The Institute of Medicine (IOM, 2010) is unambiguous in its call for nurses practicing in the United States to achieve higher levels of education. It is a call directed not only toward the nursing population, but also toward institutions of higher education. Its report recommends improvements within the educational system to promote seamless academic advancement (IOM, 2010). This initial recommendation is reemphasized in a progress report issued in 2016 by the National Academy of Sciences (Altman, Butler, & Shern, 2016). Although improvements have been made, for one segment of the nursing population, barriers to educational advancement and professional development remain. An RN who matriculates with an associate degree or diploma from an institution that lacks national nursing accreditation will find limited opportunities for advancement. Often, degrees from discipline-specific accredited institutions are prerequisites for admission to advanced coursework at many colleges. Although such barriers exist to protect the integrity and quality of nursing education, thus ensuring the proper preparation of graduates, at issue is whether such barriers to advancement are justified by evidence suggesting the barred population is ill suited for educational advancement. With respect to RNs from programs lacking discipline-specific accreditation, one way to assess preparedness for academic advancement is to analyze their academic performance and completion rates in a baccalaureate nursing (BSN) program.
The IOM is not alone in its call for seamless academic progression. Similar wording, calling for seamless transition in academic advancement, was used in a joint statement issued by organizations that include the National League for Nursing and the American Association of Colleges of Nursing (National League for Nursing, 2018). The statement affirms the IOM's position that every nurse should have access to educational advancement opportunities.
Researchers have determined a variety of barriers, or seams, that may exist for nurses in terms of educational advancement. Megginson (2008) identified sentinel factors, including time, fear, lack of recognition for past educational accomplishments, and negative prior educational experiences. Sarver, Cichra, and Kline (2015) similarly included time commitment and expenses among the barriers to educational progress. Additional obstacles to educational advancement are family obligations, planned retirement, and a perceived lack of benefit (Warshawsky, Brandford, Barnum, & Westneat, 2015).
Many of the factors identified in the literature refer to states that reside internally within the nurse. For example, fear, negative prior experiences, and family commitments are barriers that depend on the nurse to resolve. Financial concerns often are addressed at the institutional level as hospitals increasingly are providing monetary compensation to offset educational expenses. One barrier resides unresolved within institutions of higher education: an RN with financial support who decides to pursue advanced education will find limited opportunities if academic program admission standards fail to recognize his or her past educational accomplishments. This barrier, originally identified by Megginson (2008), disproportionately affects applicants who matriculate from schools and colleges that lack discipline-specific accreditation.
National program accreditation for educational institutions ensures program quality with the oversight of state and federal governing bodies (Eaton, 2015). In general, educational institutions must be accredited by a regional accrediting agency, such as the Southern Region Education Board. Educational programs in nursing must be approved by the state board of nursing for graduates to qualify for the licensure examination, the National Council Licensure Examination for Registered Nurses (NCLEXRN®). In addition, educational programs in nursing may seek discipline accreditation through one of three accrediting bodies: the Accreditation Commission for Education in Nursing (ACEN), the Commission for Nursing Education Accreditation, and the Commission on Collegiate Nursing Education. Notably, ACEN is the only programmatic accreditor that serves programs awarding associate degrees and diplomas in nursing.
Although prospective students are advised to pursue degrees from institutions whose programs hold discipline-specific accreditation, they do not always choose that path for entry into professional practice. Considerations such as work and family obligations can override accreditation as decisive factors in choosing an education program (Raines & Tagliareni, 2008). Factors identified as influencing consumer choice for entry points into nursing often include personal career goals related to becoming a nurse, convenience in access to programs, coupled with work and family obligations, and program costs. Further diluting a focus on the importance of accreditation in driving consumer choice is that the various entry routes (diploma, associate degree, and baccalaureate degree) all lead to the same point of professional licensure (Raines & Tagliareni, 2008). Moreover, eligibility to sit for nursing licensure in most states does not include programmatic (discipline-specific) accreditation (National Council of State Boards of Nursing, 2011).
RNs who complete coursework at an institution that lacks programmatic accreditation typically have a lower probability of passing the NCLEX-RN (Oklahoma Board of Nursing, 2003), as accreditation requires the maintenance of pass rates that meet quality benchmark standards of the accrediting agencies (ACEN, 2017; National Council of State Boards of Nursing, 2016). For example, the ACEN flags a decline in licensure examination pass rates below 80% as an event that requires rectification for continued accreditation (ACEN, 2017). Among available nursing programs that lack national nursing accreditation in proximity to the host institution, NCLEX-RN passage rates for student populations range between 26% and 67% (Edwards, 2015). The qualifications of instructional teams are also typically higher in programs with national nursing accreditation (ACEN, 2017).
