Within professional nursing, there has been a trend by health-care agencies to increase the level of training of both present and new employees. In the past, bedside nursing had traditionally been provided by three levels of practitioners: the nurse's aide, the licensed practical nurse, and the registered nurse. Both RNs and LPNs have been utilized by many health-care agencies. One result of the trend toward higher levels of training has been to increase the ratio of RNs to LPNs or to utilize only RNs. Some agencies have adopted policies mandating that all currently employed LPNs obtain licensure as RNs within a given period in order to maintain their current positions.
In response to the challenge for educators and employers to provide timely and appropriate programs for practicing LPNs who wish to become RNs, three alternatives have been implemented:
1. An LPN may enter a nursing program at the entry level.
2. An LPN may enter the second year of a two-year program after completing a transition course and all prerequisites.
3. An LPN may participate in an accelerated program specifically designed for LPNs.
The first approach is lengthy and requires a substantial financial and time commitment from the student. Moreover, it does not account for the skills and knowledge that practicing LPNs already possess. The second approach also is not tailored to meet the special needs of LPNs. The teaching of skills and theoretical content in the second year is designed for students with no previous nursing experience. In addition, the theoretical knowledge of LPNs may be outdated by the time they return to school. The third alternative allows LPNs to complete their training in a shorter time with a curriculum that addresses their particular needs.
According to a random survey by Pullen (1988), of 414 schools accredited by the National League for Nursing, LPNs comprised 16% of the schools' enrollment. Ninety-one percent of the schools offered some type of advanced placement, mostly in the form of challenge examinations; 57% required additional criteria including other examinations, work experience, and minimum grade point averages. There were few programs that offered separate tracks geared to LPN needs: 49% of the schools surveyed required LPNs to complete transition courses that covered a wide variety of content areas prior to their entering into the rest of the ADN program; 59% of the schools surveyed implemented strategies for role transition. However, only 29% reported specific measures to validate resocialization. Several recent articles describe specific program designs for returning LPNs (Kraus & Wilson, 1987; Neidlinger, Koch, & Laprade, 1988; "Plowing1" 1988; Williams & Gallimore, 1987).
Research comparing state board examination scores and clinical performance of LPN-ItN students with generic ADN students was reported by Burbach (1987). In this program, LPNs were admitted directly into the second year without prerequisite entry testing in theory or clinical skills, and there was nò transition course; the study evaluated the wisdom of the decision not to require entry criteria. For the years 1976 to 1981, generic students scored significantly higher than LPN-admitted students. No significant differences in scores between the two groups were noted for the years 1982 to 1984. Burbach speculated that the higher scores of generic students from 1976 to 1981 might be due to changes in the state board testing format in 1982, implementation of a "big sister/brother" program for LPN students in 1982, and the admission of more scholastically average generic students in recent years. The author concluded that the 1982 to 1984 findings supported the premise that LPNs persevere and succeed in ADN completion programs.
But with the increased responsibility and skill entailed in the transition from LPN to RN comes a need for changes in perceptions of roles within the health-care system. Role concept in nursing has been identified as an area of concern for nursing educators, but the process by which a student becomes socialized to a particular role concept is not known. It is hypothesized that faculty role modeling, knowledge gained in the field, and the amount of time that a student practices the role are important factors (Conway, 1983). Weiss (1984) found that nursing must educate students for autonomy and responsibility. Role socialization has been examined in baccalaureate students (McCain, 1985) using the Cohen Model of Professional Socialization and also by Croker and Brodie (1974) using the Nurses' Professional Orientation Scale. A complete review of the literature on the socialization and roles of nursing (Conway, 1983) over the previous 10 years cites studies that compare associate and baccalaureate degree programs. However, no research on role perception in LPNs who have completed registered nursing programs was identified.
In western Washington, several educational and service organizations implemented a program to provide an intensive RN training program for LPNs who would not otherwise be able to continue with their present employers. The LPN-RN upgrade program reduces the total calendar time for students who are working LPNs without reducing contact hours for required prerequisites and second-year nursing courses. The students must successfully complete those requirements to earn an associate degree in nursing.
