The RN to BSN Transition: A Qualitative Systematic Review.

Approximately 60% of registered nurses (RNs) still enter practice with an associate's degree or diploma in nursing (ADN). Due to recommendations to change entry level to practice to the bachelor's degree in nursing (BSN), there are now more than 700 RN to BSN programs in the United States. The purpose of this qualitative systematic review was to understand more about what occurs when an RN returns to school for a BSN and to develop a model of the transition. The qualitative findings of 19 research reports were included, which translates to approximately 445 RNs' perspectives on the RN to BSN transition. A visual representation of the RN to BSN transition was also generated. A seamless transition of the RN to a BSN does not exist at this time. The results are useful to nurses, academicians, and health care organizations as they move to meet current recommendations.

Background

Approximately 60% of newly licensed registered nurses (RNs) still enter practice with an associate’s degree or diploma in nursing (ADN), despite ongoing recommendations from leading health care and nursing organizations that propose entry to nursing practice should be at the bachelor’s degree level (Aiken, Cheung, & Olds, 2009; The Institute of Medicine, 2010; McEwen, White, Pullis, & Krawtz, 2012). An important factor motivating organizations to increase the number of bedside bachelor’s prepared nurses (BSNs) is that BSNs are consistently associated with improved patient outcomes (Aiken et al., 2003; Aiken, 2014; Estabrooks, Midodzi, Cummings, Ricker, & Giovannetti, 2005; Yakusheva, Lindrooth, & Weiss, 2014). Furthermore, if the number of BSNs at the bedside increases at the current rate, the goal of having 80% BSNs will not be met until 2045, 25 years later than the current goal and 80 years after the American Nurses Association’s initial recommendations (The American Nurses Association, 1965; Future of Nursing Campaign for Action, 2015).

There are now more than 700 RN to BSN programs in the United States. In 2013, 40% of BSN graduates completed RN to BSN programs (Future of Nursing Campaign for Action, 2015). The rapid growth in the number of associate’s degree to bachelor’s degree in nursing programs (RN to BSN programs) can likely be attributed to the aforementioned recommendations (McEwen et al., 2012). The willingness of RNs to increase their education will be a crucial component of successfully increasing the percentage of bachelor’s and advanced degree nurses (The Institute of Medicine, 2010).

Concurrently, much is being written about the need for a “seamless transition” (American Association of Colleges of Nursing, 2013) from associate degree and diploma preparation to the BSN degree (Hooper, McEwen, & Mancini, 2013; The Institute of Medicine, 2010; Kumm et al., 2014; Pittman, Kurtzman, & Johnson, 2014). How this seamless transition can be achieved is ill-defined in the literature, though it is often couched in the promotion of entering an RN to BSN program immediately upon ADN completion, or matriculation agreements between ADN and BSN programs (Pittman et al., 2014). The suggested seamless transition of nurses into and out of RN to BSN programs is also complicated by the large variety and inconsistencies in program requirements and curricula (Frequently Asked Questions About RN to BSN Programs, 2015). In a national survey of RN to BSN programs, the number of clinical hours required by the participating programs varied widely and only half had a grade point average requirement (McEwen et al., 2012). Furthermore, no common language exists to discuss standards of a RN to BSN program. Accreditation of RN to BSN programs comes via the accreditation of the host nursing school, and specific standards for RN to BSN objectives do not exist (Kumm et al., 2014; McEwen et al., 2012; Robertson, Canary, Orr, Herberg, & Rutledge, 2010). As a result, RN to BSN programs remain largely unregulated by state boards of nursing (Hooper et al., 2013).

A recent meta-synthesis identified themes of nurses’ experiences with completing a RN to BSN program, including acknowledgment that they need help along the way and that the totality of the experience is challenging. Findings from this study offer little about the process of actually transitioning to a BSN (Perfetto, 2015). To date, a comprehensive model of what occurs when an RN returns for a BSN degree does not exist. A model depicting the current state of the RN to BSN transition on a continuum could inform RNs when trying to make the decision to return to school, employers when trying to assist their RNs in making the decision, and academia when trying to design their programs to accommodate RNs and be worthwhile.

A qualitative systematic review (QSR) was conducted with the aim to develop a model outlining the process of RNs returning to obtain a BSN. The research questions guiding this analysis were as follows: (a) What antecedents must exist prior to returning to school to earn a BSN degree? (b) What occurs while attending an RN to BSN program? (c) What do RNs identify as outcomes of earning a BSN degree? and (d) Does a seamless transition for RNs to become BSNs exist?

