BSN grew from 44 to 48 percent while 54 percent held a BSN degree or higher in 2016 [3]. In a national workforce study conducted in 2015, 42 percent of RNs reported having a BSN or higher degree as their initial credential, while 65 percent reported having a baccalaureate or higher degree (in any field) as their highest level of education [4].
Registered nurses are expected to manage the care of individuals, families and communities in a rapidly changing, complex health care environment as well as contribute to high quality care outcomes across all care settings. Research has demonstrated a strong connection between higher levels of nursing education and higher quality patient care outcomes, fewer medication errors and lower rates of patient mortality [5,6]. Nurses with more education have demonstrated higher levels of productivity, stronger critical thinking, better clinical judgement and are more likely to take on greater professional responsibilities and complexity of practice because of their education [5].

Population health
As more nurses were moving toward BSN completion, the Affordable Care Act (ACA) of 2010 was signed and millions of Americans gained access to health care. With that came an unprecedented amount of funding allocated to promoting the health of populations and reducing the incidence of preventable illness and disability in the U.S. In 2013, the American Association of Colleges of Nursing (AACN) recommended a stronger curricular focus on population health in nursing education programs. Promoting population health requires that nurses are prepared with knowledge of Journal of Community and Public Health Nursing diversity, strong critical thinking skills, an awareness of social justice and civic duty and an ability to solve complex problems [2]. BSN completion programs build on the foundations of associate degree education by expanding on liberal arts, nursing research, leadership and population health while transitioning the nurse to a higher level of professional practice.

Linfield RN to BSN Program
Linfield College is a small liberal arts college in the Pacific Northwest with a robust nursing school located in Portland, Oregon. The School of Nursing is regionally accredited by the Northwest Commission on Colleges and Universities, the Commission on Collegiate Nursing Education (CCNE) and recognized by the Oregon State Board of Nursing (OSBN). Linfield offers three paths for students to earn a Bachelor of Science in Nursing (BSN) including a traditional BSN degree, an accelerated BSN degree for students who have a previous bachelor's degree and an online RN to BSN degree for licensed nurses. The nursing curriculum is community-based, emphasizing leadership, health promotion, illness prevention and treatment and social justice, through a learner-centered approach to nursing education. The RN to BSN curriculum has been specifically designed for working nurses. Key features of the online RN to BSN program include 100 percent online course delivery, required local or international community service learning experiences for nurses to complete clinical requirements and the opportunity to complete electives specific to nursing practice including Evolution of Nursing, Health Disparities and Palliative Care Nursing. An important foundation for success of the RN to BSN program can be attributed to understanding the unique needs and goals of the individuals within the population served by the program.

RN to BSN student population
The online RN to BSN program attracts a diverse student population including new graduate nurses as well as nurses with practice experience. The students are geographically and generationally diverse, with experience in a variety of health care settings. The average age of the RN to BSN student in the program is 37. The majority are employed part-time or full-time and attending the online program while balancing career and family responsibilities.
Nurses who have made the decision to advance their education are motivated by a variety of personal and professional reasons. Historically, nurses have pursued continuing education and lifelong learning opportunities to stay current with health care changes, attain higher levels of education in nursing, or advance professionally. Life or work experiences often convince or motivate adults to seek out learning opportunities. The nurse's readiness to learn often develops from real life problems [7] or after realizing that a change is needed in their knowledge or skills. Most recently, nurses have responded to employer requirements for higher levels of education or to make a career change to advanced practice in nursing, a leadership position, or a role in community/population health. As adult learners, nurses in the RN to BSN program benefit from using their experience as a foundation for learning and from being involved in planning their education. Research has indicated that adults are unique in their degree of motivation, their individual experiences with learning and in using their work experiences as a rich resource for their own and others' learning [7].
Registered nurses often report barriers as they transition to baccalaureate education. Some express high levels of anxiety related to finances, age difference between themselves and other undergraduate students and challenges juggling course responsibilities with work [8]. Some nurses raise concerns about advances in technology, transferability of previous credits and recognition of their previous nursing experience. These are common concerns seen repeatedly in the literature surrounding adult education that contributes to the difficulty retaining students through degree completion [9]. To address the individual circumstances of nurses attending this specific online program, the RN to BSN team has developed a holistic approach to supporting academic progression.

Holistic Academic Progression
Academic progression for RN to BSN students in the program is supported by an interprofessional team composed of an Outreach Coordinator, Admission Counselor, Academic Advisor and Faculty Director. The interprofessional model is used to holistically support the student from the initial point of contact through degree conferment or what will be referred to as academic progression. Although each team member has distinct responsibilities, collaborative overarching strategies are effective when integrated across the student experience.
Individualized course planning is an example of a strategy that is implemented by multiple team members. Beginning with the first point of contact in the community, continuing throughout the program with skilled support from the academic advisor and culminating with faculty mentorship in the classroom, students experience multiple sources of support as they move through the program. The specific strategies implemented by the interprofessional team ( Figure 1) are discussed in the following sections.

