The World Health Organization's State of the World's Nursing 2020 report highlights the critical role nurses play in health care provision and the global need to address the shortage of registered nurses (RNs).1 Concerted efforts resulted in an increase of 4.7 million nurses worldwide between 2013 and 2018; however, despite this progress, the number of nurses remains inadequate.1,2 The high demand for RNs is due, in part, to the aging workforce, increased demand for health services due to an aging population, and greater nursing involvement in primary and aged care.1-4 A shortage of RNs can undermine the quality and accessibility of health care and can place undue strain on the limited health care providers who are available.3,5 A key strategy to strengthening the supply of RNs is to increase capacity in nursing education programs.5
Nurse educators are aware of the gap in the supply and demand of RNs.2 Despite this awareness, nursing programs are facing their own capacity issues related to faculty shortages, financial constraints, and limited access to clinical practice environments.6,7 In fact, nursing programs are turning away tens of thousands of qualified applicants each year due to the limited number of students they are able to accept.8 However, even with careful screening and selection processes, a significant number of students who enter RN programs leave before completing the program.9,10 Equally concerning, a significant number of nurse graduates do not practice after they graduate or leave the profession shortly after beginning their nursing career.10
Countries such as Australia,11 Canada,12 New Zealand,13 the United Kingdom,14 and the United States15 are offering alternate educational pathways in an attempt to increase the supply of RNs. This includes a specific pathway for post-licensure practical nurses (PLPN), also known as licensed practical nurses, registered practical nurses, or registered vocational nurses.11-14 Traditionally, students enter nursing programs directly from high school, but a bridging option provides PLPNs with college diplomas and practical nursing experience, serving as an alternate pathway to becoming an RN. These bridging programs build upon and offer credit for PLPNs’ previous education and accumulated knowledge, skills, and experience,16 allowing students to graduate in an accelerated period, and enabling nursing programs to produce a greater supply of RNs with existing resources.17 Bridging programs vary within and across countries, ranging from those dedicated solely to PLPNs who enroll in RN programs,13,18 to those that integrate PLPNs into the upper levels of traditional RN programs.19,20 Jones et al. suggest PLPNs are ideal candidates for RN programs because they are familiar with the expectations placed on health care professionals.17 Further, PLPNs enrolled in bridging programs possess many of the demographic characteristics that predict retention in traditional RN students; they are generally older, have been away from formal education for a period of time, and have experience working in health care.17,21 Yet, despite these favorable characteristics, attrition in bridging programs is a concern, with reports of up to 30% of bridging students leaving their program before completion.20
High rates of attrition may be due to the unique challenges that bridging students experience when enrolled in RN programs. Mitchell et al. describe student attrition as voluntary withdrawal, failure to graduate, removal from a program due to academic reasons, transfer to a different academic major, or failure to progress through a program as expected.22 Although bridging students are generally more mature than traditional nursing students and enter RN programs with realistic expectations of the work environment, their tendency to remain employed as PLPNs and their need to balance academic and family commitments14,15,19 may compromise their ability to successfully complete the educational program. Australian researchers, Hutchinson et al., report that bridging students often maintain their employment as PLPNs while enrolled at school, forcing them to maintain a dual identity of PLPN and RN student.11 Other international researchers indicate that the academic and time demands placed on students enrolled in RN programs are greater than the students anticipated.19 Moreover, support from faculty, peers, and family is critical to their ability to complete the RN program.19,23
Traditional efforts to support nursing students to complete the RN program may be inadequate for bridging students. For example, interventions such as assistance from faculty advisors or supplementary instruction involve prearranging additional time over and above the required instruction time,24 which PLPN students may not have.23 Furthermore, support such as clinical coaching24 may be viewed as unnecessary given PLPNs’ health care experience.25 Schultz and colleagues observe that bridging students can be disappointed by the nursing faculty's clinical expertise, which leads students to question the faculty's ability to provide support and guidance.23 It is also reported that bridging students perceive the clinical components of RN education as a setback as they are no longer able to practice independently and are unable to apply many of the skills that they routinely perform as PLPNs.25
Understanding the experiences of bridging students will help identify their unique needs and tailor appropriate educational support to help them complete nursing programs and transition into the RN role. A thorough review of the existing literature in PROSPERO, JBI Evidence Synthesis, and Cochrane Database of Systematic Reviews was performed and no current or in-progress systematic reviews on the topic were identified. One mixed-methods systematic review was located on the professional transition from the PLPN to RN role,16 however, this review focuses on the PLPN experience of being a student in a RN program. It reports on the motivators, challenges, and supports that facilitate successful completion of the program, and ultimately, the transition to a professional role. A systematic review on the experiences of bridging students enrolled in nursing programs will help address the urgent need to retain PLPN students in nursing programs and increase the supply of RNs to the workforce. The proposed review will identify, appraise, and synthesize the available qualitative evidence on the perspectives and experiences of PLPNs who enrolled in or have completed a PLPN to RN bridging program, including graduates of those programs.