Method

QSR methods were used to conduct this investigation (Finfgeld-Connett, 2008, 2010b, 2014a, 2014b; Finfgeld-Connett & Johnson, 2013). According to the QSR method, researchers use existing qualitative findings as raw data and then content analysis to generate a transferable theory of the phenomenon (Finfgeld-Connett, 2010a, 2014b). The QSR method is designed to pull together qualitative findings from different qualitative studies so that they can be synthesized and easily used in practice and policy creation (Finfgeld-Connett, 2010b).

Sample

An expansive, pearl-growing search strategy was used to locate studies to include in this QSR (Schlosser, Wendt, Bhavnani, & Nail-Chiwetalu, 2006). Expansive searches are used when the scope or goal of the QSR is saturation and fit, as opposed to exhaustive searches that are appropriate when conducting quantitative meta-analyses (Finfgeld-Connett & Johnson, 2013). The databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Google Scholar were searched using keywords and phrases that included education, nursing, baccalaureate; continuing nursing education; and nursing education research as well as education, post RN; nurse career mobility, and RN to BSN. Qualitative studies were located by combining searches using keywords and phrases with qualitative specific concepts such as phenomenology, interviews, and focus groups.

Comprehensive pearl-growing literature searches occurred once articles that addressed similar topic areas and research questions were located. Using comprehensive pearl growing, keywords used to index these articles were then used to conduct additional searches (Schlosser et al., 2006). Forward and ancestry searches were also performed by using the cited-by functions of the Scopus and Google Scholar databases and the Related Citations function of PubMed. Reference lists were also reviewed for further articles.

Within the four databases, more than 500 article titles were reviewed for relevancy. Research reports and unpublished dissertations using qualitative or mixed methods that met the inclusion criteria and addressed RNs returning to school for a BSN degree were then retrieved and reviewed. See Tables 1 and 2 for exclusion and inclusion criteria. A total of six dissertations and 13 published research reports met the inclusion criteria and were included in this QSR. Dissertations that were included aligned with the research questions of the QSR. Each dissertation offered rich qualitative data because of the absence of manuscript page restrictions. Including gray literature, such as dissertations, also decreases publication bias (Finfgeld-Connett & Johnson, 2013). The full-text dissertations were obtained via the online database ProQuest or via interlibrary loan. Ethical or institutional review board approval was unnecessary, given analysis was conducted on previously published or reported findings.

Table 1.

Study Report Inclusion Criteria.

Inclusion Criteria	Rationale
ADNs, RN to BSN students, graduates of RN to BSN Programs	All nurses are practicing nurses offering perspectives of the process
Studies in the United States	National recommendations from the Institute of Medicine and American Nurses Association and specific educational/credentialing systems
Studies conducted from 2003 to present	Conducted after Aiken’s JAMA 2003 article
Published manuscripts and unpublished dissertations	Dissertations offer rich qualitative data and should not be excluded. Inclusion decreases publication bias

Note. ADN = associate’s degree or diploma in nursing; RN = registered nurse; BSN = bachelor’s degree in nursing.

Table 2.

Study Report Exclusion Criteria.

Exclusion Criteria	Rationale
Nursing students and RN to BSN faculty	To focus on the perspectives of practicing nurses
Studies conducted outside the United States	Nursing education and licensing vary country to country
Studies conducted before 2003	To include perspectives of nurses after the recommendations started being made again
Editorials, literature reviews, advice columns	To focus on qualitative studies and findings per the process of a qualitative systematic review
Studies specific to teaching/learning methods	To focus on the general process of obtaining a BSN through a RN to BSN program

Note. RN = registered nurse; BSN = bachelor’s degree in nursing.

Data Extraction

After study attributes such as sample size and study location were noted, the findings section of the reports were printed. Key findings were then underlined, and initial and in vivo codes were handwritten in the margins. Because the raw data of this QSR consisted of qualitative findings, direct quotes or summaries of individual participants’ narratives were not included. Reflective memoing was used to describe broad categories and assisted the reviewer in identifying inter-relationships among categories. Memoing was an important step in this QSR because memos provided for discovery, interpretation, and synthesis as well as developed an audit trail (Birks, Chapman, & Francis, 2008; Finfgeld-Connett, 2014b).

Diagrams are useful tools to help summarize an emerging theory of a complex process (Buckley & Waring, 2013). A hand drawn diagram of an ADN returning to school for a BSN degree was created and evolved during the memoing process. Once steps and components of the process began to solidify, a computer-generated diagram was created to illustrate the phenomenon of an ADN returning to school for a BSN.

Validity

Consistent with Pawson (2006) and the QSR method (Finfgeld-Connett, 2014b), the studies’ actual findings were examined for saturation and fit to provide a comprehensive understanding and corresponding theory of the phenomenon of an ADN returning to school for a BSN degree. During the data extraction and analysis phases, each finding was included if it helped further explain this phenomenon. As a result, no findings from studies meeting the inclusion criteria were excluded because of poor quality.

