Three distinct areas were addressed in the 27 research studies: the raw material—the graduate entry student; the end product—the newly graduated master’s prepared nurse; and, to a lesser extent, the passage—the route from non-nurse to nurse. Refer to the Appendix (available as supplemental material in the PDF version of this article) for a detailed summary of the studies.
The Raw Material
Graduate entry students are primarily women, ranging from 86% (White, Wax, & Berrey, 2000) to 97% (Kakosh, 1967) of the total reported enrollments. Many of the authors commented that there were higher percentages of men in the graduate entry programs, compared with the national rate of approximately 7% (HRSA, 2010). The range of male students extended from 8.3% to 9% (Vinal & Whitman, 1994) to 15% (Smith & Shoffner, 1991). The mean age of these students on entry varied across the studies, but ranged from 23 (Kakosh, 1967) to 26.6 years (Munro & Krauss, 1985; Smith, 1989). The widest range of ages occurred in the study by White et al. (2000), with a range of 24 to 54 years. Anecdotally, Schraeder (1988), in her review of six graduate entry programs in the United States and Canada, and Anderson (2002), in an editorial, commented that these students are young but academically and experientially gifted.
The graduate entry students are predominately Caucasian, ranging from 78% (Pellico, Friedlaender, & Fennie, 2009) to 100% (Smith & Shoffner, 1991; White et al., 2000), and predominantly single (D’Antonio et al., 2010), with ranges of 40% (Smith & Shoffner, 1991) to 77% (Ezer, MacDonald, & Gros, 1991). Several authors reported a trend for their graduate entry programs to attract students from out of state or from other countries (Kakosh, 1967; Munro & Krauss, 1985; Smith, 1989; Smith & Shoffner, 1991). These students tended to be well traveled and bilingual, with many having Peace Corps experience (Schraeder, 1988; Slavinsky, Diers, & Dixon, 1983).
Many graduate entry students reported having met with opposition from family, friends, and counselors when they decided on nursing as a professional goal (Kakosh, 1967; Pellico, 2004; Slavinsky et al., 1983). Slavinsky et al. (1983) spoke of the students’ need to respond to the frequently posed statement, “You’re too smart to be a nurse” (p. 374). Some students (17%) had an intimate view of nursing because their mothers were nurses (Kakosh, 1967); others decided on it via a “lateral arabesque” (Slavinsky et al., 1983, p. 374) from medicine to nursing (Vinal & Whitman, 1994). Still others discovered nursing later in their academic, work, or personal lives (D’Antonio, et al., 2010; Slavinsky et al., 1983; Vinal & Whitman, 1994). Some returned to their original waylaid goal of becoming a nurse (Schraeder, 1988; Slavinsky et al., 1983; Vinal & Whitman, 1994). The researchers described graduate entry students as highly motivated, self-directed, flexible, assertive, educated individuals who are dedicated to helping people, populations, or systems (D’Antonio et al., 2010; Diers, 1976, 1987; Kakosh, 1967; McNeish, 2011; Munro & Krauss, 1985; Pellico, 2004; Rico, Beal, & Davies, 2010; Schraeder, 1988; Slavinsky et al., 1983; Smith & Shoffner, 1991; Ventura, 1979; Vinal & Whitman, 1994; Wright, 1988).
Financing their education required obtaining personal loans for 59% of graduate entry students (Kakosh, 1967). A majority of the researchers noted securing finances as a major problem for students (D’Antonio et al., 2010; Diers, 1987; Kakosh, 1967; Rogers & Healy, 2002; Schraeder, 1988; Slavinsky et al., 1983; Smith, 1989; Smith & Shoffner, 1991; Wassem & Sheil, 1994; Wink, 2005). A call for increased funds, scholarships, and traineeships was noted throughout the studies (Diers, 1987; Ezer et al., 1991; Kakosh, 1967; Schraeder, 1988; Smith, 1989).
Academically, these students had higher Graduate Record Examination (GRE) scores than traditional graduate nursing students who enter the profession as nurses (Cook, Becker, & Weitzel, 1996; Smith, 1989). Combined GRE scores ranged from 1000 to 1190 (Kakosh, 1967; Leuner, 1994; Munro & Krauss, 1985; Ventura, 1979). Equally high GPAs with ranges of 3.0 to 3.68 on a 4-point scale emerged in the studies (Ezer et al., 1991; Kakosh, 1967; Munro & Krauss, 1985; Smith, 1989; Smith & Shoffner, 1991; Vinal & Whitman, 1994). Anderson (2002) described similar GRE scores and GPAs between 3.5 and 4.0 in a cohort of 35 second-degree students. Using the Watson-Glaser Critical Thinking Appraisal tool, Leuner (1994) found that graduate entry students had a mean score greater than those of BSN, MBA, and medical students.