Outreach coordinator
The outreach coordinator focuses on community engagement and relationship building by providing a consistent and personalized presence in the health care community. Outreach activities include, but are not limited to, creating and maintaining relationships with health care organizations and nurse employers, engaging with nursing school alumni and other stakeholders and identifying initiatives that engage a variety of professional groups. The outreach coordinator is often the first point of contact for potential students and members of the community to learn about opportunities at the college.
The outreach coordinator serves an important role within the nursing school related to outreach and recruitment while working closely with the RN to BSN team to understand the needs of the student population and community. Specific outreach activities include serving various vendor opportunities and conferences hosted by hospitals and professional nursing organizations, delivering in-services in the community that educate nurses on the value of earning a BSN and hosting face-to-face and virtual information sessions about education advancement.
The addition of virtual information sessions has improved access to program information for nurses in the workforce including those in rural and out-of-state communities. The synchronous webinars address a variety of topics related to the online program including admission requirements, transfer planning, local and international service learning opportunities and nursing elective courses. Current students, academic advisors and faculty members have participated in the webinars to share information and reflect on their experiences in the program. The webinars are strategically designed for students who are considering their program options and help students envision themselves in the program and build on institutional loyalty. Research has demonstrated that a lack of specific, accurate information at the appropriate time is one of the top reasons that adult students choose not to enroll at a higher education institution [10]. Thus, we have committed our attention to combining outreach, enrollment and academia best practices. We strive to demonstrate our passion for health care, our sincere desire to connect with adult students and to continuously cultivate new outreach opportunities.
Through collaboration and shared responsibility, it is possible to increase the visibility of the institution and engage inquiries that provide nurses with the ability to reach their goals for advanced education. For example, the outreach coordinator and admission counselor work closely together to design and plan student recruitment which benefits the entire college. Cross-collaboration stimulates innovation by utilizing multiple perspectives to develop meaningful actions that will impact the institution [11]. Each member can focus on building relationships in the community which, in turn, helps the college attract prospective students. The elements of the interprofessional model implemented by the outreach coordinator to support academic progression is shown in Figure 1.
Strategies: Specific strategies implemented by the outreach coordinator that support academic progression include assessment of the needs of the community and institution, engaging with health care professionals and clinical organizations, participating in outreach events including individual and group meetings, partnership events, on-site and virtual information sessions, tabling at local and regional conferences, participation in marketing activities and fostering alumni and student engagement in campus activities and events.

Admission counselor
The admission counselor focuses on educating students about program requirements and their transition into a new academic environment. The counselor provides the necessary knowledge and preparation for navigating the transfer process between institutions or back into the academic environment. Many practicing nurses who have been away from the academic environment encounter changes in technology, questions about transfer credits and an unfamiliarity with higher education requirements which can cause anxiety and stress when returning to school [12]. To help students overcome challenges with academic progression, the admission counselor's goal is to build a close working relationship. A level of support that is enhanced by purposeful interactions creates a foundation for program entry and student-professional expectations [13].
The admission counselor's primary responsibility is to recruit and admit students to the institution. The counselor plays a crucial role in impacting a student's decision to enroll, commit to their academic goals and build confidence in their ability to earn the BSN. On-going, effective communication with students is essential to educate them about degree requirements and the admission process. In this way, the admission counselor facilitates the transition into the institution while assisting them to move toward matriculation. Student interactions take place in variety of formats either from the counselor's office or in the community with the primary goal of providing timely follow-up on questions related to transfer planning, transfer credit evaluations and incomplete applications. The counselor is in constant collaboration with new students, potential students and team members including the outreach coordinator, academic advisor and faculty.
In recent years, direct enrollment from associate degree nursing programs has increased because of articulation agreements designed to support educational mobility and facilitate a seamless transfer of academic credit between associate degree and baccalaureate nursing programs [2]. Community colleges have provided vital access to higher education and to associate degree nursing programs for adult students. Due to affordable prices, less strict admission requirements and sites that are geographically available, community colleges have served a valuable role in higher education and in the community. To facilitate academic progression between institutions, it is recommended that faculty representatives work collaboratively to develop agreements that reduce institutional barriers to progression [14]. The goals of the formal co-admission agreement include: Currently, the program has developed 11 partnerships with community colleges across Oregon which are supported by close collaboration between nursing programs. During an annual partnership summit, program leaders and nurse faculty from each of the institutions are invited to share updates from their respective schools. Throughout the year, the RN to BSN team provides community college classroom visits for admission counseling, transfer planning and advising sessions that support students in setting goals and making proactive decisions about progression into the baccalaureate program. It has been effective for admission counselors to make those visits with faculty members who can also share details about the nursing curriculum.
In 2006, the first of 11 co-admission agreements was signed between Linfield College and Chemeketa Community College (CCC). The agreement created a pathway for successful progression from associate degree nursing education to baccalaureate education. Today, 38 recent graduates of the CCC nursing program are currently enrolled in at least one course at Linfield College in pursuit of earning a BSN. Furthermore, under the guidelines of the co-admission agreement, an additional twelve CCC students who are enrolled in the associate degree program are currently co-admitted to Linfield College.
The agreement has successfully supported academic progression between the two nursing programs, it has also made a difference in the local health care community by providing access to education for new graduate nurses who seek employment within a large hospital system. As many hospital systems seek Magnet Recognition, nurses are required to achieve their BSN prior to employment. The partnership between Linfield and CCC increases opportunities for local nurses to stay in their community and gain employment in Magnet Recognition level hospitals. The elements of the interprofessional model implemented by the admission counselor to support academic progression is shown in Figure 1.
Strategies: Specific strategies implemented by the admission counselor that support academic progression include developing initial relationships with students that prioritize academic goals, assessing transfer credit to develop individualized course and transfer planning and educating students about the admission process. The admission counselor supports the transition of the student to the academic advisor when they advance to the point of enrollment.