Included findings were consistent with enriching the relationships between the steps in the model. This support and consistency increased confidence in the validity of the model to the point where a contradictory finding would not have influenced or required the model to be adjusted. Validity within the QSR process does not involve just repetition and saturation (Finfgeld-Connett, 2014b; Finfgeld-Connett & Johnson, 2013). Validity is also based on fit, or the idea that raw data and emergent findings enhance the depth, breadth, and meaning of developing concepts and their relationships (Morse & Singleton, 2001). Emergent findings were consistently assessed for saturation. Findings that did not pertain to the initial research questions of the QSR were noted and periodically reassessed for saturation. For example, findings related to RNs having negative experiences in ADN programs prior to entering the RN to BSN programs were not included. Findings from the QSR resulted in a cohesive and generalizable model indicating that saturation was also reached (Morse, 2015).

Findings

Attributes of the Qualitative Investigations

Details of the 19 included reports can be found in Table 3. The reports were from various geographic locations in the United States—three were conducted in the western United States, three in the Midwest, five in the South, and two in the Northeast. Five studies did not explicitly list a geographic location. Each was conducted using a phenomenological or grounded theory approach; and interviews, focus groups, online discussion board groups, and open-ended survey questions were used to collect data. Approximately 445 practicing RNs’ perspectives are included in this QSR with no identifiable overlap among study samples. Answers to each of the four research questions are addressed in the following sections.

Table 3.

Studies Included for Analysis.

Author, Date	Study Purpose	Methods	United States Location	Sample Size/Breakdown
Adorno (2010)	“To study the lived experiences of RNs who obtained an associate degree in nursing and, while working in a healthcare setting returned to school to attain a BSN” (p. vii)	Phenomenology, semi-structured interviews, field notes	Louisiana	12 graduates of RN to BSN programs
Alonzo (2009)	“To investigate what motivates ADN and diploma prepared RNs to pursue a BSN through an RN-to-BSN program” (p. vi)	Descriptive qualitative, open-ended survey and online focus group discussion	Kansas	21 RN to BSN students: 21 took the survey, 17 participated in the focus groups
Boylston and Jackson (2008)	“To recognize higher education services that accelerated RN-to-BSN students deem as important, along with their concomitant levels of satisfaction” (p. 286)	Mixed methods—survey and interview of 10 survey participants	Not specified	10 RN to BSN students
Delaney and Piscopo (2004)	“To explore ADN and diploma nurses’ perceptions of the benefits and barriers to RN-BSN programs. In addition, factors that would facilitate degree completion in academia and work environments were examined” (p. 157)	Researcher developed survey with both fixed choice and open-ended content implied. Content analysis	Connecticut	101 ADN and Diploma Nurses
Delaney and Piscopo (2007)	“To explore and describe the experience that ADN and diploma nursing graduates have when transitioning from RN to BSN” (p. 167)	Phenomenology, interviews	Not specified	12 graduates of RN to BSN programs
Doering (2012)	“Focused on the personal, social, academic, and professional experiences of ten nurses who began practicing as ADN or diploma RNs and completed their education transformation to BSN” (p. vii)	Phenomenology, interviews	Midwest	10 graduates of RN to BSN programs
Duffy et al. (2014)	“To explore RN perceptions regarding barriers/challenges and incentives/supports for BSN completion and identify recommendations to increase RN BSN completion” (p. 232)	4 focus groups with ADN and Diploma nurses	Mid-Atlantic	29 ADNs and diploma nurses, 12 BSNs (how the BSN was obtained was not specified)
		2 focus groups with BSNs
Einhellig (2012)	“To understand the experiences of RN to BSN graduates within their education experience and their subsequent reintegration into professional practice” (p. iii)	Phenomenology, interviews	Colorado	10 graduates of RN to BSN programs
John (2010)	“To understand the perceptions of the RN who has completed a BSN degree and to provide educators, nurse leaders, and hospital administrator’s information to consider for successful degree completion for nurses with less than a BSN degree” (p. iv)	Phenomenology, interviews	Florida	9 graduates of RN to BSN programs
Kalman, Wells, and Gavan (2009)	“To describe their (ADNs enrolled in a RN to BSN program) perspectives on returning to school” (p. 11)	Phenomenology, interviews	New York	11 RN to BSN students
Lillibridge and Fox (2005)	“Explored the experiences of RN to BSN graduates of 1 traditional, on-campus, part-time program . . . to obtain data about the impact degree completion had on these nurses’ personal and professional lives” (p. 13)	Semi-structured interviews	Not specified	6 graduates of RN to BSN programs
Megginson (2008)	“To identify the essence of realities and viewpoints of RN-BSN students in what incites or inhibits RN from pursuing an advanced degree to the BSN level” (p. 49)	Phenomenology, focus group interviews	Southeast	6 RN to BSN students
Morris and Faulk (2007)	“To examine whether there are resultant behavioral changes in professionalism for returning adult RN-to-BSN students and to identify teaching-learning activities that stimulate transformative learning” (p. 445)	Miles and Huberman qualitative analysis- reading and reduction of write in survey answers	Not specified	10 graduates of RN to BSN programs
Orsolini-Hain (2012)	“Investigates what influences ADNs to refrain from continuing their professional education and obtain a baccalaureate or higher-level degree” (p. 81)	Interpretive phenomenology, semi-structured interviews	California	22 ADNs
Osterman, Asselin, and Cullen (2009)	“Examines the experience of the RN who pursues a BSN to determine the meaning found by pursuit of a BSN, the extent to which the pursuit of the degree influences one’s perception of oneself as a professional, and the impact of the degree on one’s practice” (p. 109)	In-depth interviews	Northeast	11 RN to BSN students
Robbins and Hoke (2013)	“To explore RN to BSN students’ views of facilitators and challenges associated with successful program completion” (p. 21)	Focus groups	Southwest	109 RN to BSN students
Rush, Waldrop, Mitchell, and Dyches (2005)	“To gain an understanding of professional growth as experienced by RN-BSN students taking their program by distance delivery” (p. 283)	Online discussion board groups facilitated by research team members	South Carolina	36 RN to BSN students
Schwarz and Leibold (2014)	“To determine facilitators and barriers that ADNs experience in progressing toward baccalaureate nursing education” (p. 171)	Mixed methods survey	Not specified	81 RN to BSN students
Stuever (2009)	“The ways in which RNs experience professional transformation in BSN degree completion education programs informed by complexity science were explored” (p. iv)	Phenomenology	Midwest	7 RN to BSN students; 4 graduates of RN to BSN programs

