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Magnet® Facility Nurses: Pursuing a Baccalaureate Degree in Nursing
MAGNET® FACILITY NURSES: PURSUING A BACCALAUREATE DEGREE IN NURSING ELIZABETH J. WINOKUR, PHD, RN, CEN*,†, DANA N. RUTLEDGE, PHD, RN‡, AMY HAYES, MSN, RN§
AND
The aim is to explore factors that motivate and obstacles that impede nurses from pursuing baccalaureate education when employed by a Magnet® organization. In the Future of Nursing (2011), the Institute of Medicine concluded that the baccalaureate should be the minimum education for nurses. Magnet organizations are encouraged to meet the Institute of Medicine goal of 80% of nurses with a baccalaureate by 2020. In February 2014, a 15-item on-line survey was sent to nurses at a western Magnet-designated hospital to assess factors that motivate registered nurses to achieve a baccalaureate. Descriptive statistics and a general thematic analysis were completed. A 20% response rate (N = 191) was achieved. Most respondents (78%) entered nursing as associate degree/ diploma graduates, and most (84%) either had a baccalaureate or master's degree or were currently enrolled in school. Encouragement from other nurses was the factor most frequently selected as facilitating return to school. Impeding factors included age and family responsibilities. A minority of nurses reported that they did not believe that a baccalaureate would make them a better nurse. Findings suggest that peer and leadership support play a larger role in facilitating baccalaureate completion more than previously reported. Additional research is needed to explore the role of registered nurse to registered nurse encouragement in facilitating educational advancement. (Index words: Magnet; Baccalaureate education; Nursing education; Motivation; Education, post RN; School re-entry) J Prof Nurs 0:1–9, 2016. © 2015 Elsevier Inc. All rights reserved.
Background In its Future of Nursing report, the Institute of Medicine (Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine, 2011) urged nurses in all settings to work together to increase the proportion of nurses with a baccalaureate degree to 80% by 2020. The report conclusion, supported by increased complexity of health care and improved patient care outcomes, was that a baccalaureate should be the minimum educational degree for nursing. Magnet®-designated organizations have been encouraged by the American Nurses Credentialing Center to meet this goal (American Nurses Credentialing Center). The nursing literature includes a number of studies exploring factors that motivate diploma and associate degree *Clinical Educator, Nurse Researcher, St. Joseph Hospital, Clinical Education, Orange CA 92686. †Assistant Professor of Nursing, California State University, Los Angeles, CA. ‡Professor of Nursing, California State University, Fullerton, CA. §Clinical Educator, St. Joseph Hospital, Clinical Education, Orange CA 92686. Address correspondence to Dr. Winokur: St. Joseph Hospital, California State University, Clinical Education, Orange CA 92686. E-mails: [email protected], [email protected] (E.J. Winokur) 8755-7223 1 http://dx.doi.org/10.1016/j.profnurs.2015.11.003
(AD) nurses to return to school (Altmann, 2011; Delaney & Piscopo, 2004; Megginson, 2008; Schwarz & Leibold, 2014). These studies support specific barriers faced by nurses considering a baccalaureate degree. However, little is known about the effect of Magnet designation on employed nurses considering or returning to school.
Benefits of Having a Baccalaureate-Prepared Staff Aiken's (2014)recent comments on the value of employing a predominately baccalaureate workforce point to the benefits in decreasing lengths of stay and readmission rates (cost savings) and improved patient mortality. In an innovatively designed study, Yakusheva, Lindrooth, and Weiss (2014) found that patients from an urban Magnet-designated academic medical center receiving at least 80% of their care from nurses with a baccalaureate degree had significantly lower mortality (Odds Ratio = 0.891), lower odds of readmission (Odds Ratio = 0.813), and 1.9% shorter length of stay. These findings are consistent with earlier findings (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Blegen, Goode, Park, Vaughn, & Spetz, 2013). Among 168 Pennsylvania hospitals with varying educational levels among registered nurses (RNs) (0–77% RNs with bachelor's degree or higher), a 10% increase in the proportion of nurses with higher degrees Journal of Professional Nursing, Vol 0, No. 0 (January), 2016: pp 1–9 © 2015 Elsevier Inc. All rights reserved.
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decreased the risk of mortality or failure to rescue by 5% among surgical patients (Aiken et al., 2003). Among 18 teaching hospitals who had 62% of nurses with at least a baccalaureate degree, higher levels of RN education were negatively correlated with numbers of adverse events and lengths of stay for patients after taking into account staffing and hospital characteristics (Blegen et al., 2013).
Barriers and Facilitators to Returning to School Few recent studies have documented barriers and facilitators for nurses to obtain a baccalaureate degree, and fewer described AD and diploma nurse perceptions of pursuing further education (Altmann, 2011; Schwarz & Leibold, 2014). These issues merit reanalysis given the changing health care and economic climate and the possibility of an effect of Magnet designation on education seeking among RNs. Barriers have largely been identified as the multiple competing priorities in nurses' lives and work. Facilitators include the perceived personal or professional growth potential to be gained from education (Delaney & Piscopo, 2004; Schwarz & Leibold, 2014) and availability of programs that are geared to working nurses (Altmann, 2011; Megginson, 2008). In a review of 28 studies about nurses' attitudes and perceptions about returning to school, Altmann (2011) categorized incentives/disincentives into three categories: personal, professional, and academic (Table 1). An understudied barrier to returning to school is “lack of vision” (Orsolini-Hain, 2012). Lack of vision was described as lack of appreciation for what would be gained from baccalaureate or graduate education. This lack of vision may stem from work cultures that do not distinguish between the functioning knowledge and skill levels of nurses who have different academic degrees (Orsolini-Hain, 2012). Among 297 Maryland AD/diploma nurses under 50 years of age working in hospitals in 2004, and not currently in a baccalaureate or higher nursing program, only 19% planned to enroll in further nursing education (Warren & Mills, 2009). Certain factors predicted intention to return to school (e.g., planning a career in nursing, requirement of further education to maintain current position) and included organizational incentives. In this study, satisfaction with current employment was a reason for not returning to school (Warren & Mills, 2009). This latter finding indicates that having an organizational push for further education such as the Magnet benchmarks may serve to catalyze nurse action related to further education.
Factors Related to Graduation for RN-to-BSN Students Little is known about factors that facilitate RN-to-BSN (bachelor of science in nursing) student success. In a survey of 14 California schools, RN-to-BSN students were identified as generally older, married, and going to school part time while working and juggling family responsibil-
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ities (Robertson, Canary, Orr, Herberg, & Rutledge, 2010). Factors predicting academic success were flexible work schedules, nondemanding family responsibilities, financial and personal support, realistic expectations from work, personal motivation, higher grades, and fewer hours worked. These are congruent with themes identified by nurses interviewed about facilitators and barriers to BSN completion (Duffy et al., 2014). Nurses have described the importance of having an appropriate classroom environment and support from their classmates (Delaney & Piscopo, 2007). In a study comparing RNs who succeeded in obtaining a degree and those who did not, nongraduates had more negative reactions related to college attendance and did not see future benefits from the BSN (Dowell, 2000).
Conceptual Underpinnings Returning to school is a desired outcome that is related to but different from staying in school. Key constructs in the process of nurse decision-making to return to and stay in school include individual characteristics, organizational influences (Warren & Mills, 2009), and academic factors (Altmann, 2011). Individual characteristics include demographics (e.g., age, caregiving responsibilities, income), professional commitment, career identify (e.g., how much the person identifies with nursing as a career), and perceptions of what the baccalaureate degree offers a nurse. As described by Warren and Mills (2009), personal motivation is influenced by individual nurse characteristics such as perceived effort that are mediated by organizational influences. Organizational facilitators may be considered either rewards or incentives (e.g., payment for classes, on-line class offerings, forgivable loans). The characteristics of an academic program can serve as facilitators (e.g., on-line offerings, flexibility) or disincentives (e.g., travel distance, enrollment procedures). In summary, employed nurse motivation to return and stay in school is influenced by individual nurse characteristics along with organizational and academic program influences.
Local Context Related to Nursing Educational Advancement Early in 2013, a discussion about educational advancement for nurses occurred between the chief nursing officer and a human resources staff member from a twice Magnet-designated facility in the southwest. Given a nursing staff with about 60% baccalaureate education and in light of trying to achieve the 80% Institute of Medicine goal, they posed two questions: (a) what were the incentives and barriers for diploma/AD-educated staff nurses to consider returning to school and (b) when a nurse returned to school, what factors predicted graduation with a baccalaureate degree? These questions were shared with the hospital nursing research council.