Undergraduate preparation varied across the programs, with 77% having a bachelor of arts degree (Pellico et al., 2009) to 75% having a bachelor of science degree (Ezer et al., 1991), whereas the researchers who studied the program at Virginia Commonwealth University (White et al., 2000) reported that 48% of their students had a bachelor’s degree in life sciences (primarily biology), 10% in social science, and 41% in liberal arts, education, or business. Rogers and Healy (2002) noted that after 12 years of experience admitting graduate entry students, “undergraduate major does not matter” (p. 192). In summary, the raw material has not changed dramatically over the years. Graduate entry students are predominantly Caucasian women with higher-than-average entry credentials, strong personal characteristics, and diverse educational backgrounds and experiences. One could argue that the educational preparation of graduate entry students correlated to the number of prerequisites required for each school’s unique admission criteria. For example, at Yale University where the only prerequisite is a bachelor’s degree, the student population had a high percentage of bachelor’s of arts graduates (Pellico, 2004), whereas McGill University (Ezer et al., 1991), which requires 24 credits primarily in the sciences before enrolling in their graduate entry program, had a higher percentage of students with backgrounds in the sciences. In this review, financial constraints and career opposition from supporters were balanced with a strong desire to pursue, or return to, a lifelong dream.
Eighteen of the 27 researchers’ reports were based on the philosophical premise that accepting college graduates into nursing at an advanced level was not only feasible, but also desirable (Cook et. al., 1996; Diers, 1987; Ezer et al., 1991; Fullerton, Shah, Schechter, & Muller, 2000; Kakosh, 1967; Munro & Krauss, 1985; Pellico, 2004; Plummer & Phelan, 1976; Rogers & Healy, 2002; Schraeder, 1988; Slavinsky & Diers 1982; Slavinsky et al., 1983; Smith, 1989; Smith & Shoffner, 1991; Ventura, 1979; Vinal & Whitman, 1994; Wassem & Sheil, 1994; Wright, 1988). Faculty developed the graduate entry programs not simply as a means to speed up the process of becoming an advanced practice nurse, but based upon certain philosophical beliefs. One such tenet was that students prepared in other disciplines outside of nursing would add richness to the nursing profession (D’Antonio et al., 2010; Ezer et al., 1991; Kakosh, 1967; Plummer & Phelan, 1976; Rogers & Healy, 2002; Schraeder, 1988; Slavinsky et al., 1983; Ventura, 1979; Wright, 1988). The only shared prerequisite across all programs was a bachelor’s degree, predicated on the notion that college graduates are expected to have achieved a basic level of competency in processes such as analyzing complex material, transferring learning, decision making capability, communicating, and leadership ability (Munro & Krauss, 1985; Pellico, 2004; Plummer & Phalen, 1976; Schraeder, 1988; Smith & Shoffner, 1991; Ventura, 1979; Wright, 1988; Ziehm, Uibel, Fontaine, & Scherzer, 2011).
Wide variability existed related to requirements for prerequisite coursework before entry into graduate entry programs. The authors were unable to obtain the information to determine the rationale for prerequisites. An interesting study by Ventura (1979) analyzed 2 years of graduate entry students at Pace University according to their undergraduate degrees and success on National League for Nursing (NLN) Testing and State Board Examination. Ventura found no correlation between undergraduate degree and comparable nursing course. For example, psychology majors did not score higher than liberal art students on psychiatric nursing examinations, nor did biology majors score higher in medical–surgical nursing. Indeed, Ventura (1979) concluded the best preparation for nursing and advanced practice nursing was a bachelor of arts degree. He reasoned that these students were prepared to seek multidisciplinary approaches and had a holistic philosophy, which provides a good fit with nursing. It is interesting to consider that for all but one graduate entry program, prerequisite course work predominantly in the sciences, not the arts, was required for admission. However, regardless of prerequisite coursework, the schools without requirements reported student success (Kakosh, 1967; Pellico, 2004; Rogers & Healy, 2002; Schraeder, 1988; Slavinsky et al., 1983; Vinal & Whitman, 1994).
