The North American movement to elevate entry to practice for RNs from an assortment of diplomas and degrees to a bachelor's of science in nursing (BScN) (Close & Orlowski, 2015; Giddens, Keller, & Liesveld, 2015; Institute of Medicine, 2011) has led to a transformation in the delivery of nursing education. Within Ontario, Canada, this educational transformation has resulted in many universities and community colleges becoming collaborative partners to educate nursing students and meet the College of Nurses of Ontario's (CNO, 2013) entry-to-practice requirement of a baccalaureate education for licensure as an RN. An extensive review of the literature indicates a lack of information or research available on nursing students' satisfaction within collaborative programs, although these programs have existed in Ontario for almost a decade. The goals of this study were (a) to evaluate the level of undergraduate nursing students' satisfaction within a collaborative BScN program across years one to four and (b) to examine predictors of satisfaction across the program as a whole.
Background and Significance
Given the higher acuity levels and need for advanced critical thinking skills in health care, the minimum requirement for entry to practice and licensure as an RN in Ontario, Canada, was changed to a BScN degree in 2005 (CNO, 2013). Prior to this change, two pathways led to becoming an RN in Ontario. A prospective student could choose either a diploma (2 to 3 years at a community college) or a BScN (4 years at a university). To avoid decimating the community college diploma nursing programs, which were no longer allowed to prepare RNs under these new regulations because they do not grant BScN degrees, Ontario's Ministry of Training, Colleges and Universities recommended that community colleges and universities join together and establish collaborative baccalaureate programs.
Currently in Ontario, 22 collaborative baccalaureate programs function between universities and community colleges (CNO, 2013). Many partnerships have memoranda of understanding, shared curricula, shared admission processes, and shared resources. Some programs are uniquely offered at two or more sites, whereas others are offered jointly in shared spaces (Council of Ontario Universities, 2010). To evaluate whether collaborative baccalaureate programs provide satisfactory educational experiences for nursing students in a collaborative program in southwestern Ontario, two community colleges and one university partnered together to evaluate their student body on satisfaction across all years and at all sites.
Although student satisfaction is routinely measured within higher education, it tends to be measured in generic ways, omitting many components that are specific to nursing education (Chen & Lo, 2015). Institution-specific, system-wide student satisfaction tools also were found to be the normative way to measure nursing student satisfaction at each study site. No shared or comparable tool was available for use by all sites because all differed widely on what was actually assessed, and none specifically evaluated the many facets of a nursing education program (e.g., classroom and clinical teaching, laboratory facilities, and support resources). Consequently, the authors were unable to use any of these tools for equable comparisons or for a longitudinal study on nursing student satisfaction.
It is important for nurse educators to assess and seek to improve students' satisfaction within their nursing education, because satisfaction can influence later professional attitudes, career commitment, retention in the field of nursing, and engagement with nursing alumni (Alves & Raposo, 2007; Butterfield, Deusinger, Gillespie, Smithe, & Strube, 1998; Gruber, Reppel, & Voss, 2010). Therefore, to more effectively evaluate nursing student satisfaction across all 4 years of the collaborative program, and to allow for longitudinal evaluation, the Undergraduate Nursing Students Academic Satisfaction Scale (UNSASS) (Dennision & El-Masri, 2012) was used in this study. The UNSASS, a nursing-specific instrument, measures overall satisfaction with undergraduate nursing programs in total and across four subdomains: (a) in-class teaching, (b) clinical teaching, (c) program satisfaction, and (d) support and resources.
Nursing satisfaction was studied at a midsize university with two community college partners situated in the southwestern region of Ontario. Using a shared curriculum, each collaborative site separately educates a cohort of first- and second-year students for semesters one through four. Students then unite as a group to complete their fifth, sixth, and seventh semesters collectively on only the university campus. For their eighth and final semester, students who began their programs at college sites are given the opportunity to return to their college campus or to remain at the university to complete their education. Each year, the number of students who remain at the university or return to the college sites varies, making longitudinal assessment of satisfaction across the program difficult.