Study Purpose The aim of the study was to explore the factors that motivate and the obstacles that impede nurses employed in a Magnet-designated organization from returning to
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Table 1. Important Factors to Nurses Returning to School Type of factor
Disincentive/Barrier
Personal
Incentive/Facilitator
Competing priorities Lack of confidence Feeling secure in a job Perceiving the baccalaureate degree as not enhancing clinical skills Perceiving baccalaureate prepared nurses as no different or not better (even inferior to) than those with less education Lack of credit for past experience Practical issues (inflexible or long programs)
Professional
Academic
Desire for personal achievement Desire for more nursing knowledge Recognition of education level (organizational) Job security Pressure from employer to seek further education Practical constraints (e.g., work schedules)
Credit for past experience Practical issues (flexible or compact programs)
Adapted from Altmann (2011).
school for a BSN and the factors that affect baccalaureate completion among those who return to school.
Methods In February 2014, an on-line survey was sent to all RNs at a Southern California, Magnet-designated hospital. The study received exempt status by the hospital institutional review board. The study team believed that all nurses employed at the hospital had valuable insights into this study, even nurses who entered the profession with a baccalaureate degree; thus, all RNs were considered potential participants.
Measure A survey was developed by one of the co-authors and a prior hospital nurse researcher to describe the sample and address study aims; no psychometric testing was done. The newly developed survey contained 14 multiple choice/rank ordered items and one open-ended question. Demographic questions related to age, gender, race/ethnicity, educational status, and work history. Nurses were asked the number of years as an RN before beginning an educational program or number of years to complete a program. Nurses who had not gone back for a bachelor's degree and were “pretty sure they never will” were asked to select the main reason for not returning to school. Nurses who had completed a BSN degree or were working on a degree were asked about barriers and facilitators for going back to school. All respondents were asked to address—in their own words—why nurses choose or do not choose to obtain a baccalaureate.
Procedures SurveyMonkey (Menlo Park CA) provided the platform for on-line delivery and responses. To address participant confidentiality, SurveyMonkey uses Secure Sockets Layer encryption, which keeps links and survey pages secure during transmission from the hospital account to respondents and then back into the account. Over 1 month, nurses received an invitational e-mail to their hospital addresses explaining the study and their potential involvement, followed by two reminder e-mails; each communication contained a link to the survey.
Data Analysis Descriptive statistical analyses were completed using software package for statistical analysis Version 20. Descriptive statistics were used to describe the sample and responses to individual survey items. Findings from the open-ended question were analyzed using general thematic analysis (Polit & Beck, 2012, pp. 515–517). A nonlinear, iterative process was used requiring multiple readings of the raw data and was performed by two of the three authors. Responses were entered into a spreadsheet with original entries—one per row—in the left-most column and blank columns to the right. Initially, responses were reduced to discrete segments. Patterns in the data were given conceptual labels, representing broad categories based upon similarity or contrast; these were entered into the first column to the right. Subsequently, final themes/ concepts were determined and entered into the next column. Analysis of these entries in light of the conceptual underpinnings of the study led to changes in the way relationships among the concepts were perceived.
Results Approximately 20% of the hospital's nurses (N = 191) responded to the survey. Participants worked in 20 different inpatient and outpatient units. The majority were female (92%); 78% had been in RN practice more than 10 years. As seen in Table 2, over 70% of the sample was 41 years of age or greater. The majority (78%) had entered nursing as an AD or diploma graduate. Most (84%) had already completed a BSN/MSN (Master of Science in Nursing) or were currently enrolled in a program leading to the degree. Some respondents (14.7%) reported that they had no intention of obtaining a BSN. Time to return to school ranged from an immediate start upon graduation from initial nursing program to 43 years (M = 11.8 years). The majority of nurses returned to school for a BSN, whereas three reported entering AD to MSN programs.
Facilitators and Barriers for Returning for a BSN When asked to rank the barriers or facilitators of returning to a baccalaureate program (Table 3), the
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Table 2. Sample Demographics N (%)
Characteristic Age in years 20–30 31–40 41–50 50 + Gender Female Ethnicity White African American/Black Hispanic/Latino Asian Native American Other Missing Current highest degree in nursing Diploma Associate of Science in nursing Baccalaureate (bachelors of science in nursing) Masters (master of science in nursing) Other First degree in nursing Diploma Associate of science in nursing Baccalaureate (bachelors of science in nursing) Masters (master of science in nursing) Length of time as an RN (years) Primary work setting as a nurse Medical–Surgical Critical care Perioperative Mother/Baby/Labor & delivery Mental/Behavioral health Emergency Oncology Ambulatory care Specialty (e.g., informatics, endoscopy) Current degree status Initial nursing degree was BSN/MSN Completed baccalaureate degree as working nurse Baccalaureate or MSN bridge degree in process No baccalaureate degree, not in school Missing
15 41 71 64
(7.9) (21.5) (37.2) (33.5)
176 (92.1) 120 (62.8) 1 (0.5) 28 (14.7) 31 (16.2) 0 7 (3.7) 4 (2.0) 7 (3.7) 72 (37.7) 72 (37.7) 39 (20.4) 1 (0.5) 27 (14.1) 123 (64.4) 36 (18.8) 5 (2.6) Mean 5.2 ± 1.4; 1–7 60 32 22 26 3 18 17 4 9
(31.4) (16.8) (11.5) (13.6) (1.6) (9.4) (8.9) (2) (4.7)
46 (24.1) 93 (48.7) 22 (11.5) 28 (14.7) 2 (1.0)
Note. N = 191.
most highly ranked factor facilitating return was encouragement from other nurses including peers, managers, and educators (70% of respondents). Most highly ranked factors acting as barriers for a return to school were time (60%) and financial constraints (34%).
Factors Contributing to Success in Baccalaureate Completion Nurse respondents varied in their ratings of factors contributing to baccalaureate completion on degree of
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helpfulness (most = 5, least = 1; see Table 4). One factor stood out as most helpful: 37% rated “the BSN program designed for working nurses” as a 1 or 2). One factor stood out as least influential: 31% rated “support of other nurses” as 4 or 5.
Cues to Pursue Baccalaureate Education Nurses were asked to consider the series of thoughts taken before they returned to school. Then, they were to select from five items (Table 5) which one was the most important and made them commit to going back to school. For the 120 nurses who responded to this question, the most common response was “I finally decided to advance my nursing career” (40%) followed by “I learned about the goal of Magnet-designated organizations to have 80% RNs with a BSN by 2020” (24%) and “I had a conversation with a nurse who already had a BSN” (21%).
Barriers to Obtaining a BSN Nurses who had not gone back to school were asked to select the major reason for not pursuing further education (Table 6, N = 32 out of the 79 [40%] who currently had a diploma or AD as the highest in nursing). Financial concerns and no effect on competence were the most frequently chosen responses, 47% (n = 15) and 38% (n = 12). Concerns about ability to succeed in a BSN program were expressed by 16% of nurses who were not planning to return to school.
Qualitative Findings When asked why nurses choose or do not choose to obtain a BSN degree, 161 respondents (84%; n = 191) responded to this open-ended question. Nurses discussed both positive and negative influences to going back to and staying in school. The majority of nurses selected more than one factor as influencing return to school (see Figure 1, Table 7). The most frequent reasons cited were individual nurse factors such as other responsibilities (finances, time), age, and either positive or negative attitudes toward the BSN. These comments were expressed by 143 of the 161 respondents. In 72 instances, these factors were the only influencing factor reported by the participant. Statements related to the employing organization accounted for 58 of 161 comments. These comments were almost exclusively related to employer expectations (negative and positive). Some participants highlighted support received from mentors and others at the hospital as positively influencing them. Eighteen participants selected factors related to the academic institution, commenting mostly about program cost and flexibility. Supportive factors were cited less frequently and usually in conjunction with one or more influencing factors; motivation, perceived personal effort, and the impact of facilitators were each mentioned an average of 10 times. Finally, 12 individuals reported self-efficacy issues such as lack of confidence; these were predominately seen as a barrier to returning to school.
