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Too Old For School? Barriers Nurses Can Overcome When Returning to School
Too Old For School? Barriers Nurses Can Overcome When Returning to School MARCIA MORGENTHALER, RN, BSN, CNOR
T
he current nursing and nurse faculty shortages have prompted many nurses to consider obtaining a bachelor’s or an advanced degree, only to subsequently decide that the obstacles to pursuing additional education may be too great to overcome. Who has the energy to burn the midnight oil and be adequately rested for the rigors of a demanding day of patient care? This article explores the perceived barriers that may prevent nurses from pursuing a degree and possible solutions to reduce or eliminate those barriers.
PERCEIVED BARRIERS Many nurses perceive barriers to the pursuit of higher education. These barriers include time, cost, effort, diversity, geographical location, and perceived value. TIME. Time is a precious commodity and finding a work-life balance can be difficult. Many nurses work extra shifts and overtime while leading busy personal lives, and they may be challenged to find the time needed to return to school. Perioperative nurses in acute care settings face a unique challenge of juggling call schedules in addition to regular shift hours when considering whether school will fit in with the responsibilities of work and home. Shift work may prevent nurses from attending school on the days or hours school is traditionally offered, compounding the fact that completing homework requires several hours a week in addition to attending classes. Although older nurses may feel that their families are becoming less dependent on them, they may want to use their newly found free time to explore hobbies © AORN, Inc, 2009
and new skills. For others, with retirement looming, school may not seem like a viable option. Those caught in the “sandwich generation” may find themselves with the added responsibility of caring for older parents while also caring for their own families. COST. Educational expenses continue to rise during uncertain economic times, and nurses often do not want to add an economic burden to their family’s current financial situation. In addition, the opportunity to work extra shifts to increase the family income is attractive and can weigh heavily on the decision to return to school. For those nurses who do not qualify for scholarships, the full amount of the educational cost may have to be carried personally in the form of student loans or personal savings. When most people in their late 40s and older are focusing on paying off mortgages, going further into debt for a degree that may not change one’s economic or professional status may seem selfish and like a waste of money. Items to consider when calculating the total cost of education should include • books,
ABSTRACT Nurses may face a number of perceived barriers, such as geographical location, time, and cost, when deciding to return to school for additional education. Viable solutions to overcome these barriers include distance education, effective time management, and tuition assistance programs. Key words: nurse education, continuing education; advanced degree; perceived barrier; older nurses. AORN J 89 (February 2009) 335-345. © AORN, Inc, 2009.
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resource and lab fees, travel, parking fees, computer hardware and software, and any tutoring that may be necessary. EFFORT. The amount of effort involved in returning to school cannot be overemphasized when discussing potential barriers to education. Scheduling quality time to put toward studies and learning new material can be overwhelming. Nurses seeking bachelor’s degrees may need to take courses in algebra and statistics if these course requirements were not adequately fulfilled during their associate degree programs. Rusty math skills and the fear of taking tests may cause nurses to feel intimidated and make them unwilling to subject themselves to that level of discomfort. Being expected to conduct research and to write papers at a professional level also may add to older nurses’ hesitation to return to school. An apprehension of not being “smart enough” or possibly failing may be a concern. Consequently, those with poor computer skills may need to take additional classes or find tutoring to gain the skills necessary for coursework requirements. Returning to school can be intimidating, and people generally do not relish being novices again after attaining recognition as respected professionals in their field.1 If nurses do not feel supported by their peers regarding the decision to obtain a degree, the potential nursing student may simply decide not to venture onto a new path. DIVERSITY. Older RNs dominate the specialty of perioperative nursing, which combined with retirement and a reduction in hours worked by the aging nursing population leads to the shortage of nurses in this area.2 Finding ways to engage a younger nursing population in the OR is essential to providing services to the demanding patient population. But who will teach this new wave of recruits? Of nursing graduates between 2000 and 2004, 56.9% received associate degrees and 39.9% received baccalaureate or higher RN program degrees.3 Many students seek nursing as a second career. Although associate degree programs traditionally have attracted an older
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student population that are not interested in the four-year traditional baccalaureate degree programs, this finding is not directly tied to the increase in the aging RN workforce.2 Although the average age of nurses is 47 years old, 41.1% are 50 years of age or older.3 This represents a large group of professionals who may consider obtaining advanced education. Currently, there are several educational levels that qualify individuals for entry-level practice in nursing; however, this has been a topic of hot debate, which could eventually lead to a minimum of a bachelor’s degree in nursing as the mandated standard for entry-level preparedness. Ethnic or cultural restrictions on opportunity can create a barrier to education for some nurses. Foreign-trained nurses made up 15.2% of the nursing workforce in 2000,4 and that number is increasing. With some nurses sending money home to care for family members in foreign countries, less money is available to those nurses for tuition. The diversity in the nursing population is inconsistent with that of the national population. According to the 2000 US Census,5 69.5% of the US population is non-Hispanic white, yet this racial group makes up approximately 88.4% of all nurses who responded to an American Nursing Association (ANA) Survey.6 In contrast, the 2000 US Census reported 12.6% of the population to be Hispanic, 3.8% of Asian/Pacific Islander decent, and 12.7% to be black/African American. The ANA survey found that the 2004 nursing population consisted of 4.6% black/African Americans, 3.3% Asian/Pacific Islanders, and 1.8% Hispanics. The national population is not represented in the same ratios in the nursing profession. By 2060, white people will no longer be the majority racial group; the percentage will fall below 50% for the first time to an estimated 49.6%.7 Barriers to education may begin as early as high school, where some ethnic groups may have limited exposure to college preparatory courses that would qualify them for nursing studies. Lowered high school graduation rates among some minority groups also create a disparity between ethnic groups of students who pursue nursing degrees.8 With fewer numbers of ethnically diverse students qualifying for