Note. ADN = associate’s degree or diploma in nursing; RN = registered nurse; BSN = bachelor’s degree in nursing.

Taking the Steps: Four Rights

Right motivation

Ultimately, personal motivation perseveres, but RNs do indicate that skepticism and fear are involved in their decision-making processes—skepticism that the BSN degree is worthwhile (Alonzo, 2009; Delaney & Piscopo, 2004; Duffy et al., 2014; John, 2010; Megginson, 2008; Orsolini-Hain, 2012), and fear of and fear of difficulty or failure (Adorno, 2010; Alonzo, 2009; Einhellig, 2012; Megginson, 2008). The notion that a BSN degree could improve direct nursing practice or improve professionalism is initially not completely obvious to nurses, especially when considering there is inconsistent differentiation between ADNs and BSNs in the workplace (Delaney & Piscopo, 2004; Duffy et al., 2014, 2014; Megginson, 2008; Orsolini-Hain, 2012; Rush, Waldrop, Mitchell, & Dyches, 2005). Academia’s failure to recognize students’ previous nursing coursework and nursing experience is another disconcerting phenomenon (Duffy et al., 2014; Megginson, 2008), as is the lack of distinction in education differences in the workplace (Delaney & Piscopo, 2004; Megginson, 2008; Orsolini-Hain, 2012). Financial constraints, not having enough time, and competing priorities are also significant barriers cited by prospective students (Adorno, 2010; Alonzo, 2009; Delaney & Piscopo, 2004, 2007; Duffy et al., 2014; Megginson, 2008).

Despite the mixed messages and barriers, RNs are still drawn to the potential feelings of success and increased professionalism that the BSN degree could offer (Alonzo, 2009; Delaney & Piscopo, 2004; Duffy et al., 2014; Einhellig, 2012; Orsolini-Hain, 2012). Personal lifelong goals, a love of learning, and workplace pressures to return to school potentiate the nurses’ decision-making process (Adorno, 2010; Alonzo, 2009; Delaney & Piscopo, 2004, 2007; Doering, 2012; Einhellig, 2012; Megginson, 2008; Osterman, Asselin, & Cullen, 2009; Robbins & Hoke, 2013; Rush et al., 2005). ADNs also recognize the BSN as a requirement to pursuing graduate education. Many are enthused to move beyond the BSN degree (Adorno, 2010; Alonzo, 2009; Einhellig, 2012) and cite the opportunity to be a role model to their children and coworkers as motivation (Alonzo, 2009; Doering, 2012; Kalman, Wells, & Gavan, 2009). ADNs anticipate that the BSN degree is an opportunity to stay in the nursing profession longer (Megginson, 2008) or it is a means to progress out of a negative working environment (Alonzo, 2009; Einhellig, 2012).

