Increasing the number of baccalaureate prepared nurses to 80% by 2020 is one recommendation by the IOM, (now The National Academies of Sciences Engineering Medicine, Health and Medicine) (2011) to deliver safe, effective, patient-centered care to individuals in health care settings. Results of multiple research studies indicate that being cared for by a bachelor’s-prepared registered professional nurse (RN) reduces length of stay in health care facilities (Blegen, Vaughn, Goode, Spetz, & Park, 2013; Sarver, Cichra, & Kline, 2015) and enhances patient outcomes (Alamri & Sharts-Hopko, 2015; Einhellig, 2015; Jeffreys, 2015; Kern, 2014; Kovner, Brewer, Katigbak, Djukic, & Fatehi, 2012; Peterson-Graziose, Bryer, & Nikolaidou, 2016). Currently, almost 45% of RNs are educated at the associate degree level (Robert Wood Johnson Foundation, 2015) in the United States, a finding that demonstrates the need for RN-BS programs designed to support the needs of nurses returning to school to obtain a Bachelor of Science (BS) degree. Legislation has been considered in several states that would require a BS degree within 10 years of receiving the RN license (Blegen et al., 2013) and, in fact, in New York State a “BSN in 10” (S6768/A1842) bill was recently signed (New York 7 State Legislature, 2017). This further supports the development of RN-BS programs that foster progression and completion of a baccalaureate degree for practicing nurses. Essential to the success of RN-BS students is the identification of variables that influence retention. The inability of nurses to successfully complete a BS program can be costly to academic institutions, hinder registered nurses’ professional growth (Blegen et al., 2013; Einhellig, 2015) and impact patient outcomes (Blegen et al., 2013; Jeffreys, 2015). The purpose of this non-experimental correlational, longitudinal study was to examine variables that influence RN-BS student retention utilizing Jeffreys “Student Perception Appraisal Tool”.
METHODOLOGY
A longitudinal, non-experimental, descriptive research design was used to measure and evaluate how restrictive or supportive specific academic, environmental, and professional integration and socialization variables influence retention in nursing courses as perceived by RN-BS completion program students. The sample consisted of RN-BS completion students enrolled in either one public or one private college in the Northeastern United States. After signing informed consent, participants were asked to complete a demographic questionnaire and the Jeffreys Student Perception Appraisal Tool-Revised-2 (SPA-R2) (Jeffreys, 2012). Thereafter, subjects were asked to complete only the Jeffreys Student Perception Appraisal tool at the beginning (pretest) and end (posttest) of each semester of study in their program. Data was collected over a 2 year/5 semester period and was coded to ensure anonymity.
INSTRUMENT
Student perceptions of restrictive and supportive variables were measured using Jeffreys SPA-R2. The SPA-R2 is a 27-item questionnaire that measures and evaluates the influence of certain variables, as perceived by students, on retention in nursing courses (Jeffreys, 2012). Five categories of variables that can influence student retention by being perceived as supportive or restrictive, are addressed in the SPA-R2 tool; environmental (10 items); professional integration factors (5 items); personal academic (5 items); college facilities (5 items); and friend support (2 items) (Kern, 2014). These variables are measured with “a 6-point Likert-type scale. The SPA-R2 has high reliability with a Cronbach alpha of 0.89 and a split half reliability of 0.88. The content validity index was 1.0 (Jeffreys, 2007).
RESULTS
Descriptive reduction techniques were used to examine student perception of which academic, environmental, professional integration, and socialization variables supported or restricted retention in nursing courses. Variables were measured at the beginning (pre) and end of each semester (post) for five consecutive semesters at two academic institutions. Pre-survey results indicated that overall, encouragement by friends within classes and encouragement by friends outside of school were the most supportive variables for retention (M=4.44, SD=.657 and M=4.23, SD=.820 respectively). Childcare arrangements (M=2.91, SD=1.08) and family responsibilities (M=2.77, SD=1.15) were the most restrictive variables for retention. Post-survey findings indicated that overall, encouragement by friends within classes (M=4.51, SD=.577) and encouragement by friends outside of school (M=4.25, SD=.593) were the most supportive factors for retention, and childcare arrangements (M=2.79, SD=1.17) and family responsibilities (M=2.75, SD=1.10) remained the most restrictive variables for retention across all five semesters.