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college programs, fewer still will graduate from nursing programs. Nursing bears the responsibility of encouraging students from all ethnic backgrounds to pursue a nursing career by employing diversity among nursing faculty to serve as role models and to support students through outreach programs to engage the interest in nursing at a younger age.8 According to Leonard,7 non-white nursing students have a high attrition rate that may reflect a traditional education based on Eurocentric values and beliefs. Diversity in nursing curricula must embrace the richness of the nation’s multi-faceted population in order to ensure the highest quality of care to patients of all ethnic and cultural backgrounds. Although men are entering the nursing profession more than ever before, nursing is still dominated by women. Regardless of gender, heads of households may feel that they should put the needs of the family unit ahead of their own professional goals. GEOGRAPHY. Geography can present a physical barrier to educational pursuits because there may not be qualified schools within a reasonable distance of a nurse’s home. A lengthy commute may not be practical in terms of fuel costs, time, and weather considerations. VALUE. Perceiving the value of an advanced education as a personal investment is a barrier that may be difficult for some nurses to overcome. If the health care employer does not recognize nurses’ degrees in the form of money, status, or professional opportunity, many nurses may feel that the effort and expense of school is simply not worth the level of personal sacrifice necessary to attend. Hospitals that have career ladders recognize educational achievement and encourage nurses to step into leadership roles and to expand their clinical experience. Limited career mobility, job dissatisfaction, and wages that barely keep up with inflation do little to encourage nurses toward returning to school at a time when nursing leadership is most crucial. Dissatisfied staff nurses may see no need to return to school when no advantage to the current work environment is identified.9 Nursing, however, has focused on gaining recognition as a profession of lifelong learning, and nurses must comprehend the
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Finding another nurse who is also going to school may make school life easier by providing someone to study with or offer encouragement during tough classes.
direction that the profession is headed with regard to advanced education so as not to be left behind.10
SOLUTIONS
TO
PERCEIVED BARRIERS
Barriers to higher education can be overcome. Some strategies include improved time management skills, scholarship programs, and online courses. TIME. Excellent time management skills are a necessity for nurses returning to school. The ability to prioritize homework, family life, and work responsibilities takes effort and the support of peers and family members. Prospective students must take a realistic look at the amount of time personally available to devote to doing an excellent job on homework assignments while not feeling like they are neglecting other personal responsibilities. If possible, finding another nurse who is also going to school may make school life easier by providing someone to study with or offer encouragement during tough classes. Along with the responsibilities associated with returning to school, nurses must remember to take time for their own health and relaxation. Restorative activities and environments such as gardening, exercising, pursuing hobbies, or relaxing outdoors can alleviate attention fatigue and assist nurses in their ability to concentrate on academic demands.1 Keeping water and nutritional snacks handy while studying, stretching often, and taking breaks from computer work are essential components to reduce fatigue and stress. AORN JOURNAL •
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The time involved in obtaining an advanced degree may be between one and three years. Waiting for “a better time to start school” is rarely realistic—the opportunity may be now. The best time to return to school is while students are motivated and inspired to take on the challenge. If nurses wait until “the kids are gone,” “my spouse retires,” or “the house is paid off,” school will become a distant dream and other demands will take priority. The choice remains up to each individual, however, and nurses should not feel pressured to return to school if they are not interested. Talking to other nurses who have managed to successfully balance work, life, and school may provide valuable insight into what worked well and what they would have done differently. Developing a mentor relationship with an experienced nurse also can provide important social support and a sounding board for new ideas. COST. While no one can ignore the high cost of education and annual increases in tuition, nurses have several financial assistance options. Many health care employers offer some type of tuition assistance program. These programs may carry an employment clause whereby the nurse commits to continuing employment at the facility for a set number of years after graduation. For nurses who are looking to advance their career opportunities or expand their responsibilities at the same facility, this should not pose a problem; however, this type of program may not be a practical option for nurses who are considering moving or transferring to another facility after graduation or while in school. Scholarship opportunities should not be overlooked. Local civic groups and professional nursing associations offer scholarships to help defray the costs of education. The AORN Foundation awards several scholarships each year to nurses seeking advanced education. Applications for these scholarships are available at http://www.aorn.org/AORNFoundation /Scholarships. Every year, scholarship money goes unclaimed. Nurses should check to see whether a scholarship is still available, even if the application deadline has passed. In some cases, organi-
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zations have been unable to award a scholarship simply because no one applied. Nurses applying for scholarships should allow plenty of time to assemble the required paperwork such as transcripts, letters of recommendation, and personal essays, so that the scholarship packet meets the postmark deadline identified on the application.
Talking to other nurses who have managed to successfully balance work, life, and school may provide valuable insight into what worked well and what they would have done differently.