Academic advisor
The Academic Advisor's focus is on proactively advising students for progression in the major, implementing specific retention practices and collaborating with the RN to BSN team for student success. To support progression, the advisor coordinates academic plans, educates students about their degree requirements while addressing their unique academic history and creating a safe space for active listening and effective communication. To enhance retention, the advisor coordinates quarterly events for advisees, promotes a supportive environment by acknowledging student life events and audits degree plans to ensure each semester's degree candidates are cleared for graduation. The advisor also coordinates student support by engaging faculty and sharing student feedback with the larger RN to BSN team. Authentic feedback allows faculty to adjust classroom experiences and the admission counselor to utilize student testimonials in recruitment. Ultimately, the RN to BSN academic advisor sets the tone for student success with an individualized and professional advising approach to supporting student progression in the program.
The role of an academic advisor has changed significantly over the two decades this advisor has been involved in higher education. In the past, faculty saw advising as a clerical task, an obligation to the college to register students and that was all the advising that was expected of them [15]. As access to online education expanded for adults advancing their education, academic advisors have adapted to a "virtual" advising model which provides students with greater access to their advisor using communication methods that work best for them. Advances in technology allows advisors to conduct meetings at flexible times using e-mail and virtual applications including Skype© and WebEx©. The academic advisor also schedules individual phone appointments regularly with students.
In a study that addressed pre-nursing and nursing students' perceptions of the characteristics and qualities of effective academic advisors, students identified being knowledgeable as the most important characteristic of a nursing academic advisor, followed by fostering a nurturing professional relationship and being approachable [15]. Given that online students are not able to stop by the advisor's office at any time due to geographical differences and work schedules, cultivating a genuine sense of trust and caring are high priorities for the advisor. The advisor works diligently to create a solid connection with the student, as well as to support a strong connection to the college, which impacts the advising relationship as well as retention in the program. The academic advisor serves as a guide, a liaison and an advocate for students. With knowledge of adult learning principles and best practices for academic advising, RN to BSN advisors get to know each student and adapt quickly to their needs, set up processes that are focused on student success and maintain an individualized advising model. The elements of the interprofessional model implemented by the academic advisor to support academic progression is shown in Figure 1.
Strategies: Specific strategies implemented by the academic advisor include responding promptly to student requests, intentionally contacting students for advising support and course planning, providing flexible opportunities for student appointments, engaging with social support and advice for work-life balance, assisting with problem-solving when challenges arise, coaching for career opportunities and advocating for college policies and procedures.