The majority of programs profiled in these 27 research studies offered master’s degrees in a variety of advanced specialty practice roles (n = 25) with the exception of New York Medical College and McGill University in Canada. The program created at the New York Medical College continues today at Pace University, where specialty practice options are now available. McGill’s model of nursing did not lend itself to specialty practice, as Canada’s model of health care delivery did not at that time use nurse practitioners (NPs).
Admission rates of 31% to 41% were seen in the applications to graduate entry programs in the 1980s (Diers, 1987). A few years later, Vinal and Whitman (1994) stated that in 1991, there were 105 applications for 30 seats in their program at the University of Virginia, which equated to a 28.6% acceptance rate for the graduate entry program. Wassem and Sheil’s (1994) analysis of 14 second-degree programs (six of which were graduate entry programs) revealed that applications and subsequent admissions to BSN programs were higher than for graduate entry programs. However, in the most recent study included in this review, Ziehm et al. (2011) noted that more than 600 applications were received for the 84 seats in their graduate entry program. On the basis of the most recent studies, graduate entry programs continue to remain a strong career choice for college graduates.
The programs were predominantly full time; however, two schools offered both full-time and part-time enrollment options (Fullerton et al., 2000; Vinal & Whitman, 1994). If schools of nursing have traditional undergraduate and accelerated master’s degree programs, students could move between curricula and adjust their plans of study if desired (Wink, 2005). The length of all but two programs was 3 years of full-time study; New York Medical College, now Pace University, was 2 years plus a summer session (Kakosh, 1967; Ventura, 1979), whereas Fullerton et al. (2000) described the State University of New York Health Science Center, which offered an option of a 1-year postbaccalaureate certification program or a 2-year master’s degree, both of which were approved by the American College of Nurse-Midwives for non-nurse candidates as direct entry certified midwives. Completion of the basic curricula was recognized with certificates of completion or a bachelor’s degree in nursing; graduate entry students were then eligible to sit for the National Council Licensure Examination for Registered Nurses (NCLEX-RN®).
Five of the studies discussed class size. Graduate entry enrollment ranged from 20 to 84 students annually, with the exception of Pace University, which at its peak admitted 50 students twice per year (Diers, 1987; Pellico et al., 2009; Schraeder, 1988). Faculty at the University of Virginia rationalized 30 as the optimal graduate entry class size (Vinal & Whitman 1994), based on student-to-faculty ratio and faculty obligations to other programs. However, it should be noted that the authors of that report defined neither the ratio nor the obligations. Overall, attrition rates in graduate entry programs are typically low; the rates in this review range from zero (Diers, 1987; Fullerton et al., 2000; Ziehm et al, 2011) in three schools surveyed to a high of 15% as reported by Ventura (1979). There were no further data regarding withdrawal or dismissal rates in these studies.
Graduate entry programs were expensive to run, compared with typical undergraduate programs. The increased cost was related to the faculty-to-student ratio of 1:5 (Schraeder, 1988) and 1:6 (Pellico, 2004), compared with the typical undergraduate ratio (at the time of the studies) of 1:8 or 1:10. Schraeder (1988) also considered the costs associated with retaining doctorally prepared faculty, as well as the need for individualized learning plans for a diverse student body. Diers (1987) called for an examination of curricula by nursing leaders. If the aim is to continue to admit bright and talented students, the educational experience must be attractive for them (Diers, 1987, p. 1635). A dearth of this type of analysis is noted in the literature. In fact, the 48 articles selected for our study addressed the topic of curricula superficially.
Some programs integrated graduate entry students with pre-existing undergraduate nursing students (Rogers & Healy, 2002; Wassem & Sheil, 1994), whereas others had unique curricula for this population (Diers, 1976; Munro & Krauss, 1985; Wink, 2005; Ziehm et al., 2011). Diers (1976) noted that faculty designed the first-year graduate course content by building backwards; that is, faculty “defined what they expected their graduate students to know upon entry to the specialty programs” and planned curricula accordingly (pp. 95–96). The pedagogical methods noted for this population of students included case studies, clinical stories, clinical immersion, reflective journaling, role-playing seminars, simulation, skills laboratory training, and emphasis on research, dialogue, and development of specific materials appropriate for these students (Fullerton et al., 2000; McNeish, 2011; Pellico, 2004; Rico et al., 2010; Schreier, Peery, & McLean, 2008; Schraeder, 1988; Vinal & Whitman, 1994; Wright, 1988). The enduring merit of clinical experiences to prepare graduate entry students for advanced practice nursing emerged as a prominent finding in the literature (Kakosh, 1967; McNeish, 2011; Pellico, 2004; Plummer & Phelan, 1976; Rico et al., 2010; Wright, 1988; Ziehm et al., 2011), with particular importance related to quality preceptorships, practicum assignments, opportunities for scientific problem solving, highlighting provision of comprehensive care, and ability to function as a team member.