Student loans offer another opportunity for funding scholastic endeavors. Nurses should check with the college or university’s financial counselors for a list of lenders and information on how to apply. Nurses also should verify whether a loan accrues interest during the school term or whether the interest is deferred until after graduation. Interest rates vary among lenders and types of loans, so prospective students should read the loan information carefully before committing to a loan program. Paying with cash on a class-by-class basis is not feasible for most nursing students but remains an option. Some college programs provide a break between classes, allowing nurses to budget money and take classes as they are financially able. Other universities offer payment plans so money can be paid with each paycheck. Universities and colleges generally increase the rate of tuition every year and students should factor this increase into any considerations regarding the length of study involved. AORN JOURNAL •
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For nurses with young children, childcare costs may need to be budgeted as well. Nurses should check with neighbors or friends to see whether reciprocal babysitting can be arranged to ease some of this cost. Flexible work schedules may be available; therefore, nurses should communicate their interest in returning to school, as well as possible scheduling needs, to their managers. If a nurse can afford the temporary reduction in pay, decreasing the number of hours worked each week may help with the time constraints for completing schoolwork. The disparity of wages between nurse faculty and clinical nursing positions discourages many nurses from seeking faculty positions. Some health care employers are assisting with the faculty shortage by creating partnerships with local nursing programs in which staff nurses rotate as instructors while maintaining staff positions. Both parties benefit from the creation of such a program. Interested nurses should check with the human resources department of their health care facility to see if a similar program exists. Most community colleges require faculty members to have a master’s degree for associate degree classroom teaching, but generally allow nurses with bachelor’s degrees to teach clinical rotations. Universities and four-year colleges require faculty members to obtain a doctorate in order to teach nursing at the bachelor’s or master’s level. EFFORT. Before signing up for an educational program, the prospective student should evaluate the personal and professional motivations that are driving the scholastic endeavor, as well as the expected result after the degree is obtained. Ultimately, there should be a plan in place regarding what to do with the degree and how the knowledge gained will be put into practice. Graduating with a bachelor’s or advanced degree must be personally satisfying. Returning to school requires changes to any previous routine with fewer hours available for sleep and restricted hours to spend on hobbies, recreational activities, and personal interests or with family and friends. Isolation can result and students should find ways to nurture relationships for social support and stress reduction.
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The amount of effort put forth to achieve the desired educational results truly depends on the individual. For some students, getting Bs for coursework is acceptable, while others feel strongly that they must achieve As. Regardless of the grade involved, each individual must feel that the effort expended results in a grade that accurately reflects his or her grasp of the course content. Employers do not generally ask to see the grade point average received during the program, but tuition assistance programs may specify that only nurses receiving grades of A or B will be reimbursed, which would be an important aspect to define before entering into a tuition-reimbursement contract. DIVERSITY AND GEOGRAPHY. The Internet has had a profound effect on the way people learn, live, and work. Nurses now can attend college and university programs online, often with clinical opportunities in their own community—thereby eliminating a lengthy commute and allowing them to work around a full- or part-time schedule. In the case of perioperative nurses, the ability to balance coursework around a call schedule can be particularly appealing. Nursing must represent the art of caring in manners that appeal to people of a wide range of cultures and backgrounds to support diversity among its members. Leadership roles must be encouraged among underrepresented groups to provide positive role models to students considering nursing as a profession when many other lucrative fields may garner attention. Minority recruitment and retention must be encouraged to meet the needs of a diverse society. Men in nursing continue to be underrepresented, perhaps because of a historically female dominance in the profession. Recruitment campaigns must be consciously designed to mentor and support minorities in addition to partnering with federal funding to reduce the cost of education. Nursing also must work to change the image of the profession from one of making beds to that of a career with attractive and satisfying long-term options. Health care organizations can enhance an interest in nursing as a profession by providing workplaces where nurses are valued and education is supported. VALUE. Care provided by nurses educated at the baccalaureate level or higher has been
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associated with improved patient outcomes.11 The value of a highly educated RN workforce should be supported by employers and recognized as an investment in meeting the needs of a diverse patient population with rising acuity levels. The level of nursing education and staff preparedness can have a profound effect on the quality of patient care and positive patient outcomes. An educated workforce translates to improved patient satisfaction and can result in financial savings to the health care organization. Integration of professional behaviors such as critical thinking, reflection, increased confidence, and increased collaboration with other health care members promotes the internalization of professional values into workplace responsibilities and these behaviors are fostered through higher education curricula.12,13 These attributes contribute to levels of patient advocacy and peer mentoring. Perioperative nurses benefit from leadership skills gained through advanced education because they must be able to multitask on several levels while collaborating with the health care team. In determining cost versus value, nurses can go to the AORN web site and use the annually updated compensation calculator to achieve perspective on the financial advantage that may be gained by returning to school. The salary calculator is based on AORN’s annual salary survey and is meant to be used only as a general guideline.14 While financial incentives to education exist, nurses also seek opportunities for growth, rewarding work environments, and autonomy over practice.15 Experienced nurses may begin to disengage from patient care activities because of job dissatisfaction. Advanced educational opportunities, however, may stimulate nurses to become more actively involved in direct patient care activities, to define professional nursing roles, and to assist in the continuous effort to maximize positive patient outcomes through the development of evidence-based practices.13,16 Valuing RN education can assist employers with recruitment and retention efforts, thereby stabilizing the RN workforce and increasing employee job satisfaction. Tuition assistance programs and career ladders can reinforce the value
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of degrees in the workplace environment. In addition, advanced education generally leads to increased job satisfaction, higher salaries, and higher levels of job flexibility.9 Nursing careers can be revitalized with opportunities created by advanced education. The relationship between a degree and improved methods of critical thinking, a larger knowledge base, and competence should be evaluated with regard to the level of influence of nursing experience.17 In 2004 the majority of the nursing population (42.2%) had an associate degree as an initial preparation degree compared to 30.5% for baccalaureate preparation and 0.5% for master’s and higher degrees.6 Recent research links nurses with an educational level of a bachelor’s degree or higher with improved patient outcomes.11 The value of this research should be shared with nurses and health care organizations to underscore the benefit of continuing education and the relationship of nurse education to quality care. When encouraging nurses to seek advanced education, educators must be able to introduce the importance of an increased knowledge base on decision making and evidence-based practice. A degree may result in a change in practice, and exposure to evidence-based practice can help support necessary changes to nurse practice and policy within an organization. Through education, nurses are empowered to participate proactively in contributing to improved levels of patient care and raising the bar of excellence among their peers. Continuous learning and higher education prepare nurses for a practice environment that is becoming increasingly complex and provides the tools necessary to develop valuable leadership skills to augment expert clinical proficiency.