Right time

The perception that a BSN degree could expedite career change or mobility and increase professionalism, as well as the admitted desire for this to occur, is an impetus to pursuing enrollment and contributes to the timing of enrollment (Adorno, 2010; Alonzo, 2009; Delaney & Piscopo, 2007; Doering, 2012; Duffy et al., 2014; Einhellig, 2012; John, 2010; Kalman et al., 2009; Lillibridge & Fox, 2005; Robbins & Hoke, 2013; Rush et al., 2005).

An ADN must be in the right time of his or her life to consider enrolling in an RN to BSN program (Adorno, 2010; Alonzo, 2009; Kalman et al., 2009; Megginson, 2008; Osterman et al., 2009). The right time is determined by the nurses’ children and family and varies, that is, having no children, having young children, or having older children were all listed as either contributing factors or barriers in the timing of enrollment and decision-making process (Alonzo, 2009; Kalman et al., 2009; Megginson, 2008; Osterman et al., 2009).

Right program

Nurses describe navigation or the start of a journey as they make the decision to enroll in a particular school (Alonzo, 2009; Delaney & Piscopo, 2007; Duffy et al., 2014; John, 2010; Megginson, 2008; Rush et al., 2005). Convenience is paramount in the program selection process and supersedes consideration given to the quality of the school, curricula, and faculty. Convenience includes geographic proximity, mode of instruction delivery (i.e., face-to-face, hybrid, or online), and scheduling flexibility, as well as accessibility and the user-friendliness of the program (Adorno, 2010; Alonzo, 2009; Boylston & Jackson, 2008; Doering, 2012; Duffy et al., 2014; Megginson, 2008; Osterman et al., 2009; Rush et al., 2005; Schwarz & Leibold, 2014). Course schedules, collaboration between their employers and the school, as well as services offered by the school, such as technology and research support, are also important criteria in choosing a program (Alonzo, 2009; Boylston & Jackson, 2008; Duffy et al., 2014; Robbins & Hoke, 2013).

Right price

Associate degree nurses must also address the financial obligations of enrolling in and attending school. The financial obligations of returning for a BSN degree are often viewed as a deterrent or obstacle to enrolling (Alonzo, 2009; Delaney & Piscopo, 2004; Duffy et al., 2014; Osterman et al., 2009). Financial considerations remain omnipresent while attending RN to BSN programs, as students attempt to negotiate the financial burden on their families and maintain current lifestyles. (Alonzo, 2009; Duffy et al., 2014; John, 2010; Lillibridge & Fox, 2005; Robbins & Hoke, 2013). Access to tuition reimbursement and loan forgiveness are viewed as facilitators in making the decision to pursue a BSN degree and influence the program the nurses choose (Alonzo, 2009; Boylston & Jackson, 2008; Doering, 2012; Duffy et al., 2014; Einhellig, 2012; Kalman et al., 2009; Megginson, 2008; Robbins & Hoke, 2013). However, tuition assistance is not always enough to allow nurses to reduce their hours at work. Therefore, ADNs manage to complete course assignments and clinical hours around their work schedules (Adorno, 2010; Alonzo, 2009; Duffy et al., 2014; Kalman et al., 2009; Megginson, 2008; Rush et al., 2005; Schwarz & Leibold, 2014).

Transition: With an Umbrella of Support

Once they are enrolled in the RN to BSN program and begin progressing through their coursework, RNs frequently speak of a transition (Adorno, 2010; Delaney & Piscopo, 2007; Duffy et al., 2014; Einhellig, 2012; Lillibridge & Fox, 2005; Rush et al., 2005; Stuever, 2009). The transition is also referred to as a transformation (Doering, 2012; Morris & Faulk, 2007; Stuever, 2009), or a transformative journey (John, 2010), or an evolution (Einhellig, 2012; Rush et al., 2005). The transition is not without its ongoing challenges and RNs must have certain forms of support to be successful.

Families

To balance their multiple roles and responsibilities, RNs rely on material and emotional support provided by families via shared responsibilities such as child care and financial stability (Adorno, 2010; Alonzo, 2009; Doering, 2012; Duffy et al., 2014; John, 2010; Kalman et al., 2009; Lillibridge & Fox, 2005; Osterman et al., 2009; Robbins & Hoke, 2013). Nurses rely on spouses, specifically husbands (Adorno, 2010; Kalman et al., 2009) and grown children (Kalman et al., 2009), to provide not just material support but also emotional support in the form of encouragement and continued motivation (Alonzo, 2009; Kalman et al., 2009). Nurses would not be able to return to school without some form of family support. Family is also the one thing that could cause an RN to BSN student to stop attending the program (Boylston & Jackson, 2008).