The initial findings of an ongoing longitudinal study are reported here using a quantitative, exploratory, cross-sectional, descriptive study design to assess satisfaction in students enrolled in a collaborative BScN program in the 2013–2014 academic year. All students in years one through four on every site of the collaborative BScN program were targeted for participation. No exclusion criteria existed. A priori power analysis using G*Power 3.1 (Faul, Erdfekder, Buchner, & Lang 2009) indicated that a sample size of at least 160 participants would be required to detect a relatively small effect size (ES = 0.3; Cohen, 1992) for a power of .80 and an alpha of .05.
A standard demographic survey was developed and used along with the UNSASS long form (UNSASS-L) (Dennison & El-Masri, 2012). The UNSASS-L specifically measures undergraduate nursing students' satisfaction with their nursing education. UNSASS-L is a valid and reliable tool, with a reported content validity index of 0.83 and a test–retest correlational coefficient of 0.88 (Dennison & El-Masri, 2012; Ewers & Carter, 2014; Su, 2013; Taylor, 2012). The instrument consists of 49 items scored on a 5-point Likert-type scale ranging from 1 = strongly disagree to 5 = strongly agree. Possible scores range from 49 to 245, where a higher score indicates higher satisfaction. UNSASS-L also captures student satisfaction across four subdomains: faculty in-class teaching (15 items; possible scores = 15 to 75), clinical teaching (15 items; possible scores = 15 to 75), program design and delivery (14 items; possible scores = 14 to 70), and support and resources (5 items; possible scores = 5 to 25). Higher scores on each subdomain also indicate higher satisfaction. The internal consistency for the UNSASS-L in this study was excellent (Cronbach's alpha = .97).
Flott and Linden (2015) suggested that any type of conflict is associated with lower satisfaction within all domains of nursing education. Conflict within nursing education, mainly in the form of academic incivility or disruptive behavior, increases student stress, jeopardizes learning outcomes, and decreases students' satisfaction with their nursing education (Clark, Nguyen, & Barbosa-Leiker, 2014; Clark & Springer, 2010; Seibel, 2014). There were no questions on conflict in the UNSASS-L; therefore, three yes-or-no questions on conflict were developed and added to the study packet. The questions asked the student whether he or she had ever had a conflict with a faculty or staff member in clinical settings or with other students while enrolled in the collaborative BScN program. Initial validity and reliability of the three added questions on conflict was measured using Pearson product–moment correlation and Cronbach's alpha. Items one (r = .894, p ⩽ .001), two (r = .922, p ⩽ .001), and three (r = .876, p ⩽ .001) were all greater than the r-table product of .088, suggesting validity along with a Cronbach's alpha of .88, finding high internal consistency.
Data collection commenced after all participating sites granted ethical approval. One research assistant was hired and collected data at two separate times on all college collaborative sites and four times on the university site. Data collection occurred in the fall semester at the end of October for students registered in semester three, semester five, and semester eight. To capture all students' feedback for the ongoing longitudinal study, year one data collection occurred at the end of semester two in the winter; it was felt that students could not effectively evaluate the program in their first semester on any campus. Ongoing data collection for a longitudinal study currently occurs at the end of February for all years of the program to eliminate two data collection points.
After explaining the purpose and the methods of the study, the research assistant sought voluntary participation from all nursing students. Information letters were provided to and written informed consent was obtained from the students prior to completion of the survey. Students were given the choice of completing the questionnaires using paper and pencil or online, during class hours. Those who chose to complete the online version were provided with a link to the research study on the Internet. The first-year group was given only the option to complete the survey online via an e-mail invitation. Both surveys, electronic and paper and pencil, took approximate 20 minutes to complete. To maximize participation in the study, participants were given the opportunity to be included in a draw for a $100 Visa® gift card.
Statistical analysis was done using SPSS® version 22. Prior to analysis, the database was screened for missing data, outliers, and normality. Mean substitution for missing data was used when the proportion of missing data was very small (<0.05%) and of a random nature (Tabachnick & Fidell, 2007). Descriptive statistics provided an overall picture of the current cohort of nursing students, along with their overall satisfaction level and their satisfaction levels in the four subdomains. Correlational assessment and regression analysis were performed to further explore any relationships between the variables and to assess for any predictors of overall satisfaction with nursing education in a collaborative BScN program.