COMMITTING TO THE ENDEAVOR Degree completion offers a sense of accomplishment, a chance to change directions within the profession of nursing, and the opportunity to seek out new challenges for personal and professional growth. With many state and federal nursing associations contemplating support of a move toward the bachelor’s degree in nursing as entry level into practice, the decision is not so much how to overcome
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barriers to pursuing education, but when. Older nurses must weigh the time they plan to stay in the nursing profession against the costs involved in attaining a degree. Higher education, however, allows experienced nurses to enhance their knowledge base while capitalizing on their years of direct patient care to empower the leadership of nursing and to effect positive change in the profession. Doing so may help retain qualified nurses in the workforce to ease the staffing shortage and to improve the environment of care. Many nurses have considered returning to school at some time during their careers, but have not followed through because of time, cost, or other obligations. These concerns are justified, but if a nurse is truly interested, the barriers to education can be overcome. Self-discipline is crucial for optimal time management and educational success. Nurses must fairly evaluate how much time they are willing to commit to the endeavor. Age is not the sole barrier to nurses returning to school—the biggest hurdle may be the nurse’s perception of what he or she is capable of achieving. In the words of the poet George Eliot, “It is never too late to be what you might have been.”
REFERENCES 1. Sanders CM, Yankou D, Andrusyszn MA. Attention and restoration in post-RN students. J Contin Educ Nurs. 2005;36(5):218-225. 2. Auerbach DI, Buerhaus PI, Staiger DO. Associate degree graduates and the rapidly aging RN workforce. Nurs Econ. 2000;18(4):178-184. 3. The Registered Nurse Population: Findings from the March 2004 National Sample Survey of Registered Nurses. Rockville, MD: US Department of Health & Human Services, Health Resources and Services Administration, Bureau of Health Professions; 2006. 4. Polsky D, Ross SJ, Brush BL, Sochalski J. Trends in characteristics and country of origin among foreigntrained nurses in the United States, 1999-2000. Am J Public Health. 2007;97(5):895-899.
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5. Race and Ethnicity. US Census Bureau. http://fact finder.census.gov/jsp/saff/SAFFInfo.jsp?_pageId=tp 9_race-ethnicity. Accessed December 30, 2008. 6. Background and education. American Nurses Association. http://nursingworld.org/MainMenu categories/ThePracticeofProfessionalNursing/Info forNurses/ANA. 7. Leonard T. Exploring diversity in nursing education: research findings. J Cult Divers. 2006;13(2):87-96. 8. Coffman JM, Rosenoff E, Grumbach K. Racial/ ethnic disparities in nursing. Health Aff (Millwood). 2001;20(3):263-272. 9. Sochalski J. Trends: Nursing shortage redux: Turning the corner on an enduring problem: enhanced career ladders, better wages, flexible hours, and a more satisfying workplace would aid in retaining RNs in the nursing workforce. Health Aff (Millwood). 2002;21(5):157-163. 10. Clunie S. The current trend and importance of postgraduate education for nurses. Nurs J. 2006;10(1): 18-23. 11. Aiken LH, Clarke SP, Cheung RB, et al. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290(12):1617-1623. 12. Morris AH, Faulk D. Perspective transformation: enhancing the development of professionalism in RN-to-BSN students. J Nurs Educ. 2007;46(10):445-451. 13. Goode CJ, Pinkerton S, McCausland MP, et al. Documenting chief nursing officers’ preference for BSN-prepared nurses. J Nurs Adm. 2001;31(2):55-59. 14. Annual salary survey and compensation calculator. AORN, Inc. http://www.aorn.org/CareerCenter /SalarySurvey. Accessed November 13, 2008. 15. Levett-Jones TL. Continuing education for nurses: A necessity or a nicety? J Contin Educ Nurs. 2005;36(5):229-233. 16. Blegen MA, Vaughn TE, Goode CJ. Nurse experience and education: effect on quality of care. J Nurs Adm. 2001;31(1):33-39. 17. Ridley RT. The relationship between nurse education level and patient safety: An integrated review. J Nurs Educ. 2008;47(4):149-156.
Marcia Morgenthaler, RN, BSN, CNOR, is the evening shift charge nurse and orthopedic resource nurse in the OR at Skagit Valley Hospital, Mount Vernon, VA.