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Table 3. Barriers or Facilitators to Going Back for Baccalaureate Education (Rank Ordered) n (%)
n (%)
n (%)
n (%)
n (%)
1
2
3
4
5
Barrier or facilitator Barriers Time constraints Financial constraints Lack of support from other nurses Lack of family support Feeling like I might not be successful Facilitators Close geographic proximity of programs Encouragement from other nurses Access to on-line programs Availability of hospital financial support Possibility of future advancement in nursing
114 65 5 8 7
(59.7) (34.0) (2.6) (4.2) (3.7)
48 77 17 16 22
(25.1) (40.3) (8.9) (8.4) (11.5)
11 (5.8) 24 (12.6) 44 (23.0) 52 (27.2) 53 (27.7)
9 13 46 56 39
(4.7) (6.8) (24.1) (29.3) (20.4)
9 (4.7) 12 (6.3) 79 (41.4) 59 (30.9) 70 (36.6)
21 134 21 29 25
(11.0) (70.2) (11.0) (15.2) (13.1)
43 13 58 56 39
(22.5) (6.8) (30.4) (29.3) (20.4)
45 (23.6) 13 (6.8) 50 (26.2) 33 (17.3) 46 (24.1)
38 21 24 44 34
(19.9) (11.0) (12.6) (23.0) (17.8)
44 (23.0) 10 (5.2) 38 (19.9) 29 (15.2) 47 (24.6)
Note. N = 191. Barriers coded with 1 being the biggest challenge/barrier and 5 as the least challenging. Facilitators coded as 1 being the most helpful factor and 5 being the least helpful.
Choosing Not to Pursue Further Education One of the most common themes related to why nurses do not return to school was the perceived lack of value of the baccalaureate degree. Nurses mentioned several factors surrounding this perception: lack of financial gain, the need to invest precious time and energy, and the fact that they had experienced a lack of respect for baccalaureate nurses. More difficult to summarize were comments that indicated a view that better educated nurses (e.g., those with baccalaureate degrees) show no difference in thinking/acting than lesser educated nurses (e.g., those with AD or diploma degrees). In addition, many respondents stated that nurses who wanted to stay at the bedside or, specifically, “did not want to be a nurse manager” did not need further education. Along this line, some reported that they did not believe that achieving a BSN would make them a better nurse. As expected, competing responsibilities were often mentioned as barriers. These included financial and time constraints along with age and family responsibilities. A minority (n = 5; 3%) perceived financial disincentives to return to school (e.g., less able to work extra shifts or take management positions while in school).
Choosing to Pursue Further Education Fifteen nurses (9%) indicated that they succumbed to returning to school because they were “out of excuses!” Specific personal facilitators noted were having a personal goal or feeling family support to achieve more education
or inversely feeling “professionally left behind.” Nine nurses (5%) mentioned something about the encouragement by peers who were returning to school, even to the point of feeling “pressure” to enroll. Employing organizational incentives were mentioned by many. Eleven nurses (7%) directly indicated that the Magnet push for increased levels of education at the hospital was the impetus that helped them take the step. Others (26; 15%) cited a worry over ongoing or future employability without baccalaureate education (“I could not progress in my specialty without it”). Eleven (7%) mentioned hospital financial incentives (tuition reimbursement) and rewards (salary increases based upon education). Other nurses (n = 26; 16%) reported pressure due to the existence of an organizational expectation to get the BSN. Ten nurses (6%) reported that program characteristics (need for multiple transcripts, how classes were offered, technical support) were important to them as influential academic facilitators/barriers.
Discussion By and large, our findings supported the literature-driven conceptual underpinnings for our study. Prior studies with nurses working in hospitals had indicated that employed nurse motivation to return and stay in school is influenced by individual nurse characteristics along with organizational and academic program influences (Altmann, 2011; Delaney & Piscopo, 2004, 2007;
Table 4. Factors Contributing to Success in Baccalaureate Completion Factor Support of other nurses including managers and educators Availability of funding BSN program designed for working nurses and workable for me Availability of hospital financial support Realization that I could be successful academically
1 8 21 46 27 18
(4.2) (11.0) (24.1) (14.1) (9.4)
2 18 26 24 27 19
(9.4) (13.6) (12.6) (14.1) (9.9)
3
4
5
17 (8.9) 29 (15.2) 20 (10.5) 25 (13.1) 8 (4.2)
26 (13.6) 19 (9.9) 9 (4.7) 13 (6.8) 18 (9.4)
33 (17.3) 9 (4.7) 4 (2.1) 10 (5.2) 36 (18.8)
Note. N = 89. Factors coded with 1 being the most helpful factor and 5 being the least influential. Missing data make some rows not add up to 89 participants.
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Table 5. Cues That Spurred Nurses to Pursue Baccalaureate Education Cue
N (%)
Decided to advance nursing career Learned about the Magnet-designated organization goal of 80% RNs with a BSN by 2020 Conversation with nurse who had a BSN Announcement on bulletin board in hospital or on-line Funding available from a specific source
48 (40.0) 29 (24.1) 25 (20.8) 11 (9.2) 7 (0.1)
Note. n = 120.
Megginson, 2008; Schwarz & Leibold, 2014; Warren & Mills, 2009). This was reflected by nurses' responses in our sample from a southern California Magnetdesignated hospital with approximately 62% of its nursing staff having achieved a baccalaureate or higher degree. Major individual nurse factors identified by our sample were time and financial constraints, both identified in earlier studies as competing priorities (Altmann, 2011; Delaney & Piscopo, 2004, 2007; Megginson, 2008). Health care institutions can consider use of both incentives (e.g., things which make it less expensive to go to school) and rewards such as pay increases for increased education and clinical ladders that are tied to enhanced professional activities related to educational attainment or to actual attainment of further education. An innovative strategy that might be considered in some situations was suggested by one of our participants: allowing nurses to use their accumulated paid time off when enrolled in an educational program. Another nurse suggested including nurses in the float pool in educational benefits provided by the hospital. These strategies make economic sense given the findings of improved patient outcomes when nurses are better educated (Aiken et al., 2003; Aiken, 2014; Blegen et al., 2013; Yakusheva et al., 2014). Insecurity about the ability to succeed in school or lack of efficacy was reported by a number of nurses (e.g., “the thought of returning to school after 20 years was terrifying; “…going back is difficult because of learning to write papers”). This was compounded by lack of comfort with technology for other nurses. This lack of confidence has been documented (Carlson, 1992 as cited in Altmann, 2011). Although supportive resources may be available in traditional face-to-face RN-to-BSN curricula, they are not readily accessible in many on-line programs. Moreover, nurses may not consider returning Table 6. Main Reasons for Not Achieving a Baccalaureate Degree Reason
N (%)
I believe it will not pay off financially I do not see how it will make me a more competent nurse I don’t feel like I would be successful in a BSN program My nurse friends are not doing it
15 (46.8) 12 (37.5)
Note. n = 32.
5 (15.6) 0
to school due to fear of academic/technical issues (e.g., poor writing or computer skills), and these same issues may cause them problems when enrolled. Health care institutions may address and minimize these concerns through provision of employer-based resources tailored to individual nurse needs such as computer classes, writing assistance, and peer mentoring. One Magnetdesignated hospital developed a nurse-led, hospital-based academic advising service that supports the needs of nurses considering and participating in academic programs (Wendler, Fyans, & Kirkbride, 2013). Hospitals should consider how to provide adequate library resources and access to librarians. Our findings suggest that peer and leadership support play a larger role in facilitating BSN completion than has been previously reported. While lack of peer support was not considered a barrier, encouragement by other nurses (including organizational leaders) to return to school was the major facilitator reported by our participants. Openended comments from nurses supported this (e.g., “employee engagement and support from other nurses,” “…had friends who had started the BSN program and didn't want to be left behind....”). Nurses considering going back to school or in baccalaureate programs continue to need encouragement for these actions. Nurse leaders in hospitals can encourage staff in a variety of ways. One of our respondents stated, The nurse educator for my department strongly encourages all staff to further our careers. Once the degree is obtained, she will again begin questioning when we are returning to obtain the next higher degree IE: ADN-BSN, BSN-Master… She is encouraging and an amazing resource for staff who have decided to return to further their nursing degree. Future research is needed to examine the role of RN-to-RN encouragement in facilitating educational advancement. Hospital administrators might want to have brainstorming discussions among nurse managers to determine creative ways that they might positively impact staff nurses to return to school. Bedside nurses who do not have personal goals that include enhanced education may not be able to overcome the barriers to going back to school nor their own perceptions of the value of the baccalaureate degree. For example, “It has been my experiences at the bedside that have taught me to be a GOOD DIPLOMA nurse!! …I would NOT go back to school even if it was totally funded for me.” The implications of this are that some nurses
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INFLUENCING FACTORS
SUPPORTIVE FACTORS
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ACTION
Individual Nurse Age, responsibilities, career identity, preservation, & progression; attitudes towards BSN
Perceived personal effort
Employing Organization Incentives/expectations (e.g., tuition reimbursement, flexible schedules) Rewards (e.g., pay increase, clinical ladder) Positive culture regarding education Academic Programs Program flexibility & fit, resources (e.g., adequate advising, supportive instructors)
NURSE MOTIVATION
How well positive facilitators individual nurse barriers
RETURN TO SCHOOL
STAY IN SCHOOL
Figure 1. Conceptual underpinnings.