The non-parametric test, Spearman rho, was used to explore possible correlations of demographic and educational variables with academic, environmental, and professional integration and socialization variables. Statistically significant correlations were found in both pre- and post-survey responses. To explore possible differences in pre- and post-survey responses related to academic, environmental, and professional integration and socialization variables across all six semesters, the non-parametric Kendall’s W was used. According to the Kendall’s Coefficient of Concordance analysis, across all semesters, two variables were found to have statistically significant differences. Transportation arrangements had a Kendall coefficient of concordance of .51 (p = .037) and College tutoring services had a Kendall coefficient of concordance of .46 (p = .05).
Paired sample analysis using the Wilcoxon statistic to compare the pre- and post-survey responses, semester by semester, was performed. Statistically significant differences were noted in five semesters. In fall 2014, results indicated a significant difference in the variable “membership in nursing club or organization”, z = -2.08, p = .038. The pre-survey mean of the ranks was 7.25, while post-survey mean of the ranks was 8.92. Pairwise comparison for the variable “family emotional support” in the spring 2015 semester was significant (p =.046) with pre-survey rated higher by participants than post-survey responses. Significant differences were observed in the spring 2016 semester (p = .014) for the variable “financial aid and/or scholarship” with post-survey responses rated higher than pre-survey responses.
The sample consisted of RN-BS completion students enrolled in a public college and a private university. A Mann Whitney U test was conducted to evaluate differences in survey responses to retention variables between nursing students enrolled in these two institutions. Pre- and post-survey responses were also averaged over all semesters to explore significant differences between institutions. Nursing students attending the public college found the variables of financial aid and/or scholarships (z = -2.979, p =.003), encouragement by friends outside of school (z = -2.340; p = .019), and encouragement from friends within classes (z = -2.618, p = .009) more supportive than students attending the private university. Conversely, the public college students felt more restricted by hours of employment (z = -2.242, p = .025) than those attending the private university. Results indicated that private university students felt more supported by student support services (z = -2.398, p = .017) and college library services (z = -2.300, p = .021) than their counterparts at public college. Finally, a reliability analysis was conducted to test internal consistency of the SPA-R2 pre- and post-test instrument for each semester of the study. Very high Cronbach alpha scores ranging from .894 to .961 were found indicating a high degree of internal consistency.
DISCUSSION
The changing needs of healthcare demand a nursing workforce equipped to face many current challenges and future changes. To prepare such a workforce, attention must be shifted to retention of nursing students by identifying variables that can influence it (Jeffreys, 2015). This longitudinal, multisite study contributes to the limited body of research on retention of RN-BS students. The results of this study indicate that the most supportive variables for retention are encouragement by friends within classes and encouragement by friends outside of school, while the most restrictive are childcare arrangements and family responsibilities across all five semesters. Maintaining balance between work, school, and personal life is a challenge for nurses returning to school to complete their baccalaureate degrees (Einhellig, 2015; Kovner et al., 2012). Managing personal responsibilities, time, and money can be a barrier in continuing their education (Gillespie & Langston, 2014). Support from families, friends and coworkers is essential and pivotal to their success in school (Alamri 2015, Perfetto 2015). Although there is conflicting evidence related to the influence of outside friends on retention (Jeffreys, 2012), this variable remained consistently supportive in this study pre- and-post survey in all semesters.
Financial resources such as tuition support from employers or from financial aid and/or scholarships are variables that can influence the decision to return to school and complete an RN to BS program (Gillespie & Langston, 2014). In this study, the pre- and post-survey mean differences in the variables of “membership in nursing club or organization”, “family emotional support”, and “financial aid and/or scholarship” were found to be statistically significant. This can be attributed to the fact that although these environmental variables may be perceived to be either restrictive or supportive, those perceptions can be significantly different between the beginning of a course and after completion of a course, semester, or program (Jeffreys, 2015). Initially students might be more optimistic and underestimate the impact of environmental or academic factors on their progress and eventually, retention.
CONCLUSION
The challenge for nursing is to identify variables that influence retention in this population and develop retention strategies specific to their unique needs. Collaboration between students, faculty, policy makers, and institutions may provide the necessary support for RN students to successfully complete their education and deliver high level, safe, quality patient care.