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T
he current nursing and nurse faculty shortages have prompted many nurses to consider obtaining a bachelor’s or an advanced degree, only to subsequently decide that the obstacles to pursuing additional education may be too great to overcome. Who has the energy to burn the midnight oil and be adequately rested for the rigors of a demanding day of patient care? This article explores the perceived barriers that may prevent nurses from pursuing a degree and possible solutions to reduce or eliminate those barriers.
PERCEIVED BARRIERS Many nurses perceive barriers to the pursuit of higher education. These barriers include time, cost, effort, diversity, geographical location, and perceived value. TIME. Time is a precious commodity and finding a work-life balance can be difficult. Many nurses work extra shifts and overtime while leading busy personal lives, and they may be challenged to find the time needed to return to school. Perioperative nurses in acute care settings face a unique challenge of juggling call schedules in addition to regular shift hours when considering whether school will fit in with the responsibilities of work and home. Shift work may prevent nurses from attending school on the days or hours school is traditionally offered, compounding the fact that completing homework requires several hours a week in addition to attending classes. Although older nurses may feel that their families are becoming less dependent on them, they may want to use their newly found free time to explore hobbies © AORN, Inc, 2009
and new skills. For others, with retirement looming, school may not seem like a viable option. Those caught in the “sandwich generation” may find themselves with the added responsibility of caring for older parents while also caring for their own families. COST. Educational expenses continue to rise during uncertain economic times, and nurses often do not want to add an economic burden to their family’s current financial situation. In addition, the opportunity to work extra shifts to increase the family income is attractive and can weigh heavily on the decision to return to school. For those nurses who do not qualify for scholarships, the full amount of the educational cost may have to be carried personally in the form of student loans or personal savings. When most people in their late 40s and older are focusing on paying off mortgages, going further into debt for a degree that may not change one’s economic or professional status may seem selfish and like a waste of money. Items to consider when calculating the total cost of education should include • books,
ABSTRACT Nurses may face a number of perceived barriers, such as geographical location, time, and cost, when deciding to return to school for additional education. Viable solutions to overcome these barriers include distance education, effective time management, and tuition assistance programs. Key words: nurse education, continuing education; advanced degree; perceived barrier; older nurses. AORN J 89 (February 2009) 335-345. © AORN, Inc, 2009.
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resource and lab fees, travel, parking fees, computer hardware and software, and any tutoring that may be necessary. EFFORT. The amount of effort involved in returning to school cannot be overemphasized when discussing potential barriers to education. Scheduling quality time to put toward studies and learning new material can be overwhelming. Nurses seeking bachelor’s degrees may need to take courses in algebra and statistics if these course requirements were not adequately fulfilled during their associate degree programs. Rusty math skills and the fear of taking tests may cause nurses to feel intimidated and make them unwilling to subject themselves to that level of discomfort. Being expected to conduct research and to write papers at a professional level also may add to older nurses’ hesitation to return to school. An apprehension of not being “smart enough” or possibly failing may be a concern. Consequently, those with poor computer skills may need to take additional classes or find tutoring to gain the skills necessary for coursework requirements. Returning to school can be intimidating, and people generally do not relish being novices again after attaining recognition as respected professionals in their field.1 If nurses do not feel supported by their peers regarding the decision to obtain a degree, the potential nursing student may simply decide not to venture onto a new path. DIVERSITY. Older RNs dominate the specialty of perioperative nursing, which combined with retirement and a reduction in hours worked by the aging nursing population leads to the shortage of nurses in this area.2 Finding ways to engage a younger nursing population in the OR is essential to providing services to the demanding patient population. But who will teach this new wave of recruits? Of nursing graduates between 2000 and 2004, 56.9% received associate degrees and 39.9% received baccalaureate or higher RN program degrees.3 Many students seek nursing as a second career. Although associate degree programs traditionally have attracted an older
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student population that are not interested in the four-year traditional baccalaureate degree programs, this finding is not directly tied to the increase in the aging RN workforce.2 Although the average age of nurses is 47 years old, 41.1% are 50 years of age or older.3 This represents a large group of professionals who may consider obtaining advanced education. Currently, there are several educational levels that qualify individuals for entry-level practice in nursing; however, this has been a topic of hot debate, which could eventually lead to a minimum of a bachelor’s degree in nursing as the mandated standard for entry-level preparedness. Ethnic or cultural restrictions on opportunity can create a barrier to education for some nurses. Foreign-trained nurses made up 15.2% of the nursing workforce in 2000,4 and that number is increasing. With some nurses sending money home to care for family members in foreign countries, less money is available to those nurses for tuition. The diversity in the nursing population is inconsistent with that of the national population. According to the 2000 US Census,5 69.5% of the US population is non-Hispanic white, yet this racial group makes up approximately 88.4% of all nurses who responded to an American Nursing Association (ANA) Survey.6 In contrast, the 2000 US Census reported 12.6% of the population to be Hispanic, 3.8% of Asian/Pacific Islander decent, and 12.7% to be black/African American. The ANA survey found that the 2004 nursing population consisted of 4.6% black/African Americans, 3.3% Asian/Pacific Islanders, and 1.8% Hispanics. The national population is not represented in the same ratios in the nursing profession. By 2060, white people will no longer be the majority racial group; the percentage will fall below 50% for the first time to an estimated 49.6%.7 Barriers to education may begin as early as high school, where some ethnic groups may have limited exposure to college preparatory courses that would qualify them for nursing studies. Lowered high school graduation rates among some minority groups also create a disparity between ethnic groups of students who pursue nursing degrees.8 With fewer numbers of ethnically diverse students qualifying for