An important issue identified at the onset of the program was whether there may be differences in the perception of the registered nurse role between LPNs who completed their RN training in the LPN-RN upgrade project and students in the conventional ADN programs. A second issue involved potential differences in academic achievement. Because the calendar time for completion of the nursing program was reduced, the nursing role concept and academic achievement of the LPN-RN student might be different from that of a similar student in a conventional ADN program. If calendar time was an important factor, there would be important implications for program planning for future articulation and upgrade programs in nursing. Therefore, a study of the effectiveness of an accelerated program was designed and implemented.
Purpose of the Study
The purpose of this study was to compare accelerated and conventional programs in order to find the degree to which LPNs enrolled in an accelerated ADN program were socialized into the professional nursing role and to compare their academic knowledge of nursing.
The design of this study was quasi-experimental, in which the control group was randomized and the study group was a convenience sample.
The LPN-RN Upgrade Project
The LPN-RN project was an intensive one-year collaborative project offered by four hospitals and two community colleges specifically for LPN employees of the participating hospitals. The extensive work experience and special educational needs of working LPNs were recognized in the development of the project. Class times were arranged to accommodate work schedules and travel demands of the students. The program included the same prerequisite biology, social sciences, and English courses as the twoyear conventional programs. However, the format for prerequisites was modified to include the option of coordinated studies. For example, English and psychology courses were integrated and team taught. The required hours for prerequisites, second-year nursing theory courses, and secondyear clinical practice were equivalent to those of the conventional two-year program. Clinical experiences included adult medical-surgical, pediatrie, and maternalchild nursing. The LPNs' employers, when possible, contributed matching funds by providing in-hospital clinical sites, classrooms, and laboratory supplies.
For the study group, a convenience sample of all LPN-RN students from the four hospitals was selected for participation. For the control group, ADN students in the conventional programs were randomly selected from the secondyear ADN class roster. A random sample of ADN students was chosen because of the discrepancy in numbers between the two populations (76 ADN and 44 LPN-RN students). Demographic factors for these groups included age, sex, previous experience in health-related fields, and ethnic group.
Some interesting differences in the groups were noted. The urban group was 82% white whereas the rural group was 100%. The percent of urban subjects with dependents living at home was 41%; that of the rural group, 85%. The average age in the urban group was 40 years and that of the rural group 34.8 years. There was a wider standard deviation in age between urban and rural (9.5 years versus 6.5 years, respectively). Average previous LPN experience in the LPN-RN group was 11.5 years; in the ADN group, 4 years. Chi square and analysis of variance revealed no significant differences for and of these variables.
Instruments and Procedures
Several tools have been developed to measure nurses' professional role socialization (Cracker & Brodie, 1974; Pankratz & Pankratz, 1974; Cohen & Jordet, 1988; McCain, 1985; Minnick, Yocom, & Scheruble, 1987). The criteria used in selecting an evaluation tool for this study were good reliability, validity with nursing student subjects, and contemporary relevance. Minnick, Yocom, and Scheruble's Professional Nursing Questionnaire was selected. The PNQ was designed to measure differences in the socialization of BSN students between freshman and junior years resulting from differences in clinical teaching strategies. The PNQ consists of 63 items divided into six subscales. Each subscale measures a different dimension of professional role socialization. The six subscales and the dimension of professional role addressed by each are:
1. Attitudes toward delivery of patient care (20 items with a total score range of 20 to 80).
2. Attitudes regarding the rewards of a nursing career (nine items with total score range of 9 to 36).
3. Expectations of students regarding their obligations to patients (16 items with a total score range of 16 to 64).
4. Expectations of students regarding patient obligations to a student (eight items with a total score range of 8 to 32).
5. Values regarding nurse characteristics of importance to nursing practice (six items rank ordered).
6. Attitudes regarding responsibility for delivery of nursing care (four items rank ordered).
A lower score on subscales 1 through 4 was interpreted by the authors of the PNQ as indicating a more positive attitude and value. However, in interpreting scores, the authors cautioned against equating a low score with a better attitude; a very low score may reflect a highly idealistic value. The first four subscales use interval level ratings from 1 (strongly agree) to 4 (strongly disagree). The last two scales are rank ordered and are still being interpreted; therefore, only the first four subscales were used for comparison. The internal consistency (Cronbach's alphas) of the scales ranged from 0.64 to 0.76 (Minnick, Yocum, & Scherubel, 1987). It was estimated that it would take each subject about 20 minutes to complete the PNQ.