Given that significant size differences existed in participation from one program year to the next, an aggregate format was used for all data assessment in this initial report. A total of 625 students (54% response rate) participated in study data collection, with 560 complete surveys used for analysis. All years of the program were represented—year one (9%), year two (43%), year three (32%), and year four (16%)—with the majority of students self-identifying as Caucasian (79%). Students likewise reported working at least part time (61.2%) in non-nursing jobs (50.5%), along with being in relationships (60%) and childless (86.8%). A surprising number of students reported experiencing conflict with faculty (21.45%), in the clinical setting (16.5%), and with student colleagues (22.7%). Finally, the majority of students chose to participate in the survey using paper and pen (67.8%) over the computerized version (32.2%).
Student Satisfaction with the Collaborative BScN Program
The level of satisfaction reported by the study participants was consistently in the agree to strongly agree range, with an overall total UNSASS-L satisfaction score of 183.9 (M ± SD = 183.9 ± 32.7) of a possible 245 points. Scores were also predominantly in the agree to strongly agree range for the four subdomains of faculty teaching (M ± SD = 54.9 ± 11.2) of a possible 75, clinical teaching (M ± SD = 57.2 ± 12.7) of a possible 75, design and delivery (M ± SD = 49.7 ± 9.7) of a possible 70, and support and resources (M ± SD = 22.1 ± 4.9) of a possible 25 points.
In an attempt to identify predictors of satisfaction, correlation and standard multiple regression analyses were conducted. Being in a relationship (r = .84, p ⩽ .05) and not having dependent children (r = .94, p ⩽ .05) had a significant positive relationship with overall satisfaction. Conflict had a negative relationship with satisfaction in all domains: (a) conflict with faculty (r = −.18, p ⩽ .001), (b) conflict in clinical settings (r = −.22, p = .001) and (c) conflict with other students (r = −.10, p = .05). Finally, a standard multiple regression analysis was performed to determine whether any of the significantly correlated variables were predictors of student satisfaction. The identified significant predictor variables accounted for only 3% of the variance in overall satisfaction (F[5, 547] = 3.95, p < .002).
All nursing students across all sites participated in this study; however, the low representation of first-year students may be related to having only the option of online participation at a time separate from the other years' data collection in this initial data collection. In this time of digital globalization, it was surprising to find that students preferred to participate in this study using the paper-and-pen format rather than online. Nulty (2008) and Lochner (2016) suggested that students, when given the option of paper and pen versus online, are less likely to select online questionnaires, citing concerns of anonymity and the ability to link their responses back to the person giving them. This may have contributed to the lower use of the online option in this study overall, as well as the lower number of first-year participants. It is essential that researchers, when choosing a data collection method, realize that a lower sample size may be an outcome if only an online data collection method is used.
Although, from an observational perspective, the student body was somewhat multiethnic, this study had an overwhelming proportion of Caucasian participation. George, Duran, and Norris (2014) suggested that a combination of mistrust and competing demands may contribute to reasons why individuals from ethnic minorities choose not to participate in research. Mistrust in the anonymity promised along with fear of being identified and reprisal if they gave unfavorable comments could be contributing factors to why multiethnic nursing students refused to participate in this study. In addition, they may not have attributed value to the study. A concerted effort to engage nursing students from ethnic minorities in research would ensure equal representation from all groups and results that reflect the opinion of the whole student body.
The majority of study participants were working at least part time to supplement their ability to pay for both the rising costs of living and tuition. The lack of employment opportunities for students directly within the field of nursing was felt to be a direct result of continued funding cuts to health care in Ontario (Ontario Health Coalition, 2016). Tuononen, Parpala, Mattsson, and Lindblom-Ylänne (2016) found that working while studying at the postsecondary level can be either beneficial or detrimental to student outcomes. Nurse educators must remain diligent regarding potential issues triggered by students working while going to school.
Being in a relationship can be either supportive for or disruptive to student progression in nursing education (Andrew, Maslin-Prothero, Costello, Dare, & Robinson, 2015). These results suggest that being partnered is positively associated with overall satisfaction and that these nursing students are in supportive relationships. Having dependent children can be burdensome for students pursuing postsecondary education because they have many competing obligations that can take away from maximizing their postsecondary educational experience (Polidano, Tabasso, & Tseng, 2012).