Morgenthaler
college programs, fewer still will graduate from nursing programs. Nursing bears the responsibility of encouraging students from all ethnic backgrounds to pursue a nursing career by employing diversity among nursing faculty to serve as role models and to support students through outreach programs to engage the interest in nursing at a younger age.8 According to Leonard,7 non-white nursing students have a high attrition rate that may reflect a traditional education based on Eurocentric values and beliefs. Diversity in nursing curricula must embrace the richness of the nation’s multi-faceted population in order to ensure the highest quality of care to patients of all ethnic and cultural backgrounds. Although men are entering the nursing profession more than ever before, nursing is still dominated by women. Regardless of gender, heads of households may feel that they should put the needs of the family unit ahead of their own professional goals. GEOGRAPHY. Geography can present a physical barrier to educational pursuits because there may not be qualified schools within a reasonable distance of a nurse’s home. A lengthy commute may not be practical in terms of fuel costs, time, and weather considerations. VALUE. Perceiving the value of an advanced education as a personal investment is a barrier that may be difficult for some nurses to overcome. If the health care employer does not recognize nurses’ degrees in the form of money, status, or professional opportunity, many nurses may feel that the effort and expense of school is simply not worth the level of personal sacrifice necessary to attend. Hospitals that have career ladders recognize educational achievement and encourage nurses to step into leadership roles and to expand their clinical experience. Limited career mobility, job dissatisfaction, and wages that barely keep up with inflation do little to encourage nurses toward returning to school at a time when nursing leadership is most crucial. Dissatisfied staff nurses may see no need to return to school when no advantage to the current work environment is identified.9 Nursing, however, has focused on gaining recognition as a profession of lifelong learning, and nurses must comprehend the
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Finding another nurse who is also going to school may make school life easier by providing someone to study with or offer encouragement during tough classes.
direction that the profession is headed with regard to advanced education so as not to be left behind.10
SOLUTIONS
TO
PERCEIVED BARRIERS
Barriers to higher education can be overcome. Some strategies include improved time management skills, scholarship programs, and online courses. TIME. Excellent time management skills are a necessity for nurses returning to school. The ability to prioritize homework, family life, and work responsibilities takes effort and the support of peers and family members. Prospective students must take a realistic look at the amount of time personally available to devote to doing an excellent job on homework assignments while not feeling like they are neglecting other personal responsibilities. If possible, finding another nurse who is also going to school may make school life easier by providing someone to study with or offer encouragement during tough classes. Along with the responsibilities associated with returning to school, nurses must remember to take time for their own health and relaxation. Restorative activities and environments such as gardening, exercising, pursuing hobbies, or relaxing outdoors can alleviate attention fatigue and assist nurses in their ability to concentrate on academic demands.1 Keeping water and nutritional snacks handy while studying, stretching often, and taking breaks from computer work are essential components to reduce fatigue and stress. AORN JOURNAL •
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The time involved in obtaining an advanced degree may be between one and three years. Waiting for “a better time to start school” is rarely realistic—the opportunity may be now. The best time to return to school is while students are motivated and inspired to take on the challenge. If nurses wait until “the kids are gone,” “my spouse retires,” or “the house is paid off,” school will become a distant dream and other demands will take priority. The choice remains up to each individual, however, and nurses should not feel pressured to return to school if they are not interested. Talking to other nurses who have managed to successfully balance work, life, and school may provide valuable insight into what worked well and what they would have done differently. Developing a mentor relationship with an experienced nurse also can provide important social support and a sounding board for new ideas. COST. While no one can ignore the high cost of education and annual increases in tuition, nurses have several financial assistance options. Many health care employers offer some type of tuition assistance program. These programs may carry an employment clause whereby the nurse commits to continuing employment at the facility for a set number of years after graduation. For nurses who are looking to advance their career opportunities or expand their responsibilities at the same facility, this should not pose a problem; however, this type of program may not be a practical option for nurses who are considering moving or transferring to another facility after graduation or while in school. Scholarship opportunities should not be overlooked. Local civic groups and professional nursing associations offer scholarships to help defray the costs of education. The AORN Foundation awards several scholarships each year to nurses seeking advanced education. Applications for these scholarships are available at http://www.aorn.org/AORNFoundation /Scholarships. Every year, scholarship money goes unclaimed. Nurses should check to see whether a scholarship is still available, even if the application deadline has passed. In some cases, organi-
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zations have been unable to award a scholarship simply because no one applied. Nurses applying for scholarships should allow plenty of time to assemble the required paperwork such as transcripts, letters of recommendation, and personal essays, so that the scholarship packet meets the postmark deadline identified on the application.
Talking to other nurses who have managed to successfully balance work, life, and school may provide valuable insight into what worked well and what they would have done differently.