As noted earlier, graduate entry students were adults who already achieved success at an undergraduate level. The students expected to be successful in this new endeavor; however, they quickly recognized that this educational experience was different from their previous academic encounters (Diers, 1976; McNeish, 2011; Pellico, 2004; Slavinsky et al., 1983; Vinal & Whitman, 1994). McNeish (2011) described the differences as “high stakes learning situations,” in which graduate entry students were experiencing fast-paced physical work and patients’ lives hung in the balance (p. 199). In addition, the level of intimacy and intensity of hospital nursing, which has been depicted as a “foreign country” (McNeish, 2011, p. 200), left students feeling “awkward and transparent” (Pellico, 2004, p. 134). Graduate entry students exhibited the need for reassurance that they would be prepared adequately to enact nursing roles (Cook et al., 1996; D’Antonio et al., 2010; Diers, 1976; Kakosh, 1967; McNeish, 2011; Pellico, 2004; Rico et al., 2010; Wright, 1988). Clinical hours, courses, or both were added to curricula to support students’ sense of mastery (Kakosh, 1967; Fullerton et al., 2000). Interestingly, Fullerton et al. (2000) noted similar needs for opportunities to learn, reinforce, and practice basic skills for both entering novice RNs and non-nurse entry students (p. 47).
Graduate entry students spoke of the challenges of learning the kinesthetic skills that at first glance appeared to be simple (Diers, 1976; McNeish, 2011; Pellico, 2004; Slavinsky et al., 1983; Vinal & Whitman, 1994; Wright, 1988; Ziehm et al., 2011). These students have been described as just as awkward and needy as high school learners (Kakosh, 1967), more interesting and demanding (D’Antonio et al., 2010; Ventura, 1979), and impatient if they perceive the course is unrelated to clinical nursing (Diers, 1987; Vinal & Whitman, 1994; Wright, 1988; Ziehm et al., 2011). Fullerton et al. (2000) observed the success of keeping the nontraditional students as a cohort early on in the program as a means of bolstering their “knowledge, skills, and confidence” (p. 48). In addition, although there is limited evidence to support a cohort model for graduate entry programs, it has been noted by faculty educators that these students require specific types of support during the prelicensure and advanced practice portion of the curricula. Further study will assist in clarifying the best approaches to educating these accelerated students at various stages of their preparation.
Several researchers suggested the students’ need for encouragement, balanced criticism, and hands-on learning (Kakosh, 1967; McNeish, 2011; Pellico, 2004; Vinal & Whitman, 1994; Wright, 1988). Graduate entry students would ask questions that appeared on the surface to be basic or elemental to the subject under discussion, yet their queries related to the practical, applied side of science. Even the students who majored in the sciences could not answer what appeared at first to be a simple question (Ventura, 1979). When teaching science courses, Dubin (1982) encouraged graduate entry program administrators to hire a scientist committed to the special needs of this population of students, rather than “farm out” courses to a variety of departments where one might reasonably expect redundancy and extraneous material. In addition, she cautioned that the educator must “select from all the scientific disciplines not only what is relevant, but what may someday be relevant” (p. 38). To do so requires a scientist who can distill the relationship of various scientific disciplines to nursing science.