Although students in the investigated population may be at a disadvantage when taking the NCLEX-RN, as the data suggest, many students do successfully pass the test and earn a license to practice. RNs educated at institutions that lack national nursing accreditation are employed across the professional spectrum. Upon passing the NCLEX-RN, these graduates are employed by hospitals, nursing homes, and medical offices. As these nurses attempt to advance their levels of education, they may be denied admission to BSN programs not because of their records of performance, but rather because the institution from which they matriculated lacks national nursing accreditation (ACEN, 2013).
If it is the case that such applicants are intellectually prepared for academic progression and success, then college admission standards that exclude these RNs may not be in alignment with the goals of the IOM. Intellectual preparation for academic progression can be measured in several ways. In higher education, factors that identify college readiness are correlated with on-time completion rates (Mattern, Shaw, & Marini, 2013). Therefore, one way to assess the preparation of RNs from institutions that lack national nursing accreditation is to compare their on-time completion rates in an RN-to-BSN program to the on-time completion rates of the student body within the RN-to-BSN program.
Grade point average (GPA) is an additional, established tool to measure student success in coursework and college programs (Kauffman, 2015). As a measure of course outcomes for students, GPA can indicate whether students enrolled in a program did, in fact, succeed in completing coursework. Within an RN-to-BSN program, the GPAs of students who matriculated from institutions that lack programmatic accreditation may be compared to the GPAs of other student populations to identify potential disparities in student performance and investigate the implications of such disparities.
This exploratory study was conducted using convenience sampling. With permission from the host internal review board, data were collected regarding students enrolled in an online RN-to-BSN program at a single-purpose institution. The institution was accredited by the Commission on Collegiate Nursing Education. Requirements for admission into the program mandate that candidates hold degrees from ACEN-accredited institutions, with exceptions granted primarily to students residing in remote areas in which access to institutions with appropriate accreditation is limited.
The program accepts applicants for admission three times each year. Admissions records of students entering the program between May 2014 and August 2016 were reviewed. Over a period of seven terms, a total of 385 students, which included 36 students who were granted exceptions, enrolled in the program. Students admitted by exception were from Iowa (n = 17), Michigan (n = 8), Ohio (n = 6), and California (n = 5). Students admitted under exception were given access to the same materials that were available to all students in the program. Students admitted under exception were not identified to faculty, nor did they receive additional orientation services or academic support.
Students within the program may enroll full time and complete the degree program within four semesters (1 year and 4 months). Alternatively, students may choose a part-time schedule and complete the program within seven semesters (2 years and 4 months). On-time completion for the program is defined to encompass completion within 10.5 semesters. However, for the study, on-time completion was defined more narrowly to designate students who completed the program within seven semesters. The on-time completion rate of students admitted under exception was compared with the on-time completion rate calculated for the overall student population within the program using the seven-semester time frame.
In addition, GPA data from the 2014–2015 and 2015–2016 academic years were reviewed. The GPA calculation was based on a traditional 4-point scale that is used as an indicator of student academic success at the institution. For analysis, students who were enrolled during the 2014–2015 and 2015–2016 academic years were separated into subgroups: students admitted using the program's established standards and students admitted under exception. The aggregate average GPAs for each group were compared. Differences in average GPAs were tested with GraphPad software for significance using an unpaired t test to determine p values.
Finally, program GPA records also formed a basis for an academic withdrawal comparison between the two groups. The investigated program requires that students maintain a GPA of 2.0 to continue enrollment. Data for determining the academic withdrawal rate were identified using the same grouping and records of information that provided GPA figures for calculations of aggregate group performances. Individual GPAs below 2.0 were flagged to calculate the rate of academic withdrawal in each respective group.
Of the 36 students admitted under exception, 25 began the program before fall of 2015 and therefore produced data to assess the on-time completion rate at the time of the investigation in 2017. Of the 25 students, 19 completed the degree program within seven semesters, generating a completion rate for students admitted by exception at 76%. The program as a whole reports that 61% (66 of 109) of students entering during the 2013–2014 academic year were able to successfully complete the program in seven semesters. For those students entering during the 2014–2015 academic year, 50% (66 of 132) successfully completed the program in seven semesters. The higher rate of successful on-time completion in students admitted by exception indicates appropriate preparation for educational opportunities. Notably, the overall 5-year (10.5 semesters) completion rate for the program of study for students admitted during the 2014–2015 academic year was 70.6%. However, data relevant to this one-time completion rate for those entering the program by exception during later academic years are not yet available to provide a comparison.