What are the experiences of PLPNs who are enrolled or have completed a PLPN to RN bridging program?
The sub-questions include:
- i) What motivates PLPNs to enroll in RN bridging programs?
- ii) What academic supports help PLPN students successfully complete PLPN to RN bridging programs?
- iii) What causes PLPN attrition from RN bridging programs?
This review will consider primary studies that include PLPNs who are enrolled or who have completed an accelerated RN licensure education program, regardless of the length of the program. Current or former students of accelerated programs may be licensed practical nurses, registered practical nurses, or registered vocational nurses. The accelerated RN bridging program can be at the diploma, certificate, associate, or baccalaureate level. All participants will be included regardless of culture, race, sex, or gender.
Phenomena of interest
This review will consider studies that explore the experiences of students or former students of a PLPN to RN bridging program. Experiences will include the views, understandings, or impressions of being enrolled in the program. Experiences will be within the context of participation in the program, and will include personal accounts, views, and understandings of being a student in the program. Motivators will include, but will not be limited to, financial, professional, or personal reasons for enrolling in the program. Academic support will include, but will not be limited to, any instructional, psychological, emotional, or financial provisions to assist bridging students to succeed in the nursing program. Attrition will include any reason for leaving the bridging program and will include, but will not be limited to, involuntary dismissal due to academic reasons, failure to progress through the program as expected, and voluntary withdrawal due to personal, financial, or professional reasons.
This review will consider students from PLPN to RN bridging programs in any setting. All studies will be included regardless of geographical location.
Types of studies
The review will consider studies on qualitative data including, but not limited to, research designs such as phenomenology, grounded theory, ethnography, action research, and feminist research. Qualitative data from qualitative descriptive or mixed methods studies will also be included.
This systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence.26 The review title for this protocol has been registered in PROSPERO (CRD42021278408).
A three-step search strategy was developed in collaboration with a library scientist trained in JBI systematic review methodology. The strategy will be used to find both published and unpublished studies. The first step was an initial limited search of CINAHL (EBSCO) with full text to identify articles on the topic (see Appendix I for preliminary search strategy). The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles, will be adapted for each included information source. Next, a search will be conducted using all identified keywords and index terms across all included databases. Finally, the reference lists of all included articles will be searched for additional studies. The search for unpublished studies will be important for this review as the topic is under-represented in the published literature.
Only studies published in English will be included as the research team does not have the translational skills or resources to include other languages. No date limits will be applied to the searches to fully capture what is known about the phenomenon of interest.
The databases to be searched include CINAHL (EBSCO), MEDLINE (Ovid), Embase, and ERIC (EBSCO). To supplement the above, searches for gray literature will be performed in ProQuest Dissertations and Theses and GreyNet International.
Following the search, all identified citations will be collated and uploaded into EndNote v.20 (Clarivate Analytics, PA, USA) and duplicates removed. The remaining citations will be imported into Covidence (Veritas Health Innovation, Melbourne, Australia). Titles and abstracts will then be screened by two independent reviewers against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.27
Assessment of methodological quality
Eligible studies will be critically appraised by two independent reviewers for methodological quality using the standard JBI critical appraisal checklist for qualitative research.26 All studies, regardless of methodological quality, will undergo data extraction and synthesis (where possible). The impact of the methodological quality of the included studies will be considered in the analysis of findings and conclusions of the review. Authors of papers will be contacted to request missing or additional data for clarification, when required. Any disagreements between the reviewers will be resolved through discussion or with a third reviewer. The results of critical appraisal will be reported in narrative format and in a table.