Classmates

Relationships with fellow students are vital components of success in an RN to BSN program (Adorno, 2010; Boylston & Jackson, 2008; Delaney & Piscopo, 2007; Doering, 2012; John, 2010; Lillibridge & Fox, 2005; Osterman et al., 2009; Robbins & Hoke, 2013). Cohort support involves both academic collaborations and emotional bonds that are fostered as nurses progress through the program together (Doering, 2012; John, 2010; Robbins & Hoke, 2013). Cohorts also serve as a means to form professional networks after graduation (Osterman et al., 2009; Robbins & Hoke, 2013)

Institution

The academic setting can contribute support to RN to BSN students by acknowledging that the students are nontraditional adult learners (Adorno, 2010; Alonzo, 2009; Boylston & Jackson, 2008; Kalman et al., 2009; Robbins & Hoke, 2013). RN to BSN students appreciate availability of academic and financial aid advisors (Boylston & Jackson, 2008; Robbins & Hoke, 2013). Pre-planned degree requirements or transparent curricula (Robbins & Hoke, 2013; Rush et al., 2005) along with clearly outlined course responsibilities (Robbins & Hoke, 2013) help nurses navigate the education system and stay on track through graduation. Because many of these RNs begin the RN to BSN program with an unfamiliarity of technology (Alonzo, 2009; Delaney & Piscopo, 2007; Duffy et al., 2014; Megginson, 2008; Osterman et al., 2009), ongoing technical support is also beneficial (Delaney & Piscopo, 2007; Duffy et al., 2014; Robbins & Hoke, 2013). In addition, nurses describe library and research support (Boylston & Jackson, 2008; John, 2010; Osterman et al., 2009; Robbins & Hoke, 2013) offered by the schools of nursing as integral to success. Nursing staff and faculty are viewed positively when they are accessible (Duffy et al., 2014; Schwarz & Leibold, 2014) and offer flexible assignments (Alonzo, 2009; Duffy et al., 2014; Robbins & Hoke, 2013).

Workplace

Workplace influences are often positive and are cited as facilitating progression through the RN to BSN program. Financial support offered by the RN to BSNs’ employers remains a leading form of support. In addition, managers who allow time off for school and place value on the BSN competencies are viewed as positive support systems in these RNs’ journeys (Doering, 2012; Duffy et al., 2014; Einhellig, 2012; John, 2010; Kalman et al., 2009; Robbins & Hoke, 2013). RN to BSN students are also encouraged by other RNs who fondly reminisce about returning to school for a BSN and the benefits they experienced (Megginson, 2008).

Ongoing Challenges

Nurses express difficulty enrolling in an RN to BSN program related to negotiating multiple roles outside of work and school (e.g., parent, spouse, caregiver, etc.; Adorno, 2010; Alonzo, 2009; Delaney & Piscopo, 2004; Megginson, 2008). These ongoing challenges follow the nurses from the decision-making process into the actual program and do not dissipate. RN to BSN students are constantly striving for balance (Adorno, 2010; Alonzo, 2009; Delaney & Piscopo, 2007; Robbins & Hoke, 2013) while juggling roles and schedules (Kalman et al., 2009; Lillibridge & Fox, 2005; Megginson, 2008; Rush et al., 2005). Nurses frequently describe role strain (Adorno, 2010) or the notion that their priorities are constantly competing for their time and energy (Boylston & Jackson, 2008; Megginson, 2008). Thus, they identify a need to consistently and continuously balance their life and work responsibilities with their school work. In addition and as aforementioned, the pursuit of the RN to BSN degree is also wrought with financial hurdles to navigate. Ultimately, RN to BSN students make sacrifices in certain areas of their lives (John, 2010; Kalman et al., 2009) and a balance of responsibilities is maneuvered using various forms of support.

Unfortunately, RN to BSN students experience some forms of negativity from their institutions as they attempt to progress through the program. Students often believe that schools of nursing do not provide enough recognition of their previous nursing coursework and experience (Megginson, 2008). This belief is amplified when they are grouped with undergraduate students (Lillibridge & Fox, 2005; Megginson, 2008) or nurses of different ages (Delaney & Piscopo, 2007). Nurses are sometimes frustrated in trying to understand how to efficiently progress through the program (Alonzo, 2009), especially when program requirements are changeable (Rush et al., 2005) or curricula are in transition (Schwarz & Leibold, 2014). RN to BSN students desire respect and want their extensive nursing knowledge to be valued. Unfortunately, this is not always automatic (Duffy et al., 2014; Lillibridge & Fox, 2005; Megginson, 2008; Robbins & Hoke, 2013)

Similar to the institution, workplace influences are also not consistently positive (Adorno, 2010; Boylston & Jackson, 2008). Managers are often inflexible regarding work schedules and allowing for time off (Adorno, 2010; Alonzo, 2009; Megginson, 2008). In addition, RN to BSN students encounter negative comments and feedback from their coworkers about the value of the BSN degree (Doering, 2012; Duffy et al., 2014; Lillibridge & Fox, 2005; Megginson, 2008; Rush et al., 2005).