value clinical competence and bedside nursing and see little benefit to pursuing the baccalaureate. One participant stated, “diploma or AA nurses did not understand what they would gain professionally or knowledge wise....you don't know what you didn't know until after you learn it.” There may be a lack of understanding of what the baccalaureate degree offers, which may reflect an opportunity for educational programs and hospitals. Hospital nursing staff could collect and share stories or narratives that document the positive impact of baccalaureate education on the clinical competency of RNs. The influence of sharing peer testimonials about personal and professional changes secondary to their education could be tested, as this was influential to 16% of our nurses. Many nurse participants in our study described nurses not wanting to return to school due to a lack of vision of the enhanced professionalism achieved with baccalaureate education (as defined by Orsolini-Hain, 2012). Orsolini-Hain proposed that this lack of vision may stem from a work culture that does not differentiate among nurses with different educational degrees (e.g., a nurse is a nurse is a nurse). Nurse managers should reflect upon the existing culture in their areas to determine whether they openly acknowledge that nurses with baccalaureate preparation in their work areas function differently; after this, they could develop strategies to recognize this in a way that does not negate the value of nurses with lesser education. Work culture issues were reported by a minority in our sample: “If there might be something to gain (better job, more pay, etc.) then they are more apt to go. If there is no real motivation then nurses do not find the need to go back to school.” This lack of motivation also may represent satisfaction with the way things are in the work setting, as described by Warren and Mills (2009). Other participants may have a lack of vision due to the examples of nurses
they have worked with. For example, “I am embarressed [sic] by the number of nurses who have BS & MS [sic] who are unable to relate to patients, whether on a 1:1 level or as a group. Focusing more on paper principles rather than the human aspect.” A positive culture regarding education may come from working in a Magnet institution. A minority of nurse participants (15; 9%) indicated their awareness of this culture and its impact on nurse decision-making related to pursuing further education. Warren and Mills (2009) proposed that nurses undecided about returning to school (19% of nurses surveyed) might be influenced by organizational incentives such as tuition reimbursement, onsite classes, forgivable loans, and others. Although several of these incentives are available at our Magnet hospital, these were not mentioned by participants in our study. Few nurses mentioned specific influencing factors related to academic programs. This probably reflects the multiple educational opportunities in the region where the hospital functions and nurse awareness of multiple options for pursuing baccalaureate education. Our findings led us to clarify some of the relationships among study concepts, and we developed a visual model to explicate these as seen in the figure. The three types of influencing factors (individual nurse, employing organization, and academic program characteristics) may have an effect on nurses to seek further education and, once enrolled, to stay in school. Factors can serve as both positive and negative facilitators; for example, older age may serve for one nurse as a positive influence (perception of fewer family or financial responsibilities) while serving as a barrier to another (“why bother to get further education when I will not be working much longer”). At the individual nurse level, in aggregate, these factors influence nurse motivation to pursue further education and appear to be the greatest influence in our
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Table 7. Themes and Exemplars: Why Nurses Do or Do Not Choose to Obtain a Baccalaureate Degree Theme Career identity, preservation, and progression; program flexibility
Reasonable personal effort and perceived (individual responsibility)
Career identity, preservation, and progression; employer incentives; facilitators
Attitudes toward BSN
Program flexibility & fit; perceived personal effort Career identity, preservation, and progression; perceived personal effort
Career identity, preservation, and progression; program flexibility and fit; positive facilitators.
Exemplar
Individual nurse
I had always “wanted” to go back for my BSN and had tried several programs, but always found an excuse not to finish them. I finally came to realize that I was in danger of being professionally “left behind” as the nurses around me were BSN/MSN. … program was a “good fit” for me, the perfect combination of traditional classroom and on-line convenience. The thought of returned to school after twenty years was terrifying. Many experienced nurses are afraid. I was afraid all of my classes would no longer count as credits. I also was not sure that I could fit it in my schedule. Working full time, raising a family, and going to school is very challenging but not impossible. I chose to go back to school in 2005 as our hospital was seeking Magnet status and was offering a clinical ladder of advancement for those who went back to school. I also had friends who had started the BSN program and didn’t want to be left behind….I had their encouragement to go back! It is a lot of unnecessary work. Experience is more important. Older nurses with families to support are less able to attend college again and it doesn’t change the care that they give in my opinion. Too many of my classes had expired and would have to be taken again e.g. math. Really? A lot of it has to do with self-motivation. I want to continue to learn more and have a long career in nursing ahead of me. I want to be in the best position to have options open to me. Don’t know about all nurses, but for me, I ALWAYS wanted to go back and get my BSN, but life happened…. With the on-line course availability, monetary assistance from my hospital, and now, loving, supportive husband and a shorter time to achieve it, I felt this was calling me to pursue. Not necessarily for any advancement… but for my own personal goal…to achieve that degree for ME. By the time I achieve my goal of my BSN, I’ll probably be ready for retirement, so it really is the availability, shorter time commitment, financial assistance, and the pride of fulfilling a promise to myself!
sample of nurses working in a Magnet hospital. In addition, perceived personal effort and how well the influencing factors or facilitators address specific individual nurse barriers can further modify motivation, serving as supportive factors. Nurses—in our qualitative
Employer
X
Academic program X
X
X
X
X
X
X
X
X
X
data—describe the fact that attainment of further education must represent a feasible task, and this perception strongly influences whether a nurse returns to school or, once enrolled, continues enrollment. Of interest is the contrasting idea that nurses might be
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paralyzed when they perceived the effort required to attain a baccalaureate degree was too much; thus, they do not return to school. Peer and other nurse support was noted as highly important to nurses in our sample for motivating them to return to school but not so important on their continuing education. As seen in Warren and Mills' work (2009), the way in which varying facilitators actually function is that they either contradict or act to ameliorate individual nurse, organizational, or academic factors that serve as barriers to educational attainment. Limitations of our study include the newly developed survey instrument and lack of documented validity and reliability, a small nurse sample from a single institution, and the cross-sectional nature of the study. Strengths include an excellent response to the open-ended question focused on why nurses do or do not return to get a baccalaureate.
Conclusions This study documented employed nurse perceptions of factors that motivate and obstacles that impede nurses from pursuing baccalaureate education while working at a Magnet-designated facility. Influential factors included predominately those related to individual nurses and the employing organization and some related to academic programs. Nurse motivation is thus affected by external pressures along with personal goals that can be influenced by situational factors and employing agency and academic policies. Misinformation still exists among nurses related to the value of baccalaureate education. Opportunities exist for employing agencies and academic programs to enhance nurse motivation to return to school and graduate.
References Aiken, L. (2014). Baccalaureate nurses and hospital outcomes: More evidence. Medical Care, 52, 861–863, http:// dx.doi.org/10.1097/MLR.0000000000000222. Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M. & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association, 290, 1617–1623, http://dx.doi.org/10.1001/ jama.290.12.1617. Altmann, T. K. (2011). Registered nurses returning to school for a bachelors degree in nursing: Issues emerging from a metaanalysis of the research. Contemporary Nurse: A Journal for the Australian Nursing Profession, 39, 256–272. American Nurses Credentialing Center (n.d.) ANCC Magnet Recognition Program. Retrieved from http://www. nursecredentialing.org/Magnet.aspx. Blegen, M. A., Goode, C. J., Park, S. H., Vaughn, T. & Spetz, J. (2013). Baccalaureate education in nursing and patient outcomes. Journal of Nursing Administration, 43, 89–94, http:// dx.doi.org/10.1097/NNA.0b013e31827f2028.