For the purpose of comparing GPAs, the aggregate performance of students admitted by exception was contrasted with the performance of students admitted by conventional standards (Table 1). During the 2014–2015 academic year, 23 students admitted by exception participated in the program and generated an average GPA of 3.563. Within the population of students admitted by exception, student GPAs ranged from 0.0 to 4.0. During the same year, 260 students admitted by conventional standards participated in the program, generating a higher average GPA of 3.775. A similar range within this population, 0.0 to 4.0, was recorded. During the 2014–2015 academic year, the difference in population performance was not statistically significant (p = .10).
Number and Grade Point Average (GPA) of Students Enrolled in an Online RN-to-Baccalaureate Nursing (BSN) Program
During the 2015–2016 academic year, 28 students admitted under exception participated in the program and generated an average GPA of 3.639. Within the population of students admitted by exception, individual student GPAs ranged from 2.907 to 4.0. The 271 students admitted by conventional standards generated an average GPA of 3.785. Within the population of students admitted using conventional standards, individual student GPAs ranged from 2.333 to 4.0. The difference in population performances during the 2015–2016 academic year was not statistically significant (p = .165).
The rate of withdrawal due to academic reasons was the final factor for comparison in this exploratory investigation. There were no recorded withdrawals for academic reasons in any student group during the 2015–2016 academic year. During the 2014–2015 academic year, one student admitted by exception was withdrawn from the program (GPA < 2.0). During that period, within the population of students admitted using conventional standards, three students withdrew based on academic performance (GPA < 2.0). Given that 23 participating students were admitted by exception, the single academic withdrawal results in an academic withdrawal rate of 4.35% for this population. The rate of academic withdrawal in the population admitted under conventional standards was 1.15%. This finding may suggest a higher risk of academic failure within the population of students admitted by exception, although numbers do not permit the calculation of statistical significance.
Students admitted under exception had a higher on-time completion rate and therefore were prepared for educational opportunities and academic progression. At the same time, students admitted under exception may exhibit a lower level of performance in graded work than students admitted by conventional standards, as exhibited in aggregate GPA comparisons. The results of unpaired t tests indicated that the differences in GPA performances were not statistically significant (p > .05). Moreover, the average GPAs in the population admitted under exception were above 3.5 in all comparisons—a figure that is widely accepted as a sign of good academic performance.
Students within the group admitted under exception may run a higher risk of withdrawal for academic reasons. As this suggestion is based on only one GPA in the group admitted under exception during a 2-year period, more study on this aspect of student performance is recommended.
Generally, despite the potential for academic success held by nurses who matriculate from institutions that lack programmatic accreditation, such nurses still face barriers in their efforts to pursue academic advancement. Pursuant to the findings of this project, a review was conducted of 54 regionally prominent online and hybrid, fully accredited RN-to-BSN programs identified by an Internet search. Of these programs, 26% require candidates for admission hold degrees from institutions that have programmatic accreditation.
Programmatic accreditation is an important measure of quality control in nursing education. It helps protect students from predatory institutions, and it works as an extra safeguard to protect the public from poorly prepared care professionals. At the same time, meeting the recommendations of the IOM's guidelines to remove barriers is important to the initiative of advancing the education of the current RN workforce as a measure to improve the safety and quality of the nation's health care. Admissions committees in fully accredited educational institutions are advised to review admission standards as they comply with the report's goals. Case studies previously have suggested that best practices include greater flexibility in admission requirements (Pittman, Kurtzman, & Johnson, 2014). The findings of this exploratory investigation raise questions about the appropriateness of existing barriers prohibiting educational advancement for RNs who matriculate from institutions that lack national nursing accreditation.
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Number and Grade Point Average (GPA)a of Students Enrolled in an Online RN-to-Baccalaureate Nursing (BSN) Programb
|Variable||Students From Institutions With National Nursing Accreditation||Students From Institutions Without National Nursing Accreditation|
|2014–2015 academic year|
| GPA range||0.0 to 4.0||0.0 to 4.0|
| Aggregate GPA||3.755||3.563|
|2015–2016 academic year|
| GPA range||2.333 to 4.0||2.907 to 4.0|
| Aggregate GPA||3.785||3.639|
| Academic withdrawals||0||0|