Difference Makers: Delivery and Key Courses

Despite uneven institutional and work support, RN to BSN students do experience “aha” moments (Lillibridge & Fox, 2005, p. 14) or “enlightenments” (Robbins & Hoke, 2013, p. 27) that reveal the relevancy of the BSN program and complete the transition to BSN nurses. Access to an online mode of instruction is often a benefit and facilitator to growth and success (Alonzo, 2009; Rush et al., 2005). Key courses also help fully move the ADNs to BSN nurses (Delaney & Piscopo, 2007). Courses revolving around family assessment are transformative (Stuever, 2009) and improve the nurses’ roles as information managers (Morris & Faulk, 2007). The ADN’s awareness of additional resources for their patients increases through community nursing courses (Alonzo, 2009; Delaney & Piscopo, 2007; Einhellig, 2012; John, 2010). Community nursing courses “broadened the concept of the client” (Morris & Faulk, 2007, p. 448) for the graduates.

Leadership courses are also beneficial in that they help nurses view their own leaders and managers in a different way (Einhellig, 2012). The courses in leadership also expand the nurses’ knowledge and allow them to approach staff and management situations with an improved set of skills (Delaney & Piscopo, 2007). Research coursework and assignments are central to the transformation of ADNs to BSNs. Research courses make the RN to BSN students realize that research is important to the profession and can be the key to making changes in the workplace (Delaney & Piscopo, 2007). Research coursework also increases the nurses’ desire to investigate and use evidence-based practice in their own nursing work (Delaney & Piscopo, 2007; Doering, 2012; John, 2010; Lillibridge & Fox, 2005; Morris & Faulk, 2007; Osterman et al., 2009). In addition, nurses feel empowered to conduct their own research (Osterman et al., 2009).

Outcomes

Findings regarding negative outcomes were not identified. In addition, the foreseen benefits of the BSN degree identified by ADNs are very similar to the actual benefits identified by RN to BSN students and graduates. RN to BSN graduates, now bachelor’s prepared nurses, speak positively of their transformation and note improvements in their personal and professional lives, as well as in their individual nursing practice.

Personal

RN to BSN graduates identify a personal transformation (Doering, 2012) and emotional evolution (Einhellig, 2012) as a result of obtaining the BSN degree. Upon graduation, the nurses also gain a sense of personal achievement and fulfillment (Adorno, 2010; Duffy et al., 2014; John, 2010; Lillibridge & Fox, 2005). RN to BSN graduates report improved self-esteem (Adorno, 2010; Delaney & Piscopo, 2007; John, 2010; Osterman et al., 2009; Stuever, 2009) and self-confidence (Delaney & Piscopo, 2007; Einhellig, 2012; Kalman et al., 2009; Lillibridge & Fox, 2005). An additional benefit of the BSN degree is a renewed interest in education and learning (Rush et al., 2005; Stuever, 2009).

Professional

From the beginning, many ADNs were motivated by the BSN degree’s potential to offer opportunities of career mobility and stability. Returning to school fulfills the predicted professional benefits (John, 2010; Megginson, 2008; Rush et al., 2005; Stuever, 2009). Increased professionalism is even noted as an unanticipated occurrence (Adorno, 2010; Einhellig, 2012; John, 2010). Consistent with leadership courses being beneficial, RN to BSN graduates see a difference in their professional perspectives (Doering, 2012; Morris & Faulk, 2007; Osterman et al., 2009; Rush et al., 2005) and an improvement in the way they interact with and approach their coworkers or staff (Delaney & Piscopo, 2007; Duffy et al., 2014). The BSN degree also improves the nurses’ ability to collaborate with their coworkers (Adorno, 2010; Morris & Faulk, 2007; Rush et al., 2005; Stuever, 2009).

Practice

After completion of the program, RN to BSN graduates notice improvements in their nursing practice (Adorno, 2010; Einhellig, 2012; John, 2010; Stuever, 2009). The BSN degree enhances the graduates’ assessment skills (Alonzo, 2009; Einhellig, 2012; Rush et al., 2005), improves their patient outcomes (Alonzo, 2009; Duffy et al., 2014; Kalman et al., 2009), and increases critical thinking skills (Alonzo, 2009). In addition, graduates experience improved communication abilities (Adorno, 2010; Delaney & Piscopo, 2007). Because of these benefits, RN to BSN graduates become better patient advocates (Delaney & Piscopo, 2007; Duffy et al., 2014; Morris & Faulk, 2007). Finally and overwhelmingly, RN to BSN graduates report that the BSN degree changes their perspectives. They are better able to see the “big picture” of the patient after completing the BSN coursework (Delaney & Piscopo, 2007; Einhellig, 2012; Lillibridge & Fox, 2005; Osterman et al., 2009; Rush et al., 2005). Similarly, RN to BSN graduates report envisioning the whole or global perspective of the patient (Doering, 2012; Einhellig, 2012; Lillibridge & Fox, 2005; Stuever, 2009).