Overall, students in all years of the program and at all sites were satisfied with their nursing education within this collaborative program design. Therefore, this type of collaborative educational program is satisfactory for formal nursing education in Ontario, Canada, from a student perspective. These findings, in part, support the 2015 decision by the Ministry of Education and Training that collaborative nursing programs are viable and will remain the standard for nursing education in Ontario. Combining of two levels of education into one for nursing has positioned Ontario well ahead of other jurisdictions that continue to struggle with how to achieve only a bachelor's degree as entry to nursing practice and licensure for RNs (Close & Orlowski, 2015; Institute of Medicine, 2011). However, given that this is the first study of its kind to evaluate student satisfaction within collaborative nursing education programs, further study to evaluate whether this holds true for other jurisdictions is required.
Initially, no definition of conflict was given to the participants in this study. However, this was adjusted in the ongoing longitudinal survey packet. An initial review of ongoing results indicate that the findings presented in the current study are consistent with in-progress results when an operational definition of conflict was presented prior to participants answering the conflict questions. Conflict in any nursing setting, be it educational or professional, decreases satisfaction (Brinkert, 2010). Conflict within the clinical setting for nursing students, in the form of a variety of behaviors, has been reported (Tee, Özçetin, & Russell-Westhead, 2016) and is considered rampant. Conflict has also consistently been found to be associated with lower satisfaction in other studies on nursing education (Flott & Linden, 2015; Löfmark, Thorkildsen, Råholm, & Natvig, 2012; Kuh, Kinzie, Buckley, Bridges, & Hayek, 2006). Unfortunately, being aware that conflict exists in nursing education and having resources available for students who are experiencing conflict is not lowering its occurrence in this program. Therefore, the finding that students who reported any form of conflict in any setting during their education are less satisfied with this collaborative nursing education program is not unexpected.
Standard demographic variables, along with conflict, were not significant predictors of overall satisfaction in this study. Future investigations on which other variables are more predictive of overall nursing satisfaction with collaborative education are required.
The findings presented in this article could substantially differ from the findings when the ongoing longitudinal study concludes in 2020. These findings are specific to only three sites of one collaborative nursing education program in Ontario, Canada, and are not generalizable to other collaborative or noncollaborative nursing programs. Although many students in every year of the program across all of the sites participated in this study, many did not for reasons that are unknown. This could alter these results. The majority of the respondents in this preliminary data set were Caucasian, leaving the voices of other ethnic groups unheard. The use of two different collection times may have influenced the results, although in the ongoing longitudinal study this variation has been removed. Overall, although helpful, these preliminary results should be viewed with caution because they may change at the conclusion of the ongoing longitudinal study.
Implications and Suggestions for Future Study
Within Ontario, these nursing students are currently satisfied with their education within a collaborative BScN nursing program, suggesting that partnerships between colleges and universities are capable of delivering satisfactory education within this sector. Satisfaction decreased significantly when any type of conflict emerged in any teaching setting. Given that conflict affects the whole educational experience, interventional studies on conflict, its root cause, and methodology to decrease and resolve it are necessary within nursing education.
The ongoing longitudinal student satisfaction study has the potential to reveal changes in satisfaction over time, satisfaction within each year of the program, and satisfaction at the time of transition from year two to year three, when all of the students become one cohort on the university site. The results presented in this study and the ongoing longitudinal study will help educators to understand both program satisfaction and transition pressures experienced by BScN students in collaborative programs. In addition, it will provide reason for intervening when satisfaction levels change at any level of the 4-year program. Given that conflict was identified as a central issue in this study, continued assessment and potentially a study specific to this phenomenon is required. New studies of nursing students' satisfaction could also be initiated using various forms of nursing baccalaureate education delivery to inform educators on how well individual program designs are working and determine whether students are satisfied with these different variations in nursing education programs. Finally, a concerted effort to engage all ethnic groups within nursing educational programs is compulsory to ensure that silent minorities are not ignored and thus confirm that results are truly accurate for all members within BScN collaborative programs.
Overall, the students in this study are currently satisfied with all areas of their nursing education in this collaborative model of nursing education in Ontario, Canada. Conflict remains an ongoing area of concern in nursing education that significantly decreases satisfaction with the educational experience and requires immediate evaluation and intervention to decrease this ongoing effect.
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