RETURN OF PROFESSIONAL NURSING QUESTIONNAIRES FOLLOWING DISTRIBUTION AT TIME 1 AND TIME 2
Administration of the PNQ
The PNQ was administered to each LPN-RN subject in the week prior to the first day of nursing classes (Time 1) and at the completion of the program (Time 2), an interval of approximately 9 months. The questionnaire was distributed to second-year ADN subjects concurrently. Subjects were instructed to return questionnaires to their class representatives who, in turn, delivered the completed forms to the investigators in a sealed envelope. Subjects were assured that questionnaire responses would not be shared with their instructors. In a cover letter that preceded the questionnaire, subjects were informed that participation in the study was voluntary.
The number of questionnaires that were returned at Time 1 and Time 2 for the two groups ranged from 71.0% to 91.3%. Only the 51 subjects who responded at both Time 1 and Time 2 were retained for the analysis (Table). The measures of internal consistency (Cronbach's alphas) of the four scales for the sample were similar to those of Minnick, Yocom, and Scherubel (1987), ranging from 0.55 to 0.75.
Source of Bias
Although the LPN-RN project curriculum reflected the same overall educational objectives, selected aspects of course organization, content, and sequence were modified, as described above, to meet the particular learning needs of LPN-RN students. Additional part-time faculty were hired specifically to teach portions of the LPN-RN project curriculum in both schools. Analysis of variance (ANOVA), or chisquares where appropriate, were performed on all demographic variables to determine if these factors accounted for differences in PNQ scores.
To examine whether there was a difference in role socialization between LPN-RN and ADN students at the completion of the program, scores were compared at Time 2. Independent t-tests between the groups revealed no significant differences between the groups on all four subscales. The lack of differences between the groups suggests that they were comparable in role socialization. Since two of the programs (one ADN and one LPN-RN upgrade) were situated in rural areas and two in urban areas, the authors were curious as to whether analysis of this factor might yield significant differences. However, no significant differences were noted between the urban and rural groups on all four subscales. Although this outcome seemed to support the effectiveness of the program, the authors questioned whether there were real changes and examined whether there were differences at Time 1. G-tests between the groups revealed no significant differences between the LPN-RN and ADN groups and none between the urban and rural ones. This finding suggests that both conventional and upgrade project subjects had equivalent RN role perceptions at the outset of the study. The results of ANOVA on the demographic factors revealed only one significant potential source of bias (age >55), and was judged to be inconsequential since it could be attributed to one subject.
Although the groups' scores were not significantly different at Time 1 or Time 2, the authors were interested in knowing if any change had occurred within each group over time. Paired t-tests for the LPN-RN group revealed that although mean scores increased over time, none were significant. However, when the two ADN groups were combined, there was a significant increase in scores for subscale 3, which sampled the students' obligations to the patient (T(24)= 2.11, p<.04). A significant increase in scores for subscale 3 was also found in the rural grouping (T(16)= 2.53, p<.02). There was not a significant increase in either the LPN-RN grouping or the urban grouping.
At first, the results seemed to indicate that the accelerated program was effective in socializing LPN students to the RN role. Since there were no significant differences between the groups at Time 2, it appeared that the accelerated program had achieved one of its major goals. But further investigation revealed that there had also been no significant differences between the groups at Time 1.
There are several possible explanations for this. The first is that the instrument used, the PNQ, was not sensitive enough to measure actual differences in the study population over only nine months. The PNQ was originally designed and tested for changes over a longer period in a different population. The moderate alphas of the subscales would indicate that the internal stability or reliability is questionable. A second explanation is that the LPN-RN group was more knowledgeable about the RN role than had been anticipated. Students in the LPN-RN group had extensive contact with RNs in their LPN work experience, which was borne out by post-study interviews with some of the subjects. In seeking an explanation for the results, students were asked for their views about the study and the outcomes. One subject explained that the LPN-RN students had answered the questionnaires at Time 1 based on what they had observed RN roles to be.