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Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine (2011). The future of nursing. Leading change, advancing health report recommendations. Advising the nation/Improving health. Retrieved from www.iom.edu/nursing 2011. Delaney, C. & Piscopo, B. (2004). RN-BSN programs: Associate degree and diploma nurses’ perceptions of the benefits and barriers to returning to school. Journal for Nurses in Staff Development, 20, 157–161. Delaney, C. & Piscopo, B. (2007). There really is a difference: Nurses' experiences with transitioning from RNs to BSNs. Journal of Professional Nursing, 23, 167–173. Dowell, M. (2000). Why they succeed: Completion, retention, and early departure of registered nurses returning for the baccalaureate degree in nursing ([dissertation abstract]. UMI Order AAI3004255). Duffy, M. T., Friesen, M. A., Speroni, K. G., Swengros, D., Shanks, L. A., Waiter, P. A. & Sheridan, M. J. (2014). BSN completion barriers, challenges, incentives, and strategies. Journal of Nursing Administration, 44, 232–236, http:// dx.doi.org/10.1097/NNA.0000000000000054. Megginson, L. (2008). RN-BSN education: 21st century barriers and incentives. Journal of Nursing Management, 16, 47–55, http://dx.doi.org/10.1111/j.1365-2934.2007.00784.x. Orsolini-Hain, L. (2012). Mixed messages: Hospital practices that serve as disincentives for associate degree–prepared nurses to return to school. Nursing Outlook, 60, 81–90, http:// dx.doi.org/10.1016/j.outlook.2011.05.007. Polit, D. F. & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice (9th ed.). Philadelphia, PA: Wolters Kluwer/Lippincott, Williams, & Wilkins. Robertson, S., Canary, C., Orr, M., Herberg, P. & Rutledge, D. (2010). Factors related to progression and graduation rates for RN-to-bachelor of science in nursing programs: Searching for realistic benchmarks. Journal of Professional Nursing, 26, 99–107, http://dx.doi.org/10.1016/j.profnurs.2009.09.003. Schwarz, L. & Leibold, N. (2014). Perceived facilitators and barriers to baccalaureate degree completion among registered nurses with an associate's degree. Journal of Continuing Education in Nursing, 45, 171–180, http://dx.doi.org/10.3928/ 00220124-20140219-03. Warren, J. & Mills, M. (2009). Motivating registered nurses to return for an advanced degree. Journal of Continuing Education in Nursing, 40, 200–209, http://dx.doi.org/10.3928/ 00220124-20090422-01. Wendler, M. C., Fyans, P. M. & Kirkbride, G. (2013). No more “fumbling alone”: Effect of a nurse-led academic advising service in a Magnet® hospital. The Journal of Continuing Education in Nursing, 44, 218–224, http://dx.doi.org/10.3928/ 00220124-20130315-24. Yakusheva, O., Lindrooth, R. & Weiss, M. (2014). Economic evaluation of the 80% baccalaureate nurse workforce recommendation: A patient-level analysis. Medical Care, 52, 864–869, http://dx.doi.org/10.1097/MLR.0000000000000189.
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The aim is to explore factors that motivate and obstacles that impede nurses from pursuing baccalaureate education when employed by a Magnet® organization. In the Future of Nursing (2011), the Institute of Medicine concluded that the baccalaureate should be the minimum education for nurses. Magnet organizations are encouraged to meet the Institute of Medicine goal of 80% of nurses with a baccalaureate by 2020. In February 2014, a 15-item on-line survey was sent to nurses at a western Magnet-designated hospital to assess factors that motivate registered nurses to achieve a baccalaureate. Descriptive statistics and a general thematic analysis were completed. A 20% response rate (N = 191) was achieved. Most respondents (78%) entered nursing as associate degree/ diploma graduates, and most (84%) either had a baccalaureate or master's degree or were currently enrolled in school. Encouragement from other nurses was the factor most frequently selected as facilitating return to school. Impeding factors included age and family responsibilities. A minority of nurses reported that they did not believe that a baccalaureate would make them a better nurse. Findings suggest that peer and leadership support play a larger role in facilitating baccalaureate completion more than previously reported. Additional research is needed to explore the role of registered nurse to registered nurse encouragement in facilitating educational advancement. (Index words: Magnet; Baccalaureate education; Nursing education; Motivation; Education, post RN; School re-entry) J Prof Nurs 0:1–9, 2016. © 2015 Elsevier Inc. All rights reserved.
Background In its Future of Nursing report, the Institute of Medicine (Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine, 2011) urged nurses in all settings to work together to increase the proportion of nurses with a baccalaureate degree to 80% by 2020. The report conclusion, supported by increased complexity of health care and improved patient care outcomes, was that a baccalaureate should be the minimum educational degree for nursing. Magnet®-designated organizations have been encouraged by the American Nurses Credentialing Center to meet this goal (American Nurses Credentialing Center). The nursing literature includes a number of studies exploring factors that motivate diploma and associate degree *Clinical Educator, Nurse Researcher, St. Joseph Hospital, Clinical Education, Orange CA 92686. †Assistant Professor of Nursing, California State University, Los Angeles, CA. ‡Professor of Nursing, California State University, Fullerton, CA. §Clinical Educator, St. Joseph Hospital, Clinical Education, Orange CA 92686. Address correspondence to Dr. Winokur: St. Joseph Hospital, California State University, Clinical Education, Orange CA 92686. E-mails: [email protected], [email protected] (E.J. Winokur) 8755-7223 1 http://dx.doi.org/10.1016/j.profnurs.2015.11.003
(AD) nurses to return to school (Altmann, 2011; Delaney & Piscopo, 2004; Megginson, 2008; Schwarz & Leibold, 2014). These studies support specific barriers faced by nurses considering a baccalaureate degree. However, little is known about the effect of Magnet designation on employed nurses considering or returning to school.
Benefits of Having a Baccalaureate-Prepared Staff Aiken's (2014)recent comments on the value of employing a predominately baccalaureate workforce point to the benefits in decreasing lengths of stay and readmission rates (cost savings) and improved patient mortality. In an innovatively designed study, Yakusheva, Lindrooth, and Weiss (2014) found that patients from an urban Magnet-designated academic medical center receiving at least 80% of their care from nurses with a baccalaureate degree had significantly lower mortality (Odds Ratio = 0.891), lower odds of readmission (Odds Ratio = 0.813), and 1.9% shorter length of stay. These findings are consistent with earlier findings (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Blegen, Goode, Park, Vaughn, & Spetz, 2013). Among 168 Pennsylvania hospitals with varying educational levels among registered nurses (RNs) (0–77% RNs with bachelor's degree or higher), a 10% increase in the proportion of nurses with higher degrees Journal of Professional Nursing, Vol 0, No. 0 (January), 2016: pp 1–9 © 2015 Elsevier Inc. All rights reserved.
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decreased the risk of mortality or failure to rescue by 5% among surgical patients (Aiken et al., 2003). Among 18 teaching hospitals who had 62% of nurses with at least a baccalaureate degree, higher levels of RN education were negatively correlated with numbers of adverse events and lengths of stay for patients after taking into account staffing and hospital characteristics (Blegen et al., 2013).
Barriers and Facilitators to Returning to School Few recent studies have documented barriers and facilitators for nurses to obtain a baccalaureate degree, and fewer described AD and diploma nurse perceptions of pursuing further education (Altmann, 2011; Schwarz & Leibold, 2014). These issues merit reanalysis given the changing health care and economic climate and the possibility of an effect of Magnet designation on education seeking among RNs. Barriers have largely been identified as the multiple competing priorities in nurses' lives and work. Facilitators include the perceived personal or professional growth potential to be gained from education (Delaney & Piscopo, 2004; Schwarz & Leibold, 2014) and availability of programs that are geared to working nurses (Altmann, 2011; Megginson, 2008). In a review of 28 studies about nurses' attitudes and perceptions about returning to school, Altmann (2011) categorized incentives/disincentives into three categories: personal, professional, and academic (Table 1). An understudied barrier to returning to school is “lack of vision” (Orsolini-Hain, 2012). Lack of vision was described as lack of appreciation for what would be gained from baccalaureate or graduate education. This lack of vision may stem from work cultures that do not distinguish between the functioning knowledge and skill levels of nurses who have different academic degrees (Orsolini-Hain, 2012). Among 297 Maryland AD/diploma nurses under 50 years of age working in hospitals in 2004, and not currently in a baccalaureate or higher nursing program, only 19% planned to enroll in further nursing education (Warren & Mills, 2009). Certain factors predicted intention to return to school (e.g., planning a career in nursing, requirement of further education to maintain current position) and included organizational incentives. In this study, satisfaction with current employment was a reason for not returning to school (Warren & Mills, 2009). This latter finding indicates that having an organizational push for further education such as the Magnet benchmarks may serve to catalyze nurse action related to further education.
Factors Related to Graduation for RN-to-BSN Students Little is known about factors that facilitate RN-to-BSN (bachelor of science in nursing) student success. In a survey of 14 California schools, RN-to-BSN students were identified as generally older, married, and going to school part time while working and juggling family responsibil-
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ities (Robertson, Canary, Orr, Herberg, & Rutledge, 2010). Factors predicting academic success were flexible work schedules, nondemanding family responsibilities, financial and personal support, realistic expectations from work, personal motivation, higher grades, and fewer hours worked. These are congruent with themes identified by nurses interviewed about facilitators and barriers to BSN completion (Duffy et al., 2014). Nurses have described the importance of having an appropriate classroom environment and support from their classmates (Delaney & Piscopo, 2007). In a study comparing RNs who succeeded in obtaining a degree and those who did not, nongraduates had more negative reactions related to college attendance and did not see future benefits from the BSN (Dowell, 2000).
