Among the practice professions, nursing is unique in that it allows multiple entry levels into practice. In a recent national study of nursing education funded by the Carnegie Foundation for the Advancement of Teaching, Benner, Sutphen, Leonard, and Day (2010) noted that, compared with other professional practices, nursing education mandates relatively little time to develop the background understanding and professional role formation of the practice. Moreover, these authors asserted that nursing practice requires the exercise of responsibility and judgment in “high risk underdetermined situations” (Benner et al., 2010, pp. 216–217).
In response, a collaborative partnership was formed between a community college-based associate’s degree nursing program and a university-based baccalaureate program to pilot a direct transition program for students from associate’s degree to baccalaureate degree in nursing. Unlike a traditional registered nurse (RN) to bachelor’s of science in nursing (BSN) program in which students must have successfully passed the national nurse licensing examination for admission, these associate’s degree students co-enrolled in the baccalaureate program during their second year, concomitantly completing their associate’s degree classes. This article reports the findings of a phenomenological study to explore the experiences, trajectory, and widening of horizons of the students as they completed this accelerated associate’s degree to baccalaureate degree program (ADN to BSN).
According to Benner et al. (2010), students who pursue a baccalaureate degree have the advantage of learning more, particularly in areas such as leadership, health policy, community health, and research. The additional time required to earn a baccalaureate degree allows students to learn in greater depth compared with students in an associate’s degree program. Other nurse educators suggested that baccalaureate degree programs place more focus on theory, leadership, critical thinking, and practice-based research (Blais, Hayes, & Kozier, 2005). Qualitative and quantitative studies of RN to BSN programs found that students reported a more holistic understanding of the practice environment (Delaney & Piscopo, 2007; Lillibridge & Fox, 2005; Zuzelo, 2001), a greater appreciation of the influence of research on practice (Zuzelo, 2001), and an increased perception of their professional role and identity (Kubsch, Hansen, & Huyser-Eatwell, 2008; Lillibridge & Fox, 2005). In addition, studies have described a transition in the understanding of leadership and advocacy roles (Lillibridge & Fox, 2005; Zuzelo, 2001). However, all of these studies were of RNs returning to school to obtain a BSN. Therefore, it was difficult to determine the effect of differences in work experiences compared with the potential effect of baccalaureate-level classes when determining the influence of ADN to BSN programs on professional role development. The study participants moved directly from a community college associate’s degree program to a university baccalaureate program (with some concurrent enrollment of classes). To date, no literature has described this transition. When the students in this study entered the program, they had not yet taken the National Council Licensure Examination (NCLEX). The decision by students to continue their education while completing an associate’s degree program was potentially filled with challenges. The journey of seamlessly continuing education from the associate’s degree to the baccalaureate degree without taking a break or gaining practical experience has not been addressed in the literature. The potential burden of studying for the NCLEX and obtaining and orienting to a new job has not been mentioned in the traditional literature on ADN to BSN programs. Furthermore, the authors believed that exploring the lived experience of these students over time could more clearly articulate the nature of the transition from associate’s degree-educated nurse to baccalaureate-educated nurse.
This qualitative study used phenomenological research methods. Phenomenological methods recognize the situated nature of phenomena across time and space and within a particular culture. Researchers attempt to insightfully interpret and describe the way that the world occurs for the group being studied through accounts of their everyday experiences. Thus, phenomenology was considered the most appropriate research method to describe transitions in students’ experiences over the time spent within the program of study. According to Van Manen (1990), meaning is created within the four existentials of lived experience: spatiality (lived space), corporeality (lived body), temporality (lived time), and relationality or communality (lived other). From within these phenomenological understandings, the primary research question was: What is the lived experience of nursing students in a direct ADN to BSN program?
Sample and Setting
All students entering the second year of a 2-year ADN program at a community college in the western United States were purposely recruited and invited to participate in the collaborative transition program. Subsequently, all students participating in the first cohort of the transition program were invited to participate in the research study. All agreed to participate. Study participants’ (N = 14) ages ranged from 21 to 41 years, with a median of 26 years. The majority were female (n = 13). Participants reported their ethnicity as Asian American (including Pacific Islander) (n = 11), White (n = 1), and other (n = 2).