Student loans offer another opportunity for funding scholastic endeavors. Nurses should check with the college or university’s financial counselors for a list of lenders and information on how to apply. Nurses also should verify whether a loan accrues interest during the school term or whether the interest is deferred until after graduation. Interest rates vary among lenders and types of loans, so prospective students should read the loan information carefully before committing to a loan program. Paying with cash on a class-by-class basis is not feasible for most nursing students but remains an option. Some college programs provide a break between classes, allowing nurses to budget money and take classes as they are financially able. Other universities offer payment plans so money can be paid with each paycheck. Universities and colleges generally increase the rate of tuition every year and students should factor this increase into any considerations regarding the length of study involved. AORN JOURNAL •
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For nurses with young children, childcare costs may need to be budgeted as well. Nurses should check with neighbors or friends to see whether reciprocal babysitting can be arranged to ease some of this cost. Flexible work schedules may be available; therefore, nurses should communicate their interest in returning to school, as well as possible scheduling needs, to their managers. If a nurse can afford the temporary reduction in pay, decreasing the number of hours worked each week may help with the time constraints for completing schoolwork. The disparity of wages between nurse faculty and clinical nursing positions discourages many nurses from seeking faculty positions. Some health care employers are assisting with the faculty shortage by creating partnerships with local nursing programs in which staff nurses rotate as instructors while maintaining staff positions. Both parties benefit from the creation of such a program. Interested nurses should check with the human resources department of their health care facility to see if a similar program exists. Most community colleges require faculty members to have a master’s degree for associate degree classroom teaching, but generally allow nurses with bachelor’s degrees to teach clinical rotations. Universities and four-year colleges require faculty members to obtain a doctorate in order to teach nursing at the bachelor’s or master’s level. EFFORT. Before signing up for an educational program, the prospective student should evaluate the personal and professional motivations that are driving the scholastic endeavor, as well as the expected result after the degree is obtained. Ultimately, there should be a plan in place regarding what to do with the degree and how the knowledge gained will be put into practice. Graduating with a bachelor’s or advanced degree must be personally satisfying. Returning to school requires changes to any previous routine with fewer hours available for sleep and restricted hours to spend on hobbies, recreational activities, and personal interests or with family and friends. Isolation can result and students should find ways to nurture relationships for social support and stress reduction.
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The amount of effort put forth to achieve the desired educational results truly depends on the individual. For some students, getting Bs for coursework is acceptable, while others feel strongly that they must achieve As. Regardless of the grade involved, each individual must feel that the effort expended results in a grade that accurately reflects his or her grasp of the course content. Employers do not generally ask to see the grade point average received during the program, but tuition assistance programs may specify that only nurses receiving grades of A or B will be reimbursed, which would be an important aspect to define before entering into a tuition-reimbursement contract. DIVERSITY AND GEOGRAPHY. The Internet has had a profound effect on the way people learn, live, and work. Nurses now can attend college and university programs online, often with clinical opportunities in their own community—thereby eliminating a lengthy commute and allowing them to work around a full- or part-time schedule. In the case of perioperative nurses, the ability to balance coursework around a call schedule can be particularly appealing. Nursing must represent the art of caring in manners that appeal to people of a wide range of cultures and backgrounds to support diversity among its members. Leadership roles must be encouraged among underrepresented groups to provide positive role models to students considering nursing as a profession when many other lucrative fields may garner attention. Minority recruitment and retention must be encouraged to meet the needs of a diverse society. Men in nursing continue to be underrepresented, perhaps because of a historically female dominance in the profession. Recruitment campaigns must be consciously designed to mentor and support minorities in addition to partnering with federal funding to reduce the cost of education. Nursing also must work to change the image of the profession from one of making beds to that of a career with attractive and satisfying long-term options. Health care organizations can enhance an interest in nursing as a profession by providing workplaces where nurses are valued and education is supported. VALUE. Care provided by nurses educated at the baccalaureate level or higher has been
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associated with improved patient outcomes.11 The value of a highly educated RN workforce should be supported by employers and recognized as an investment in meeting the needs of a diverse patient population with rising acuity levels. The level of nursing education and staff preparedness can have a profound effect on the quality of patient care and positive patient outcomes. An educated workforce translates to improved patient satisfaction and can result in financial savings to the health care organization. Integration of professional behaviors such as critical thinking, reflection, increased confidence, and increased collaboration with other health care members promotes the internalization of professional values into workplace responsibilities and these behaviors are fostered through higher education curricula.12,13 These attributes contribute to levels of patient advocacy and peer mentoring. Perioperative nurses benefit from leadership skills gained through advanced education because they must be able to multitask on several levels while collaborating with the health care team. In determining cost versus value, nurses can go to the AORN web site and use the annually updated compensation calculator to achieve perspective on the financial advantage that may be gained by returning to school. The salary calculator is based on AORN’s annual salary survey and is meant to be used only as a general guideline.14 While financial incentives to education exist, nurses also seek opportunities for growth, rewarding work environments, and autonomy over practice.15 Experienced nurses may begin to disengage from patient care activities because of job dissatisfaction. Advanced educational opportunities, however, may stimulate nurses to become more actively involved in direct patient care activities, to define professional nursing roles, and to assist in the continuous effort to maximize positive patient outcomes through the development of evidence-based practices.13,16 Valuing RN education can assist employers with recruitment and retention efforts, thereby stabilizing the RN workforce and increasing employee job satisfaction. Tuition assistance programs and career ladders can reinforce the value
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of degrees in the workplace environment. In addition, advanced education generally leads to increased job satisfaction, higher salaries, and higher levels of job flexibility.9 Nursing careers can be revitalized with opportunities created by advanced education. The relationship between a degree and improved methods of critical thinking, a larger knowledge base, and competence should be evaluated with regard to the level of influence of nursing experience.17 In 2004 the majority of the nursing population (42.2%) had an associate degree as an initial preparation degree compared to 30.5% for baccalaureate preparation and 0.5% for master’s and higher degrees.6 Recent research links nurses with an educational level of a bachelor’s degree or higher with improved patient outcomes.11 The value of this research should be shared with nurses and health care organizations to underscore the benefit of continuing education and the relationship of nurse education to quality care. When encouraging nurses to seek advanced education, educators must be able to introduce the importance of an increased knowledge base on decision making and evidence-based practice. A degree may result in a change in practice, and exposure to evidence-based practice can help support necessary changes to nurse practice and policy within an organization. Through education, nurses are empowered to participate proactively in contributing to improved levels of patient care and raising the bar of excellence among their peers. Continuous learning and higher education prepare nurses for a practice environment that is becoming increasingly complex and provides the tools necessary to develop valuable leadership skills to augment expert clinical proficiency.