The need to choose faculty wisely for these students was noted by the researchers (Cook et al., 1996; McNeish, 2011; Pellico, 2004; Rico et al., 2010; Schraeder, 1988; Vinal & Whitman, 1994; Wink, 2005; Wright, 1988). Qualities the researchers considered to be necessary for faculty included the need to be clinically expert, open, patient, and passionate, and possess a well developed sense of humor, as these students are challenging and continually questioning (Diers, 1987; Pellico, 2004; Rico et al., 2010; Schraeder, 1988; Slavinsky et al., 1983; Smith, 1989; Ventura, 1979; Vinal & Whitman, 1994; Wright, 1988). According to Vinal and Whitman (1994), principles of andragogy (i.e., adult learning principles) “are easier to preach than they are to practice” (p. 40). The authors elucidated issues of contradictions within this graduate entry student body, such as students’ desire to be treated as colleagues by the nursing instructors, despite their novice status. The need to be stimulated appears to co-exist with the need to be “spoon fed.” Students wanted balanced criticisms, yet were harshly honest with faculty (Vinal & Whitman, 1994; Wright, 1988). Vinal and Whitman (1994) commented on the “unanticipated and somewhat startling issue that arose [that] involved faculty frustration over poor evaluations received from this group of students” (p. 40). Slavinsky and Diers (1982) also noted the graduate entry students’ harsh criticism of faculty and speculated that it was related to the students’ present role conflict. Faculty accustomed to teaching traditional undergraduate nursing students may experience frustration in teaching this cohort for these reasons. Student and faculty perceptions and expectations are important to understand, and researchers are starting to explore these issues.
Rico et al. (2010) described six themes that emerged in their study of graduate entry students’ perceptions of best faculty teaching practices. Faculty characteristics that enhanced learning included appreciating graduate entry students as adult learners, challenging and motivating students while supporting them, and communicating a passionate interest in the profession. Thus, it appears that personal interest in each student, combined with passion for the profession, facilitated learning. In addition, these students noted faculty “who have their foot in practice” as those whom they regard highly, as this characteristic facilitates sharing of patient care cases (p. 153). Finally, faculty who varied their teaching style in the classroom and clinical settings and who use the Socratic method for case presentations were also characterized as having the greatest effect on learning.
Schraeder (1988) described the challenge of recruiting and retaining faculty in a study of five graduate entry programs: “It takes an open, highly competent, self-assured faculty with a well developed sense of humor to establish a supporting milieu” (p. 38). Faculty must be adept at both advanced practice and general bedside care (Schraeder, 1988; Wassem & Sheil, 1994; Wright, 1988). Yet, according to Wassem and Sheil’s study (1994) of 14 second-degree programs (and of those, six were graduate entry), only one program was using separate faculty to teach the second-degree students. However, if a school of nursing maintained both types of programs (generic baccalaureate and accelerated master’s program), Wassem and Sheil (1994) noted a cost–benefit ratio for faculty simultaneously teaching in both generic and second-degree option programs. Of note, these researchers also noted faculty work overload as a barrier to second-degree nursing program development and implementation, noting that sufficient faculty time and resources need to be devoted to these programs and that the teaching and administration of the curricula need a dedicated full-time faculty effort.
Authors of six of the studies demonstrated that at specific points in the graduate entry programs, no differences were noted between the graduate entry students and the traditional RN graduate students (Fullerton, 2000; Munro & Krauss, 1985; Smith, 1989; Smith & Shoffner, 1991; Ventura, 1979; Vinal & Whitman, 1994). Ventura (1979) noted that at the 1-year mark, one could not distinguish the graduate entry from the traditional master’s degree nursing student. Munro and Krauss (1985) demonstrated no differences on academic or theoretical grades when comparing graduate entry students to traditional RN master’s students at the end of the first and second years of their specialty program. This finding was supported by Fullerton et al. (2000), who found no statistical difference in the students’ ability to complete midwifery modules. In Pellico’s (2004) thematic analysis of graduate entry students journals, the theme “masquerading and identifying” detailed the trajectory from impostor to nurse that occurred during the first year of nursing school. It appears that the first year may be the pivotal time period for graduate entry students to begin to see themselves as nurses.
Wassem and Sheil (1994) wrote of practical obstacles encountered by faculty when developing these programs, such as competition for clinical sites, whereas others noted a significant barrier of hostility directed at the graduate entry students from RNs, clinical preceptors, and traditional graduate students (Cook et al., 1996; Pellico, 2004; Rogers & Healy, 2002; White et al., 2000; Wright, 1988). Several authors noted the challenge in marketing these programs when considering the image of nursing (Diers, 1987; Pellico, 2004; Schraeder, 1988; Slavinsky et al., 1983). A graduate of an accelerated master’s degree program for non-nurse college graduates responded to the question, “What does it mean for a woman with options to choose a traditionally female career?” illustrating the struggles many of the students faced when entering nursing (Shaw, 2000). The image of nursing in a culture that views the profession without professional status remains an ongoing challenge for the student population. However, given the sheer volume of non-nurse college graduates entering advanced practice nursing, it appears it is a challenge they are willing to take up.