Data Collection: Interviews
After institutional human subjects approval was obtained, five rounds of small group interviews were conducted, with two to five participants in each group, throughout an 18-month period to capture the temporality (lived time) of students’ experiences. The first interviews took place during the participants’ first semester of concurrent coursework, and concluding interviews were held at the end of their final semester. The semi-structured interviews lasted 60 to 90 minutes and were conducted in a confidential setting at either the community college or the university. A small group interview format was used because it allowed students in a closely knit cohort to build on the statements of other students while in dialogue (Benner, Tanner, & Chesla, 1996), thus capturing the communality and relationship of the students within the experience of learning. The audiotaped interviews were professionally transcribed.
After verbatim transcription of the interviews was completed, the authors undertook a multistep interpretive analytic process of reading and re-reading data informed by interpretive phenomenological traditions (Benner, 1994; Finlay, 2009; Van Manen, 1990). Periodic group interpretive discussions were held to refine thematic analysis and ultimately describe the findings in a coherent whole view of the phenomenon. Two of the researchers were experts in phenomenological methods. The other two members of the research team were administrators of the transition program. These interpretive group discussions, conducted over time, allowed the authors to build on earlier discussions and continue to reframe themes as more of the meaning of the transition was articulated in light of subsequent interviews.
Trustworthiness of Findings
The historical and philosophical underpinnings of phenomenology assume an indissolvable connection between the researcher and the researched. Within this hermeneutic circle, the researchers strive to “open up” their understanding of the phenomenon with the goal of approaching the phenomenon in a more informed way at the completion of the study (Gadamer, 2004). Implicit in this understanding is that representation of the phenomenon will always be incomplete; however, certain features of the study enhance the trustworthiness of the findings. In this study, multiple views of the phenomenon were opened up through the perspectives of the four researchers, two of whom had extensive training and experience in phenomenological methods. In addition, the interpretations were synthesized through multiple dialogical interpretive sessions during the 18 months of the study and confirmed by an expert researcher outside of the study. Finally, the “voice” of the participants was included in narratives that represented themes within the findings.
In interpreting the findings, the researchers noted an overarching theme of a transformative change that occurred over time. This change was described in three phases as opening doors, opening eyes, and opening minds. Initially, students articulated a sense of “a golden ticket” of increased opportunity provided by their inclusion in the pilot program. In interviews conducted midway through the program, students were discovering a new world of ideas and had been introduced to a different teaching and learning style compared with their associate’s degree education. In concluding interviews, students articulated a new personal identity as a professional nurse that included an expanded role beyond the bedside. Students had also taken up the value of lifelong learning and were confident in their intention to continue their education beyond the baccalaureate degree.
First Interviews: Opening Doors
Initially, students were ambivalent about the decision to participate in the transition program because the program was new to them and to the community college and the university. They were concerned about the “unknown” and about failing, with one student noting that “no one has done this before.” Most of the participants had only considered career goals that focused on earning an associate’s degree, passing the NCLEX, and securing employment as a registered nurse. Yet, students acknowledged that a decision not to enroll in this transition program could lead them to regret what they did not try.
For two semesters, the students were enrolled in at least one baccalaureate-level class while finishing the associate’s degree program. As one student stated, taking part in the transition program could “jeopardize my nursing education” by leading to poor performance in the associate’s degree program classes that took place concurrently with the baccalaureate-level classes. After they successfully completed the first baccalaureate classes, students felt some relief at crossing one hurdle and had the sense that the program was “do-able.”