COMMITTING TO THE ENDEAVOR Degree completion offers a sense of accomplishment, a chance to change directions within the profession of nursing, and the opportunity to seek out new challenges for personal and professional growth. With many state and federal nursing associations contemplating support of a move toward the bachelor’s degree in nursing as entry level into practice, the decision is not so much how to overcome
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barriers to pursuing education, but when. Older nurses must weigh the time they plan to stay in the nursing profession against the costs involved in attaining a degree. Higher education, however, allows experienced nurses to enhance their knowledge base while capitalizing on their years of direct patient care to empower the leadership of nursing and to effect positive change in the profession. Doing so may help retain qualified nurses in the workforce to ease the staffing shortage and to improve the environment of care. Many nurses have considered returning to school at some time during their careers, but have not followed through because of time, cost, or other obligations. These concerns are justified, but if a nurse is truly interested, the barriers to education can be overcome. Self-discipline is crucial for optimal time management and educational success. Nurses must fairly evaluate how much time they are willing to commit to the endeavor. Age is not the sole barrier to nurses returning to school—the biggest hurdle may be the nurse’s perception of what he or she is capable of achieving. In the words of the poet George Eliot, “It is never too late to be what you might have been.”
REFERENCES 1. Sanders CM, Yankou D, Andrusyszn MA. Attention and restoration in post-RN students. J Contin Educ Nurs. 2005;36(5):218-225. 2. Auerbach DI, Buerhaus PI, Staiger DO. Associate degree graduates and the rapidly aging RN workforce. Nurs Econ. 2000;18(4):178-184. 3. The Registered Nurse Population: Findings from the March 2004 National Sample Survey of Registered Nurses. Rockville, MD: US Department of Health & Human Services, Health Resources and Services Administration, Bureau of Health Professions; 2006. 4. Polsky D, Ross SJ, Brush BL, Sochalski J. Trends in characteristics and country of origin among foreigntrained nurses in the United States, 1999-2000. Am J Public Health. 2007;97(5):895-899.
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5. Race and Ethnicity. US Census Bureau. http://fact finder.census.gov/jsp/saff/SAFFInfo.jsp?_pageId=tp 9_race-ethnicity. Accessed December 30, 2008. 6. Background and education. American Nurses Association. http://nursingworld.org/MainMenu categories/ThePracticeofProfessionalNursing/Info forNurses/ANA. 7. Leonard T. Exploring diversity in nursing education: research findings. J Cult Divers. 2006;13(2):87-96. 8. Coffman JM, Rosenoff E, Grumbach K. Racial/ ethnic disparities in nursing. Health Aff (Millwood). 2001;20(3):263-272. 9. Sochalski J. Trends: Nursing shortage redux: Turning the corner on an enduring problem: enhanced career ladders, better wages, flexible hours, and a more satisfying workplace would aid in retaining RNs in the nursing workforce. Health Aff (Millwood). 2002;21(5):157-163. 10. Clunie S. The current trend and importance of postgraduate education for nurses. Nurs J. 2006;10(1): 18-23. 11. Aiken LH, Clarke SP, Cheung RB, et al. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290(12):1617-1623. 12. Morris AH, Faulk D. Perspective transformation: enhancing the development of professionalism in RN-to-BSN students. J Nurs Educ. 2007;46(10):445-451. 13. Goode CJ, Pinkerton S, McCausland MP, et al. Documenting chief nursing officers’ preference for BSN-prepared nurses. J Nurs Adm. 2001;31(2):55-59. 14. Annual salary survey and compensation calculator. AORN, Inc. http://www.aorn.org/CareerCenter /SalarySurvey. Accessed November 13, 2008. 15. Levett-Jones TL. Continuing education for nurses: A necessity or a nicety? J Contin Educ Nurs. 2005;36(5):229-233. 16. Blegen MA, Vaughn TE, Goode CJ. Nurse experience and education: effect on quality of care. J Nurs Adm. 2001;31(1):33-39. 17. Ridley RT. The relationship between nurse education level and patient safety: An integrated review. J Nurs Educ. 2008;47(4):149-156.
Marcia Morgenthaler, RN, BSN, CNOR, is the evening shift charge nurse and orthopedic resource nurse in the OR at Skagit Valley Hospital, Mount Vernon, VA.
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