The authors of these studies reported the bachelor’s degree as the universal prerequisite for graduate entry education. Regardless of the students’ educational or life histories, their experiences in nursing education were different than those they brought from other programs. Students often presented with a variety of contradictions and experienced the first year as a crucial period. Despite wide variation in educational preparation, prerequisite work, and curricular design, nontraditional students succeeded in graduate entry programs. The exact skill set for educators that facilitates learning in that first year and evidenced-based research on curricular design has yet to be elucidated.
The End Product
The graduate entry students demonstrated success when defined in terms of NLN test scores, RN licensure and certification examinations, grade point average, critical thinking measures, and employee satisfaction. Klakovich and dela Cruz (2006) reported that 90% of graduate entry programs were using a variety of NCLEX-RN preparation resources; they found a mixed response regarding their predictive value, quality, and worth. Achievement rates of 100% pass on RN licensure examinations were not unusual; in fact, graduate entry students’ scores were higher than those of traditional baccalaureate graduates in Plummer and Phelan’s study (1976). Fullerton et al. (2000) noted that some RNs withdrew or were dismissed from the midwifery program, whereas all the non-nurse students were successful. Furthermore, no differences existed between science and non-science students on NLN and RN licensure examination results as reported for two separate classes at Pace University. This finding warrants a review of science elective prerequisites required for admission (Leuner, 1994; Ventura, 1979).
In Vinal and Whitman’s (1997) study of University of Virginia graduate entry students (N = 17), all scored above the 95th percentile on the Mosby Assess Test and 100% successfully passed the NCLEX-RN. Munro and Krauss’ (1985) ex-post facto study of theoretical and clinical grades revealed no differences at the end of the first year of specialty and graduation between traditional graduate and graduate entry students (N = 435). Similarly, no differences were noted in ongoing testing related to key nursing concepts and role identity, compared with traditional master’s students (Vinal & Whitman, 1994). Researchers have demonstrated that both the graduate entry students and traditional graduate students were well prepared for their roles (Ezer et al., 1991; Fullerton et al., 2000; Plummer & Phelan, 1976; Rogers & Healy, 2002; Smith, 1989; Smith & Shoffner, 1991). Smith and Shoffner (1991) found few differences between traditional and graduate entry family nurse practitioners (FNPs) (N = 48) in their academic success, readiness for clinical practice, and employment status. It would be interesting to reassess preparation for practice given the increased complexity of patient management, national call for NP residencies, and expanding roles for NPs (Campo, McNulty, Sabatini, & Fitzpatrick, 2008).
Evidence also exists that graduate entry students stay in nursing (Schraeder, 1988; Slavinsky et al., 1983; Smith & Shoffner, 1991). Ezer et al. (1991) reported that 87% of the students surveyed (N = 48) were satisfied with their career choice. Smith and Shoffner (1991) revealed that 97% of the graduate entry students (N = 48) were employed, compared with 89% of the traditional educational group (N = 43). The concern that graduate entry students would not align themselves with the nursing profession noted by researchers appears to be unfounded (Cook et al., 1996; Slavinsky et al., 1983; Slavinsky & Diers, 1982; Vinal & Whitman, 1994; Ziehm et al, 2011). In Vinal and Whitman’s (1994) study, graduate entry students’ 5-year goals pertained to patient care, whereas traditional students were drawn to education and administration along with patient care. It is interesting to consider that graduates of accelerated master’s entry programs continue to work as clinicians in larger numbers than do traditional RN-to-master of science in nursing (MSN) graduates.