Conceptual Underpinnings Returning to school is a desired outcome that is related to but different from staying in school. Key constructs in the process of nurse decision-making to return to and stay in school include individual characteristics, organizational influences (Warren & Mills, 2009), and academic factors (Altmann, 2011). Individual characteristics include demographics (e.g., age, caregiving responsibilities, income), professional commitment, career identify (e.g., how much the person identifies with nursing as a career), and perceptions of what the baccalaureate degree offers a nurse. As described by Warren and Mills (2009), personal motivation is influenced by individual nurse characteristics such as perceived effort that are mediated by organizational influences. Organizational facilitators may be considered either rewards or incentives (e.g., payment for classes, on-line class offerings, forgivable loans). The characteristics of an academic program can serve as facilitators (e.g., on-line offerings, flexibility) or disincentives (e.g., travel distance, enrollment procedures). In summary, employed nurse motivation to return and stay in school is influenced by individual nurse characteristics along with organizational and academic program influences.
Local Context Related to Nursing Educational Advancement Early in 2013, a discussion about educational advancement for nurses occurred between the chief nursing officer and a human resources staff member from a twice Magnet-designated facility in the southwest. Given a nursing staff with about 60% baccalaureate education and in light of trying to achieve the 80% Institute of Medicine goal, they posed two questions: (a) what were the incentives and barriers for diploma/AD-educated staff nurses to consider returning to school and (b) when a nurse returned to school, what factors predicted graduation with a baccalaureate degree? These questions were shared with the hospital nursing research council.
Study Purpose The aim of the study was to explore the factors that motivate and the obstacles that impede nurses employed in a Magnet-designated organization from returning to
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Table 1. Important Factors to Nurses Returning to School Type of factor
Disincentive/Barrier
Personal
Incentive/Facilitator
Competing priorities Lack of confidence Feeling secure in a job Perceiving the baccalaureate degree as not enhancing clinical skills Perceiving baccalaureate prepared nurses as no different or not better (even inferior to) than those with less education Lack of credit for past experience Practical issues (inflexible or long programs)
Professional
Academic
Desire for personal achievement Desire for more nursing knowledge Recognition of education level (organizational) Job security Pressure from employer to seek further education Practical constraints (e.g., work schedules)
Credit for past experience Practical issues (flexible or compact programs)
Adapted from Altmann (2011).
school for a BSN and the factors that affect baccalaureate completion among those who return to school.
Methods In February 2014, an on-line survey was sent to all RNs at a Southern California, Magnet-designated hospital. The study received exempt status by the hospital institutional review board. The study team believed that all nurses employed at the hospital had valuable insights into this study, even nurses who entered the profession with a baccalaureate degree; thus, all RNs were considered potential participants.
Measure A survey was developed by one of the co-authors and a prior hospital nurse researcher to describe the sample and address study aims; no psychometric testing was done. The newly developed survey contained 14 multiple choice/rank ordered items and one open-ended question. Demographic questions related to age, gender, race/ethnicity, educational status, and work history. Nurses were asked the number of years as an RN before beginning an educational program or number of years to complete a program. Nurses who had not gone back for a bachelor's degree and were “pretty sure they never will” were asked to select the main reason for not returning to school. Nurses who had completed a BSN degree or were working on a degree were asked about barriers and facilitators for going back to school. All respondents were asked to address—in their own words—why nurses choose or do not choose to obtain a baccalaureate.
Procedures SurveyMonkey (Menlo Park CA) provided the platform for on-line delivery and responses. To address participant confidentiality, SurveyMonkey uses Secure Sockets Layer encryption, which keeps links and survey pages secure during transmission from the hospital account to respondents and then back into the account. Over 1 month, nurses received an invitational e-mail to their hospital addresses explaining the study and their potential involvement, followed by two reminder e-mails; each communication contained a link to the survey.
Data Analysis Descriptive statistical analyses were completed using software package for statistical analysis Version 20. Descriptive statistics were used to describe the sample and responses to individual survey items. Findings from the open-ended question were analyzed using general thematic analysis (Polit & Beck, 2012, pp. 515–517). A nonlinear, iterative process was used requiring multiple readings of the raw data and was performed by two of the three authors. Responses were entered into a spreadsheet with original entries—one per row—in the left-most column and blank columns to the right. Initially, responses were reduced to discrete segments. Patterns in the data were given conceptual labels, representing broad categories based upon similarity or contrast; these were entered into the first column to the right. Subsequently, final themes/ concepts were determined and entered into the next column. Analysis of these entries in light of the conceptual underpinnings of the study led to changes in the way relationships among the concepts were perceived.
Results Approximately 20% of the hospital's nurses (N = 191) responded to the survey. Participants worked in 20 different inpatient and outpatient units. The majority were female (92%); 78% had been in RN practice more than 10 years. As seen in Table 2, over 70% of the sample was 41 years of age or greater. The majority (78%) had entered nursing as an AD or diploma graduate. Most (84%) had already completed a BSN/MSN (Master of Science in Nursing) or were currently enrolled in a program leading to the degree. Some respondents (14.7%) reported that they had no intention of obtaining a BSN. Time to return to school ranged from an immediate start upon graduation from initial nursing program to 43 years (M = 11.8 years). The majority of nurses returned to school for a BSN, whereas three reported entering AD to MSN programs.
Facilitators and Barriers for Returning for a BSN When asked to rank the barriers or facilitators of returning to a baccalaureate program (Table 3), the
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Table 2. Sample Demographics N (%)
Characteristic Age in years 20–30 31–40 41–50 50 + Gender Female Ethnicity White African American/Black Hispanic/Latino Asian Native American Other Missing Current highest degree in nursing Diploma Associate of Science in nursing Baccalaureate (bachelors of science in nursing) Masters (master of science in nursing) Other First degree in nursing Diploma Associate of science in nursing Baccalaureate (bachelors of science in nursing) Masters (master of science in nursing) Length of time as an RN (years) Primary work setting as a nurse Medical–Surgical Critical care Perioperative Mother/Baby/Labor & delivery Mental/Behavioral health Emergency Oncology Ambulatory care Specialty (e.g., informatics, endoscopy) Current degree status Initial nursing degree was BSN/MSN Completed baccalaureate degree as working nurse Baccalaureate or MSN bridge degree in process No baccalaureate degree, not in school Missing
15 41 71 64
(7.9) (21.5) (37.2) (33.5)
176 (92.1) 120 (62.8) 1 (0.5) 28 (14.7) 31 (16.2) 0 7 (3.7) 4 (2.0) 7 (3.7) 72 (37.7) 72 (37.7) 39 (20.4) 1 (0.5) 27 (14.1) 123 (64.4) 36 (18.8) 5 (2.6) Mean 5.2 ± 1.4; 1–7 60 32 22 26 3 18 17 4 9
(31.4) (16.8) (11.5) (13.6) (1.6) (9.4) (8.9) (2) (4.7)
46 (24.1) 93 (48.7) 22 (11.5) 28 (14.7) 2 (1.0)
Note. N = 191.
most highly ranked factor facilitating return was encouragement from other nurses including peers, managers, and educators (70% of respondents). Most highly ranked factors acting as barriers for a return to school were time (60%) and financial constraints (34%).
Factors Contributing to Success in Baccalaureate Completion Nurse respondents varied in their ratings of factors contributing to baccalaureate completion on degree of
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helpfulness (most = 5, least = 1; see Table 4). One factor stood out as most helpful: 37% rated “the BSN program designed for working nurses” as a 1 or 2). One factor stood out as least influential: 31% rated “support of other nurses” as 4 or 5.
Cues to Pursue Baccalaureate Education Nurses were asked to consider the series of thoughts taken before they returned to school. Then, they were to select from five items (Table 5) which one was the most important and made them commit to going back to school. For the 120 nurses who responded to this question, the most common response was “I finally decided to advance my nursing career” (40%) followed by “I learned about the goal of Magnet-designated organizations to have 80% RNs with a BSN by 2020” (24%) and “I had a conversation with a nurse who already had a BSN” (21%).
Barriers to Obtaining a BSN Nurses who had not gone back to school were asked to select the major reason for not pursuing further education (Table 6, N = 32 out of the 79 [40%] who currently had a diploma or AD as the highest in nursing). Financial concerns and no effect on competence were the most frequently chosen responses, 47% (n = 15) and 38% (n = 12). Concerns about ability to succeed in a BSN program were expressed by 16% of nurses who were not planning to return to school.