But it is not clear that responses on a questionnaire will translate into desirable behaviors. Clinical instructors supervising the clinical rotations of LPN-RN students during the initial months of clinical experience observed that LPNs experienced difficulty in taking the additional responsibility inherent in RN practice. The process by which observations of the RN role are internalized and translated into behavior is not known; it may be that knowledge of the role is merely the first step. This questionnaire measured knowledge of the RN role. Other approaches to assessing behavioral outcomes ofthat knowledge must be explored.
There were interesting differences in score changes over time in subscale 3. This subscale sampled students' attitudes about their responsibilities to patients. The mean scores of both rural groups increased over time, and those of the urban LPN-RN group decreased, yielding a significant difference. In examining the groups' programs, differences were discovered in their clinical experiences. Some of the rural subjects had clinical rotations in as many as seven different facilities, whereas the urban subjects had clinical rotations in only one or two facilities in the same period. The urban LPN-RN students had their clinical experience in the same facility in which they had worked as LPNs before entering the program. How these findings may be applied to planning clinical experiences and facilitating changes in attitudes remains unknown.
Although no major differences were found in role socialization between the LPN-RN and ADN groups by the end of the program, the authors wondered if the groups were comparable in their academic achievements. The NCLEX-RN was taken by the graduates of both programs. The means of the NCLEX-RN scores were compared using t-tests; no significant differences were found in scores, indicating that the groups were similar in their academic achievement.
The study indicated that meaningful measurement of role socialization is difficult. Measurements of knowledge about the RN role that are not validated by an analysis of actual behavioral outcomes provide only a partial picture. Moreover, a measurement tool designed for one population (BSN) over a given period (2 years) may not be equally sensitive in detecting changes in a markedly different population over a shorter time. The choice of clinical settings for student placement may have an affect on students' attitudes about obligations to patients. And, perhaps most importantly, this research would support the viability and effectiveness of an alternative approach to traditional nursing programs.
- Burbach, M. (1987). A comparison of state board examination scores and clinical performance of generic and LPN-admission associate degree nursing students. AD Nurse, 2(3), 34-38.
- Cohen, B., & Jordet, C. (1988). Nursing schools students: Students' beacon to professionalism. Nursing and Health Care, 9(1), 39-41.
- Conway, M. (1983). Socialization and roles in nursing. In H.H. Werley & J. Fitzpatrick (Eds.), Annual Review of Nursing Research Vol. (1) (pp. 183-208). New York: Springer.
- Crocker, L., & Brodie, J. (1974). Development of a scale to assess student nurses' views of the professional nursing role. Applied Psychology, 39(2), 233-235.
- Kraus, C., & Wilson, S. (1987). LPN to ADN. AD Nurse, 2(2), 43.
- McCain, N. (1985). A test of Cohens developmental model for professional socialization with baccalaureate nursing students. J Nurs Educ, 24(5), 180-186.
- Minnick, A., Yocom, C., & Schenibel, J (1987). Student socialization into the professional nursing role: Psychometric assessment of the professional nursing questionnaire. Fifth Annual Research in Nursing Education Conference, Society for Nursing Research Forum, San Francisco, CA, January 14-16, 1987.
- Niedlinger, S., Koch, F., & Laprade, M. (1988). Promoting educational advancement: LVN to ADN. Nursing Management, 19(11), 55-56.
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- Plowing New Ground. (1988). AD Nurse, 32), 24-25.
- Pullen, C. (1988). Are we easing the transition from LPN to ADN? Am J Nurs, 88(8), 1129.
- Weiss, S. (1984). Educating the nursing profession for role transformation. J Nurs Educ, 23(1), 9-13.
- Williams, C., & Gallimore, K. (1987). Educational mobility in nursing: LPN to RN. Nurse Educator, 72(4), 18-21.
RETURN OF PROFESSIONAL NURSING QUESTIONNAIRES FOLLOWING DISTRIBUTION AT TIME 1 AND TIME 2