In these early interviews, students’ language and concerns were focused on the pragmatic value and potentially increased opportunity provided by their inclusion in the pilot program. For example, one student described a “chance” encounter with an accelerated program: “I still think we were handed a golden ticket. I’ve always called it that because I feel like we got it. Right at the same spot, all the stars aligned for us and we just walked in.” During a time of local job scarcity for new graduate nurses, participants felt that their potential for securing a job seemed enhanced. One participant stated, “It makes me more competitive. . . . I feel like [employers] look at you differently than the [nurse] with an ADN.” Another stated that, with a baccalaureate degree, the students would “get more respect” and remarked that the baccalaureate degree would “just open more doors for us.”
Middle Interviews: Opening Eyes
The middle interviews (third and fourth sets) focused on what the students found surprising about the BSN program and what contrasts they had noted between the BSN program and their ADN program. The participants were quick to acknowledge the value of the foundational classes in their associate’s degree program and the dedicated faculty within the program; however, they identified differences in teaching styles and time available for learning. For example, students described the vast quantity of information that they needed to absorb during the relatively short 2-year associate’s degree program, with one stating:
I think the focus in our ADN program is more geared toward education on diagnoses and framing the beginning thinking of nursing—assessment, diagnosis, interventions, evaluations—getting the students in that mindset. To do that, I think you have to spell everything out. It was very, very beneficial because the amount of information covered in those 2 years is a lot to handle. And if there’s no structure, then you won’t learn as well.
The students noted that the baccalaureate program seemed to have a less directed or regimented organizational style that sometimes caught them off-guard: “I came from a 2-year program where [the instruction is] very systematic.” In addition, the style of learning had changed for these students. The teaching style was less systematic and more conceptual, and there were more class discussions. As one participant remarked, “We’re used to sitting back and listening to a teacher, but here you have to be engaged. The teacher wants you to talk, and it’s more like a discussion rather than a lecture.” Another participant recalled a lecture experience from her associate’s degree program:
The learning style in the associate’s degree program is much different. Instructors would just post PowerPoint slides and we were to memorize them. Memorize the signs and symptoms. Memorize the medications. It was just pretty much memorization. If you have a good memory, you’re going to do well on the test. Here, it’s not like that, and that was kind of a shocker for me because that’s what I’ve been doing. Just memorizing.
One of the overarching themes noted in these middle interviews was “placing learning in a much larger context” that changed the students’ styles of practice. Gadamer referred to this as an “opening of horizons” (Gadamer, 2004, p. 302). The students’ dialogue during these interviews showed how the range of their vision was opened. Courses on evidence-based practice, community nursing, nursing theory, and leadership began to open students’ eyes to new ways of thinking about the role of nurse. One student’s comments concretely described a deeper understanding of the use of research in evidence-based practice:
Before taking the research class, I used to literally just pick articles off the website that fit the requirements that I chose. . . . I used to skip over all the statistics and the type of research. I mean, I just didn’t understand the articles before. I just looked for a quote I could use.
Another student related her ability to integrate theory, research, and practice, stating:
I’m really glad I came this far and learned so much. It helps me now on the unit just to look at policies and procedures . . . know why things are done instead of just accepting whatever’s being done. . . . [Now] I want to look into things. I want to go further and see . . . what’s the evidence behind the theory.
In each of these quotes, the students described their expanded horizons and how this experience opened up their understanding of the meaning of research or theory toward their evolving vision of themselves as practitioners. One student also described the transition toward a lifelong curiosity and an interest in lifelong learning. This is significant for any practitioner because practices continuously change and are fraught with ambiguities.
Students’ understanding of patient-centered care and the nurse’s role in promoting health and health literacy was also expanded and integrated:
Before I went through this program, I would get a shift report from a nurse and it would say that this is a complicated patient or this is a noncompliant patient, and I would wonder: Why isn’t this person taking his medications? What’s wrong with him? Just pop the pill in your mouth and take it. It’s for your blood pressure. But now the whole concept (which I’d never heard about) was health literacy. It just made such an impression on me that there’s more than this patient not being compliant. What is making this patient not take his medications? No money? Did he just lose his job? Does he not understand? Can he not read? There are so many things—language barriers, culture barriers.