The literature highlighted challenges for the graduates, teachers, the profession, and administration of graduate entry programs. The graduates, who were novices to nursing, relied strongly on faculty’s suggestions of routes to clinical expertise (Cook et al., 1996; Pellico, 2004; Rico et al., 2010; Wright, 1988). Some researchers reported faculty members’ preoccupation with students’ completing 1 year in hospital nursing before beginning professional life as advanced practice nurses (Cook et al., 1996; Vinal & Whitman, 1994), a sentiment that is often shared by other health care providers (Rich & Rodriguez, 2002; Rich, Jorden & Taylor, 2001). Several authors described faculty members’ desire for graduate entry students to seek staff nurse positions as their initial employment for 1 year because they were novice clinicians (Cook et al., 1996; Kakosh, 1967; Vinal & Whitman, 1994). Graduate entry students who initially entered acute care nursing described their experiences as similar to a hazing; however, they came to a state of comfort, confidence, and satisfaction with their work (Cook et al., 1996; White et al., 2000; Ziehm et al., 2011). White et al. (2000) reported that 14% of the participants of a program that prepares only NPs were working as RNs, yet 83% of the participants did not believe that working as an RN was necessary to be an NP. Plummer and Phelan (1976) and Ventura (1979) reported similar findings from their studies of Pace University’s Graduate School of Nursing. Although the Pace students were encouraged to assume positions as FNPs initially, many students chose to take entry positions in hospitals or community agencies. No actual numbers or percentages were provided by Ventura (1979), although 45% of the 97 participants in Plummer and Phelan’s (1976) study were employed as RNs. During the time Plummer and Phelan conducted the study, Pace University changed its program to offer specialty practice; therefore, the numbers are not unexpected. It is clear that the majority of graduate students did indeed work as advanced practice nurses.
Cook et al. (1996) challenged the prevailing notion that graduate entry graduates should begin their practice in the general hospital. These authors argued that the nostalgic reasons for completing the year no longer exist; hospitals are not generalized, but rather are unit specific. This finding was supported in a study by Rich et al. (2001), who concluded that prior nursing experience might not necessarily be an important component of successful entry into advanced practice. In today’s acute care setting, the knowledge, skills, and technology required for one nursing unit are not necessarily transferable from unit to unit. Each unit is its own unique system within a larger system. In fact, in a more recent study on graduate entry students versus traditional graduate nursing students, Rich (2005) noted a significant negative correlation between years of experience as an RN and NP skills as assessed by the NPs’ collaborating physicians.
Graduate entry students described their role according to their advanced specialist practice position (e.g., primary care provider, certified nurse-midwife, NP) (Smith & Shoffner, 1991; Ventura, 1979), not as an academic or administrator, which are the roles frequently described by traditional RN graduate students (Smith, 1989, Smith & Shoffner, 1991). Smith and Shoffner (1991) demonstrated that 67% of the graduate entry students’ first positions were in the specialty for which they had prepared, as compared with only 49% of traditional RN graduate students. This finding was supported by Smith’s (1989) earlier study in which 60% of graduate entry students sought positions as FNPs, compared with only 30% of traditional RNs who sought that option. Her findings revealed that even though the graduate entry students sought specialty practice, more than 50% assumed positions as staff nurses as their first positions, whereas 43% began as NPs.
When graduate entry students accept positions as staff RNs, techniques used to brace themselves for ward life during the novice year were positive self-talk, seeking favorable managers, and wanting to be treated as an RN and not an MSN (Cook et al., 1996). These students felt ill-prepared for the technology in acute care facilities and the obstacles encountered in the health care system (Cook et al., 1996; White et al., 2000; Ziehm et al., 2011). This finding is not surprising if one considers that the majority of programs in this review were designed to educate graduate entry students for primary care, not acute care. In the survey by Ziehm et al. (2011) of graduate entry students who opted to step out of their advanced practice preparation to gain RN experience (rates annually ranged from 0% to 59%), nurse managers favorably reviewed the graduate entry students’ performance in terms of initiative, resourcefulness, advocacy, and communication. However, they also noted weakness in performance of clinical skills, but clarified that it was not unlike their experience with traditional RN graduates. The managers also noted the graduate entry students were fast learners, compared with traditional RNs. It is important to consider that although many nurse educators believe that working as RNs is important for the students’ development, many of these graduate entry students did not concur and sought positions in the clinical area in which they were primarily educated—primary care.
An additional challenge for administrators and faculty is student satisfaction with their preparation. Seventy-seven percent of students in the study by White et al. (2000), 78% of the graduates in the study by Ezer et al. (1991), and 76% of the students in Smith and Shoffner’s (1991) research felt their programs prepared them for their profession. Although these ratings are certainly gratifying, there is room for improvement.
Graduate entry students were indistinguishable from traditional students on exit from their nursing program. Despite variability in geographical area, public or private setting, prerequisites, length of program, specialties offered, or experience within these graduate entry programs, evidence suggests that educators and students are successful in transforming a non-nurse college graduate into both an RN and an advanced practice nurse.