Discussion

The RN to BSN Transition Model

This review expands our knowledge of the RN’s experience in returning for a BSN degree. A diagram of an RN returning to school to obtain a BSN degree is presented in Figure 1. The diagram supports the meta-synthesis conducted by Perfetto (2015), and attempts to present a comprehensive model of the transition process and the multiple factors involved.

Figure 1.

The RN to BSN Transition Model

Note. ADN = associate’s degree or diploma in nursing; RN = registered nurse; BSN = bachelor’s degree in nursing.

To start, there is a decision-making process involved and key elements must be coordinated and aligned before an RN considers enrolling in an RN to BSN transition program. For diagramming purposes, this was illustrated as a staircase containing the four Rights: Right Motivation, Right Time, Right Program, and Right Price. The staircase must be climbed and each step should be accounted for before an RN officially selects and enrolls in a program. Similar to real life, if one step, for example Right Time, is missing or not in good shape, the ADN cannot feasibly enroll in a nursing program. The bottom black arrow connects the Positive Outcomes which ADNs are anticipating to the actual identified Positive Outcomes (see Figure 1).

ADNs are faced with Ongoing Challenges, depicted in the diagram with a cloud and drops of rain (Figure 1). The cloud and drops of rain follow the nurses as they make the decision to return to school, as well as during progression through the program. Throughout the decision-making process and during coursework, nurses require support, depicted in the diagram as an umbrella. Umbrellas shield the user from rain. Umbrellas are also often pictured with tightrope walkers as tools for balance, analogous to an ADN working toward balance as they navigate through school. In this diagram, the umbrella contains the various forms of support nurses require. Because of the inconsistent support and challenges offered by the ADNs’ workplace and institution, these two entities are depicted in both the cloud and the umbrella.

Despite having to traverse multiple steps, being faced with ongoing challenges, and carrying an umbrella for support, ADNs still make a noticeable transition. RN to BSN students and graduates identify the benefit of online instruction and key courses, which motivate them forward in the program and make the value of a BSN more apparent and relevant. These courses are depicted by columns because they solidify and support the RN to BSN transition and make the process meaningful. Finally, there are positive outcomes of obtaining a BSN including benefits in the nurses’ personal and professional lives as well as their nursing practice. No negative outcomes were identified. In the diagram, these positive outcomes are depicted by a certificate labeled with Bachelors of Science in Nursing.

Implications of the Model

The model reveals that a seamless transition of ADNs to BSNs does not exist. This is supported by the case studies presented by Pittman et al. (2014), which demonstrated numerous effective means of nursing academic progression. The results of this QSR and corresponding model are useful to RNs who might be considering returning to school. Within the results and model, RNs can see how others before them described the process and outcomes. The results and model are useful to academicians as well. Nursing faculty are reminded that RN to BSN students are not traditional students and that they are constantly facing challenges. Schools of nursing should also note they are perceived as both a challenge and a support system. Ideally, institutions of higher learning should be components of support and not pose a challenge. The same remains true for employers. The model is useful to health care organizations as they move toward meeting current recommendations regarding an increase in the number of practicing BSNs. The ADNs’ workplace is encouraged to strive to be part of a support system rather than a challenge. The institution and workplace challenges are avoidable components of the RNs’ journeys that should be mitigated to move toward providing a seamless transition of ADNs to BSNs.

Limitations

A limitation of this study is that qualitative work with ADNs who started but did not complete a RN to BSN program is limited. Thus, the model of the process of an ADN obtaining a BSN degree is always moving forward to graduation and positive outcomes. The search strategy and terms used to conduct this QSR should have identified studies addressing this topic area. None were located. To truly represent the process of obtaining a BSN degree and solidify the model, qualitative findings regarding students who started but did not complete a RN to BSN program would be included. This is an area of research that warrants further investigation.

Summary

Based on findings of this QSR, RNs preparing to attend a RN to BSN program are encouraged to fully assess their motivation for returning to school. Potential students should also be aware of the importance of finding the right program at the right time and place. RN to BSN students as well as academicians are encouraged to evaluate their programs to address the ongoing challenges faced by students as well as optimize the key courses that prove to make the transition more full of meaning and success. Employers should be aware of their dichotomous position of supporter and barrier and are encouraged to eliminate their barrier role. Illustrating what the RN to BSN transition looks like is important as organizations move forward to increase the number of employed BSNs and schools of nursing move to improve their RN to BSN programs.