This student’s comment described the barriers to health literacy and the detective work required by the nurse to discover the reasons behind what are traditionally considered noncompliant behaviors. To further articulate this new understanding of patient teaching, another student noted, “As nurses, we don’t just tell them. We have to be creative with our teaching. We can’t just read them a piece of paper.”
The community health setting, previously unavailable to students in an associate’s degree program, allowed the students more time, autonomy, and continuity with patients. Students noted that they had more time and better opportunities to reflect, and they were able to focus on health promotion in a more relaxed atmosphere than the acute care setting. They also felt more satisfied because they could follow through with clients over a number of weeks. Patients seemed more receptive to health teaching in their own homes, as indicated by their engaged questions.
Beyond the Bedside
The bigger picture discovered by students within the university setting went beyond visualizing themselves as bedside nurses. Leadership and community nursing classes introduced the students to health policy, health reform, and the nurse’s role within that setting:
Here, it was the roles they presented to us: the Institute of Medicine report, The Future of Nursing report. I never would have known those things even existed, and it opened my eyes to know that there’s more than just a position in [the] acute care setting. . . . As a nurse, I am more powerful than I thought I was.
Even the students’ sense of “bedside nurse” was expanded as they learned to view the patient holistically within a life world that extended before and after the patient’s time in the hospital. One student described the continuing care of the patient outside the hospital environment:
This semester was about the bigger picture. . . . In the ADN program, for me, learning about nursing was: This is my patient. What can I do for you immediately? Not the big picture of overall care, like continuing care outside of this hospital. How can I give you knowledge, or how can I help you so that you can have better choices down the road? That is the big picture. So, I guess, for me, the learning style in this BSN program is the big picture and a large scale.
The student’s comments captured the nurse’s role as educator with a goal of increasing the patient’s health literacy to optimize the patient’s future health. Furthermore, this commentary follows the foundational groundwork laid by the associate’s degree program that has been expanded through the student’s exposure to additional aspects of the professional role. The student’s evolving sense of the professional role has moved beyond the bedside and articulates a felt sense of the patient’s concerns and life world.
Final Interviews: Opening Minds
The final interviews showed students’ initial skepticism that getting a BSN would change their understanding of practice. However, they proceeded to describe the different ways in which their understanding of what it meant to be a professional nurse had been expanded.
Leadership, which is a difficult behavior to teach, was seen as an embodied relational skill required for participating in interdisciplinary communication, championing change, and promoting patient advocacy. Recommendation 7 of The Future of Nursing report (Institute of Medicine, 2010) addressed the responsibility of nursing education to lead change to advance health. Although the ADN program created a foundational knowledge of leadership principles, the baccalaureate portion of the program afforded students the time and space to take on the role of leader. A student outlined this transition during the interview:
The idea of being a leader and being an example has really been reinforced, along with what we can do and how we can make changes in the nursing field. I don’t feel like I had the backing to do that before. A year ago, I don’t think I would have tried to make this change. I just wanted to work as a nurse. Now I feel like I can make changes, and I think that’s very exciting.
When queried about the use of the word “backing,” the student noted that, within the ADN program, “It was just more like—these are your skills. This is what we learned—and then let’s go do it. Now I feel like other aspects of nursing have been brought to light for us. That’s the backing.”
With this newfound sense of professionalism, students were less anxious when talking to other health care professionals, such as nurse managers or physicians. As one student noted, “One thing that used to scare me was when I’d talk to them and they’d ask me questions—I didn’t know how to answer them. But now I feel like I can.” The participants gained confidence as leaders and confidence in their ability to take a stand on behalf of their patients. Before this program, they felt less effectual as change agents and noted that they didn’t have “the backing” to advocate for change.
Students noted that the ADN program had given them a strong foundation in the ethical principles that are foundational to nursing. From the background of their ADN program they understood their responsibility to advocate for patients and specifically noted quality and safety issues as central to good patient care. Their leadership class within the baccalaureate program would help to “bring it out more” and allow them to “stand stronger.” Another student noted that, although she learned about evidence-based practice in the ADN program, in the BSN program, she learned “to be a voice of it.”