Faculty director
A faculty member in nursing serves as the director of the RN to BSN program. The director provides leadership for delivery of the curriculum, manages the program partnerships with community colleges and clinical organizations and serves as a liaison for nursing and additional departments within the institution. The director serves on the committee that addresses admissions and progression of students in nursing and has a key role in advocating for policies that support the success of all students including students in the online program.
The RN to BSN curriculum is led by a small team of faculty who have expertise in post-licensure education and certification in online teaching. The director maintains oversight for course scheduling, mentoring and evaluation of adjunct faculty and ensuring expectations for rigor and quality assurance in online education. The RN to BSN curriculum is taught using a course lead model to ensure consistency and utilize content expertise. The full-time faculty members are seasoned educators with a strong understanding of nursing workforce issues as well as the challenges that nurses face while balancing their education program with work and family responsibilities.
The director works closely with the interprofessional team on issues impacting outreach and recruitment in the community and on student issues that affect advising, student success and retention. The benefits of having a nursing faculty member participate in the community includes having individual discussions with nurses to share details about the curriculum, the importance of continuing education in nursing and workforce issues which can be discussed in depth.
One of the strongest elements within the interprofessional model is providing diverse representation of team members in the community. Therefore, the faculty director participates in face-to-face and virtual information sessions, presentations at community colleges, tabling events at conferences and meeting potential students and stakeholders in a variety of formats. On-going assessment of student and stakeholder satisfaction, developing credibility in our outreach to the community and creating opportunities to improve communication about the program are all essential to maintaining a reputable program and strengthening student outcomes. The elements of the interprofessional model implemented by the faculty director to support academic progression is shown in Figure 1.
Strategies: Specific strategies implemented by the faculty director include participating in outreach and recruitment activities in the community, advising current and prospective students, collaboratively solving problems, managing program partnerships and providing leadership for delivery of the RN to BSN curriculum.

Evaluation
Program evaluation is a systematic assessment of all components of an academic program [16]. Student feedback obtained through implementation of course evaluations and student surveys are a primary source of knowledge used to understand how various elements influence program effectiveness and student success [16]. Academic advising is an integral part of a successful college experience and has been directly linked to higher persistence to graduation [17,18]. Professional advising and student-centered support are primary elements of the interprofessional model that is used throughout the RN to BSN student's academic experience.
In a recent survey conducted to evaluate student experiences with advising in the online RN to BSN program, anonymous feedback was obtained from 111 online students. Overall, students indicated satisfaction with (a) the availability of their advisors (b) individualized degree planning and (c) a supportive presence provided by their advisor during the program. Additionally, three of the student comments acknowledged the value of strong academic planning at the time of their application to the program: • I think the advising team really understands that we working nurses are pulled in many directions and don't have the same time we did in our RN program to follow up with the different aspects of completing on online program…my advisors [sic] helped me expedite my application and organize financial aid…these little things were so helpful in getting me started on the right foot. • It leaves no questions [academic planning]...I had a game plan before I started my program. • While I was sure I wanted to pursue an online BSN, Linfield became my first choice because ease of the application process…no huge data base to navigate, accessibility of advisors and academic planners.
The accessibility of the academic advisors emerged as a consistent theme described by students in their feedback. They appreciated that advisors are timely in their communication and provide multiple opportunities for communication including email, phone calls and face-to-face appointments: • My advisor is accessible and responds quickly to my questions... She has kept me informed about what I need to do with regards to registration and my academic plan. • My advisor always answers promptly and is helpful even when I'm asking redundant or stupid questions… which happens when I get overwhelmed and tired and can't figure it out on my own.
Students described advising experiences that provided individualized degree planning which made them feel like their education was "personalized" and that they were "actually known and heard" when they interacted with them. One student reflected on the importance of individual preferences in the course planning process: • Seeking professional advice, I found more than just an advice at the time of need… I found an understanding and kind friend! Thank you for helping me to be successful! • I appreciated that there was a plan and an order. I did not have to research which class to take when and when each were [sic] offered. It was just outlined for me. There was an elective that I just was not excited about. I contacted my advisor, obtained options and found a class that fit me much better.
Another student shared the unique circumstances of life and work that can create challenges to being successful in a rigorous education program: • I work full time night shift and have two young children. Going back to school was extremely intimidating with all I have on my plate. Since day 1 with my advisor [sic] she has helped make this process as easy as possible. She is always available to answer my questions and she sends me emails reminding me about registration...I couldn't stay on top of this without her!! Students that responded to the survey also described a supportive advising presence that influenced their success in the program: • Advising at Linfield is on the professional level! • The support! I had some serious life altering events occur during my schooling at Linfield and my advisor [sic] was phenomenal with helping me through the process! She went out of her way to check on me, to make sure I had everything in line to get an incomplete in the courses, so I could finish my classes at a later time! I couldn't have done it without her help! • I definitely think that the advisors are probably one of the best aspects about Linfield. Especially doing the program online, having someone there for support is comforting. • The encouragement that the advisor provides to me as a student throughout my education at Linfield.
On-going program evaluation is planned. It will be important to obtain student input on additional areas for improvement specifically related to communication that occurs between academic advisor and advisees. In addition, evaluation of the community college coagreement partnerships will guide relationship building in the community. Additional student feedback is presented in Table 1.