Qualitative Findings When asked why nurses choose or do not choose to obtain a BSN degree, 161 respondents (84%; n = 191) responded to this open-ended question. Nurses discussed both positive and negative influences to going back to and staying in school. The majority of nurses selected more than one factor as influencing return to school (see Figure 1, Table 7). The most frequent reasons cited were individual nurse factors such as other responsibilities (finances, time), age, and either positive or negative attitudes toward the BSN. These comments were expressed by 143 of the 161 respondents. In 72 instances, these factors were the only influencing factor reported by the participant. Statements related to the employing organization accounted for 58 of 161 comments. These comments were almost exclusively related to employer expectations (negative and positive). Some participants highlighted support received from mentors and others at the hospital as positively influencing them. Eighteen participants selected factors related to the academic institution, commenting mostly about program cost and flexibility. Supportive factors were cited less frequently and usually in conjunction with one or more influencing factors; motivation, perceived personal effort, and the impact of facilitators were each mentioned an average of 10 times. Finally, 12 individuals reported self-efficacy issues such as lack of confidence; these were predominately seen as a barrier to returning to school.
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Table 3. Barriers or Facilitators to Going Back for Baccalaureate Education (Rank Ordered) n (%)
n (%)
n (%)
n (%)
n (%)
1
2
3
4
5
Barrier or facilitator Barriers Time constraints Financial constraints Lack of support from other nurses Lack of family support Feeling like I might not be successful Facilitators Close geographic proximity of programs Encouragement from other nurses Access to on-line programs Availability of hospital financial support Possibility of future advancement in nursing
114 65 5 8 7
(59.7) (34.0) (2.6) (4.2) (3.7)
48 77 17 16 22
(25.1) (40.3) (8.9) (8.4) (11.5)
11 (5.8) 24 (12.6) 44 (23.0) 52 (27.2) 53 (27.7)
9 13 46 56 39
(4.7) (6.8) (24.1) (29.3) (20.4)
9 (4.7) 12 (6.3) 79 (41.4) 59 (30.9) 70 (36.6)
21 134 21 29 25
(11.0) (70.2) (11.0) (15.2) (13.1)
43 13 58 56 39
(22.5) (6.8) (30.4) (29.3) (20.4)
45 (23.6) 13 (6.8) 50 (26.2) 33 (17.3) 46 (24.1)
38 21 24 44 34
(19.9) (11.0) (12.6) (23.0) (17.8)
44 (23.0) 10 (5.2) 38 (19.9) 29 (15.2) 47 (24.6)
Note. N = 191. Barriers coded with 1 being the biggest challenge/barrier and 5 as the least challenging. Facilitators coded as 1 being the most helpful factor and 5 being the least helpful.
Choosing Not to Pursue Further Education One of the most common themes related to why nurses do not return to school was the perceived lack of value of the baccalaureate degree. Nurses mentioned several factors surrounding this perception: lack of financial gain, the need to invest precious time and energy, and the fact that they had experienced a lack of respect for baccalaureate nurses. More difficult to summarize were comments that indicated a view that better educated nurses (e.g., those with baccalaureate degrees) show no difference in thinking/acting than lesser educated nurses (e.g., those with AD or diploma degrees). In addition, many respondents stated that nurses who wanted to stay at the bedside or, specifically, “did not want to be a nurse manager” did not need further education. Along this line, some reported that they did not believe that achieving a BSN would make them a better nurse. As expected, competing responsibilities were often mentioned as barriers. These included financial and time constraints along with age and family responsibilities. A minority (n = 5; 3%) perceived financial disincentives to return to school (e.g., less able to work extra shifts or take management positions while in school).
Choosing to Pursue Further Education Fifteen nurses (9%) indicated that they succumbed to returning to school because they were “out of excuses!” Specific personal facilitators noted were having a personal goal or feeling family support to achieve more education
or inversely feeling “professionally left behind.” Nine nurses (5%) mentioned something about the encouragement by peers who were returning to school, even to the point of feeling “pressure” to enroll. Employing organizational incentives were mentioned by many. Eleven nurses (7%) directly indicated that the Magnet push for increased levels of education at the hospital was the impetus that helped them take the step. Others (26; 15%) cited a worry over ongoing or future employability without baccalaureate education (“I could not progress in my specialty without it”). Eleven (7%) mentioned hospital financial incentives (tuition reimbursement) and rewards (salary increases based upon education). Other nurses (n = 26; 16%) reported pressure due to the existence of an organizational expectation to get the BSN. Ten nurses (6%) reported that program characteristics (need for multiple transcripts, how classes were offered, technical support) were important to them as influential academic facilitators/barriers.
Discussion By and large, our findings supported the literature-driven conceptual underpinnings for our study. Prior studies with nurses working in hospitals had indicated that employed nurse motivation to return and stay in school is influenced by individual nurse characteristics along with organizational and academic program influences (Altmann, 2011; Delaney & Piscopo, 2004, 2007;
Table 4. Factors Contributing to Success in Baccalaureate Completion Factor Support of other nurses including managers and educators Availability of funding BSN program designed for working nurses and workable for me Availability of hospital financial support Realization that I could be successful academically
1 8 21 46 27 18
(4.2) (11.0) (24.1) (14.1) (9.4)
2 18 26 24 27 19
(9.4) (13.6) (12.6) (14.1) (9.9)
3
4
5
17 (8.9) 29 (15.2) 20 (10.5) 25 (13.1) 8 (4.2)
26 (13.6) 19 (9.9) 9 (4.7) 13 (6.8) 18 (9.4)
33 (17.3) 9 (4.7) 4 (2.1) 10 (5.2) 36 (18.8)
Note. N = 89. Factors coded with 1 being the most helpful factor and 5 being the least influential. Missing data make some rows not add up to 89 participants.
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Table 5. Cues That Spurred Nurses to Pursue Baccalaureate Education Cue
N (%)
Decided to advance nursing career Learned about the Magnet-designated organization goal of 80% RNs with a BSN by 2020 Conversation with nurse who had a BSN Announcement on bulletin board in hospital or on-line Funding available from a specific source
48 (40.0) 29 (24.1) 25 (20.8) 11 (9.2) 7 (0.1)
Note. n = 120.
Megginson, 2008; Schwarz & Leibold, 2014; Warren & Mills, 2009). This was reflected by nurses' responses in our sample from a southern California Magnetdesignated hospital with approximately 62% of its nursing staff having achieved a baccalaureate or higher degree. Major individual nurse factors identified by our sample were time and financial constraints, both identified in earlier studies as competing priorities (Altmann, 2011; Delaney & Piscopo, 2004, 2007; Megginson, 2008). Health care institutions can consider use of both incentives (e.g., things which make it less expensive to go to school) and rewards such as pay increases for increased education and clinical ladders that are tied to enhanced professional activities related to educational attainment or to actual attainment of further education. An innovative strategy that might be considered in some situations was suggested by one of our participants: allowing nurses to use their accumulated paid time off when enrolled in an educational program. Another nurse suggested including nurses in the float pool in educational benefits provided by the hospital. These strategies make economic sense given the findings of improved patient outcomes when nurses are better educated (Aiken et al., 2003; Aiken, 2014; Blegen et al., 2013; Yakusheva et al., 2014). Insecurity about the ability to succeed in school or lack of efficacy was reported by a number of nurses (e.g., “the thought of returning to school after 20 years was terrifying; “…going back is difficult because of learning to write papers”). This was compounded by lack of comfort with technology for other nurses. This lack of confidence has been documented (Carlson, 1992 as cited in Altmann, 2011). Although supportive resources may be available in traditional face-to-face RN-to-BSN curricula, they are not readily accessible in many on-line programs. Moreover, nurses may not consider returning Table 6. Main Reasons for Not Achieving a Baccalaureate Degree Reason
N (%)
I believe it will not pay off financially I do not see how it will make me a more competent nurse I don’t feel like I would be successful in a BSN program My nurse friends are not doing it
15 (46.8) 12 (37.5)
Note. n = 32.