Some students described aspects of gaining confidence in the professional role that are seldom articulated. For example, part of developing a culture of safety includes the value of learning from mistakes as the beginning of a self-improving practice:
I think I have gained more confidence while participating in this BSN program. . . . Also, with this confidence comes the responsibility for taking actions for myself. . . . Before, I couldn’t accept my mistakes. . . . I was just embarrassed to ask for help. I didn’t want people to know that I didn’t know. But now I’m so open to that and I think that’s what nursing is about. When I did my preceptorship, I realized that everyone asks for help. You ask for help because you want to give the best care, not because you’re telling people that you’re ignorant or you don’t know. I can do so much more if I just open up and admit that mistakes are part of learning.
This study contributes to the understanding of the transition from ADN to BSN education by providing a deep description of the lived experiences of the participants. Some findings matched descriptions of other qualitative studies of the experience of nurses in RN to BSN transition programs. For example, Lillibridge and Fox (2005) identified a theme of having an edge for career advancement that was similar to the participants’ pragmatic concerns that the baccalaureate degree would give them added value as they began to search for jobs in a relatively flat market. Themes of seeing the big picture (Delaney & Piscopo, 2007) and considering the whole view were similar to participants’ discovery of the larger context of nursing practice. Further, Delaney and Piscopo (2007) described a sense of empowerment that was comparable to the participants’ account of their growing confidence and stance as patient advocates and leaders.
This research extends previous findings not only in its focus on direct ADN to BSN transition programs but also in the participants’ description of the university as a space for learning. From within the lived space of the university setting, these students manifested a characteristic opening toward possibilities in their world. Phenomenologically speaking, spatiality, or lived space, is not about physical distances or spatial dimensions. Rather, it is about a “felt sense” of the significance of the space (Van Manen, 1990). It includes how the space affects individuals, or how they “are” in the space. The totality of a space can influence when and how a student pays attention (what is of consequence or “matters” to the student). One student’s former limited sense of leadership was described in this way:
In our associate’s degree program, we had maybe 1 or 2 hours of leadership and we weren’t paying attention. It was toward the end of the semester. We just wanted to get out and graduate, and that was it. So, leadership was just—okay, charge nurse—that’s a leader.
The student’s description gives a felt sense of the concept of leadership being “sandwiched” into an overloaded curriculum. The limited time devoted to leadership prompted the student to form an impromptu definition of a leader encapsulated in the role of charge nurse.
The university created a space for critical thinking about topics such as health literacy, cultural diversity, leadership, theory, and evidence-based practice as well as the implications of these issues within the practice environment. Faculty followed an open-door policy that encouraged open dialogue, and the space felt “less like a boot camp” than the students’ impression of the ADN program. Students were quick to add that the concentrated learning of skills within the ADN program perhaps necessitated a highly directed and linear program style. Within their group interviews, students discussed whether it was not only necessary but also beneficial to begin their learning in a more regimented environment.
Limitations, Future Research, and Implications
Limitations of this study included a single, small group of students from one school setting. The goal of an interpretive phenomenological account is to create a rich and evocative description of the phenomenon that resonates with the reader rather than to provide generalizable results. However, understanding of the significance of “created space” could be enhanced by studies of students in other settings, such as generic BSN programs or associate’s degree programs. Besides being a place for reflection and experience, what factors contribute to a sense of a learning environment? How do nursing educators and staff developers in various school and practice settings generate learning spaces that allow for learning and reflection on experience? This study provides evidence of the importance of factors in the learning environment that enhance reflection on practice.
Several implications for nurse educators, nurse managers, and policy experts can be gleaned from this study. The first is the significance of “created space” for learning and reflection on experience. The students’ lived experience of the program included a felt sense of time, space, and relationality (dialogue) toward envisioning themselves in an expanded professional role. More attention to these existential dimensions could enhance continuing education coursework as well as new graduate orientation programs. Second, as more nursing education occurs within the online environment, it will be important to consider how a sense of space and place is created online. In particular, what factors contribute to a sense of a learning environment within a virtual space or place?