5 (15.6) 0
to school due to fear of academic/technical issues (e.g., poor writing or computer skills), and these same issues may cause them problems when enrolled. Health care institutions may address and minimize these concerns through provision of employer-based resources tailored to individual nurse needs such as computer classes, writing assistance, and peer mentoring. One Magnetdesignated hospital developed a nurse-led, hospital-based academic advising service that supports the needs of nurses considering and participating in academic programs (Wendler, Fyans, & Kirkbride, 2013). Hospitals should consider how to provide adequate library resources and access to librarians. Our findings suggest that peer and leadership support play a larger role in facilitating BSN completion than has been previously reported. While lack of peer support was not considered a barrier, encouragement by other nurses (including organizational leaders) to return to school was the major facilitator reported by our participants. Openended comments from nurses supported this (e.g., “employee engagement and support from other nurses,” “…had friends who had started the BSN program and didn't want to be left behind....”). Nurses considering going back to school or in baccalaureate programs continue to need encouragement for these actions. Nurse leaders in hospitals can encourage staff in a variety of ways. One of our respondents stated, The nurse educator for my department strongly encourages all staff to further our careers. Once the degree is obtained, she will again begin questioning when we are returning to obtain the next higher degree IE: ADN-BSN, BSN-Master… She is encouraging and an amazing resource for staff who have decided to return to further their nursing degree. Future research is needed to examine the role of RN-to-RN encouragement in facilitating educational advancement. Hospital administrators might want to have brainstorming discussions among nurse managers to determine creative ways that they might positively impact staff nurses to return to school. Bedside nurses who do not have personal goals that include enhanced education may not be able to overcome the barriers to going back to school nor their own perceptions of the value of the baccalaureate degree. For example, “It has been my experiences at the bedside that have taught me to be a GOOD DIPLOMA nurse!! …I would NOT go back to school even if it was totally funded for me.” The implications of this are that some nurses
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INFLUENCING FACTORS
SUPPORTIVE FACTORS
7
ACTION
Individual Nurse Age, responsibilities, career identity, preservation, & progression; attitudes towards BSN
Perceived personal effort
Employing Organization Incentives/expectations (e.g., tuition reimbursement, flexible schedules) Rewards (e.g., pay increase, clinical ladder) Positive culture regarding education Academic Programs Program flexibility & fit, resources (e.g., adequate advising, supportive instructors)
NURSE MOTIVATION
How well positive facilitators individual nurse barriers
RETURN TO SCHOOL
STAY IN SCHOOL
Figure 1. Conceptual underpinnings.
value clinical competence and bedside nursing and see little benefit to pursuing the baccalaureate. One participant stated, “diploma or AA nurses did not understand what they would gain professionally or knowledge wise....you don't know what you didn't know until after you learn it.” There may be a lack of understanding of what the baccalaureate degree offers, which may reflect an opportunity for educational programs and hospitals. Hospital nursing staff could collect and share stories or narratives that document the positive impact of baccalaureate education on the clinical competency of RNs. The influence of sharing peer testimonials about personal and professional changes secondary to their education could be tested, as this was influential to 16% of our nurses. Many nurse participants in our study described nurses not wanting to return to school due to a lack of vision of the enhanced professionalism achieved with baccalaureate education (as defined by Orsolini-Hain, 2012). Orsolini-Hain proposed that this lack of vision may stem from a work culture that does not differentiate among nurses with different educational degrees (e.g., a nurse is a nurse is a nurse). Nurse managers should reflect upon the existing culture in their areas to determine whether they openly acknowledge that nurses with baccalaureate preparation in their work areas function differently; after this, they could develop strategies to recognize this in a way that does not negate the value of nurses with lesser education. Work culture issues were reported by a minority in our sample: “If there might be something to gain (better job, more pay, etc.) then they are more apt to go. If there is no real motivation then nurses do not find the need to go back to school.” This lack of motivation also may represent satisfaction with the way things are in the work setting, as described by Warren and Mills (2009). Other participants may have a lack of vision due to the examples of nurses
they have worked with. For example, “I am embarressed [sic] by the number of nurses who have BS & MS [sic] who are unable to relate to patients, whether on a 1:1 level or as a group. Focusing more on paper principles rather than the human aspect.” A positive culture regarding education may come from working in a Magnet institution. A minority of nurse participants (15; 9%) indicated their awareness of this culture and its impact on nurse decision-making related to pursuing further education. Warren and Mills (2009) proposed that nurses undecided about returning to school (19% of nurses surveyed) might be influenced by organizational incentives such as tuition reimbursement, onsite classes, forgivable loans, and others. Although several of these incentives are available at our Magnet hospital, these were not mentioned by participants in our study. Few nurses mentioned specific influencing factors related to academic programs. This probably reflects the multiple educational opportunities in the region where the hospital functions and nurse awareness of multiple options for pursuing baccalaureate education. Our findings led us to clarify some of the relationships among study concepts, and we developed a visual model to explicate these as seen in the figure. The three types of influencing factors (individual nurse, employing organization, and academic program characteristics) may have an effect on nurses to seek further education and, once enrolled, to stay in school. Factors can serve as both positive and negative facilitators; for example, older age may serve for one nurse as a positive influence (perception of fewer family or financial responsibilities) while serving as a barrier to another (“why bother to get further education when I will not be working much longer”). At the individual nurse level, in aggregate, these factors influence nurse motivation to pursue further education and appear to be the greatest influence in our
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Table 7. Themes and Exemplars: Why Nurses Do or Do Not Choose to Obtain a Baccalaureate Degree Theme Career identity, preservation, and progression; program flexibility
Reasonable personal effort and perceived (individual responsibility)
Career identity, preservation, and progression; employer incentives; facilitators
Attitudes toward BSN
Program flexibility & fit; perceived personal effort Career identity, preservation, and progression; perceived personal effort
Career identity, preservation, and progression; program flexibility and fit; positive facilitators.
Exemplar
Individual nurse
I had always “wanted” to go back for my BSN and had tried several programs, but always found an excuse not to finish them. I finally came to realize that I was in danger of being professionally “left behind” as the nurses around me were BSN/MSN. … program was a “good fit” for me, the perfect combination of traditional classroom and on-line convenience. The thought of returned to school after twenty years was terrifying. Many experienced nurses are afraid. I was afraid all of my classes would no longer count as credits. I also was not sure that I could fit it in my schedule. Working full time, raising a family, and going to school is very challenging but not impossible. I chose to go back to school in 2005 as our hospital was seeking Magnet status and was offering a clinical ladder of advancement for those who went back to school. I also had friends who had started the BSN program and didn’t want to be left behind….I had their encouragement to go back! It is a lot of unnecessary work. Experience is more important. Older nurses with families to support are less able to attend college again and it doesn’t change the care that they give in my opinion. Too many of my classes had expired and would have to be taken again e.g. math. Really? A lot of it has to do with self-motivation. I want to continue to learn more and have a long career in nursing ahead of me. I want to be in the best position to have options open to me. Don’t know about all nurses, but for me, I ALWAYS wanted to go back and get my BSN, but life happened…. With the on-line course availability, monetary assistance from my hospital, and now, loving, supportive husband and a shorter time to achieve it, I felt this was calling me to pursue. Not necessarily for any advancement… but for my own personal goal…to achieve that degree for ME. By the time I achieve my goal of my BSN, I’ll probably be ready for retirement, so it really is the availability, shorter time commitment, financial assistance, and the pride of fulfilling a promise to myself!
sample of nurses working in a Magnet hospital. In addition, perceived personal effort and how well the influencing factors or facilitators address specific individual nurse barriers can further modify motivation, serving as supportive factors. Nurses—in our qualitative
Employer
X
Academic program X
X
X
X
X
X
X
X
X
X
data—describe the fact that attainment of further education must represent a feasible task, and this perception strongly influences whether a nurse returns to school or, once enrolled, continues enrollment. Of interest is the contrasting idea that nurses might be
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paralyzed when they perceived the effort required to attain a baccalaureate degree was too much; thus, they do not return to school. Peer and other nurse support was noted as highly important to nurses in our sample for motivating them to return to school but not so important on their continuing education. As seen in Warren and Mills' work (2009), the way in which varying facilitators actually function is that they either contradict or act to ameliorate individual nurse, organizational, or academic factors that serve as barriers to educational attainment. Limitations of our study include the newly developed survey instrument and lack of documented validity and reliability, a small nurse sample from a single institution, and the cross-sectional nature of the study. Strengths include an excellent response to the open-ended question focused on why nurses do or do not return to get a baccalaureate.
Conclusions This study documented employed nurse perceptions of factors that motivate and obstacles that impede nurses from pursuing baccalaureate education while working at a Magnet-designated facility. Influential factors included predominately those related to individual nurses and the employing organization and some related to academic programs. Nurse motivation is thus affected by external pressures along with personal goals that can be influenced by situational factors and employing agency and academic policies. Misinformation still exists among nurses related to the value of baccalaureate education. Opportunities exist for employing agencies and academic programs to enhance nurse motivation to return to school and graduate.
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