Qualitative data will be extracted from papers included in the review by two independent reviewers using a JBI standardized data extraction tool.26 The data extracted will include specific details about the participants, the PLPN bridging program, phenomena of interest, context, culture, geographical location, study methods, and outcomes of significance to the review question and objectives. The findings, and their illustrations, will be extracted verbatim and assigned a level of credibility. There are three levels of credibility based on the JBI approach to qualitative reviews: i) unequivocal, where findings can be accompanied by an illustration that is beyond reasonable doubt and is therefore not open to challenge, ii) credible, where findings can be accompanied by an illustration that lacks clear association with it and is therefore open to challenge, and iii) not supported, where findings are not supported by the data.26 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach.28 This will involve aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings based on similarity in meaning. These categories will then be subjected to a synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form. Only unequivocal and credible findings will be included in the synthesis.
Assessing confidence in the findings
The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.28 The Summary of Findings will include the major elements of the review and details on how the ConQual score was developed. Included in the table will be the title, population, phenomena of interest, and context of the specific review. Each synthesized finding from the review will then be presented, along with the type of research informing it, score for dependability and credibility, and the overall ConQual score.29
Appendix I: Search strategy
Search conducted on December 28, 2021
1. World Health Organization. State of the world's nursing 2020: investing in education, jobs and leadership [internet]. WHO; 2020 [cited 2021 Sep 30]. Available from: https://www.who.int/publications/i/item/9789240003279
2. International Council of Nurses. The global nursing shortage and nurse retention [internet]. ICN; 2021 [cited 2011 Sep 19]. Available from: https://www.icn.ch/sites/default/files/inline-files/ICN%20Policy%20Brief_Nurse%20Shortage%20and%20Retention_0.pdf
3. World Health Organization. Global strategy and action plan on ageing and health [internet]. WHO; 2017 [cited 2021 Sep 26]. Available from: https://www.who.int/publications/i/item/global-strategy-and-action-plan-on-ageing-and-health-summary
4. World Health Organization. WHO and partners call for urgent investment in nurses [internet]. WHO; 2021 [cited 2021 Jun 25]. Available from: https://www.who.int/news/item/07-04-2020-who-and-partners-call-for-urgent-investment-in-nurses
5. McGill Nursing Collaborative for Education and Innovation in Patient- and Family-Centered Care. Global nursing shortage [internet]. 2019 [cited 2021 Jun 22]. Available from: https://www.mcgill.ca/nursing/files/nursing/nurse_shortages.pdf
6. Fawaz MA, Hamdan-Mansour AM, Tassi A. Challenges facing nursing education in the advanced healthcare environment. Int J Africia Nurs 2018;9:105–110.
7. American Association of Colleges of Nursing. AACN's vision for academic nursing [internet]. AACN; 2019 [cited 2021 Sep 22]. Available from: https://www.aacnnursing.org/Portals/42/News/White-Papers/Vision-Academic-Nursing.pdf
8. American Association of Colleges of Nursing. Fact sheet: nursing shortage [internet]. AACN; 2020 [cited 2021 Sep 26]. Available from: https://www.aacnnursing.org/Portals/42/News/Factsheets/Nursing-Shortage-Factsheet.pdf
9. Chan Z, Cheng W, Fong M, Fung Y, Ki YM, Li Y, et al. Curriculum design and attrition among undergraduate nursing students: a systematic review. Nurse Educ Today 2019;74:41–53.
10. Hamshire C, Jack K, Forsyth R, Langan A, Harris W. The wicked problem of healthcare student attrition. Nurs Inq 2019;26 (3):e12294.
11. Hutchinson L, Mitchell C, John WS. The transition experience of enrolled nurses to a bachelor of nursing at an Australian university. Contemp Nurse 2011;38 (1–2):191–200.
12. Melrose S, Wishart P. Resisting, reaching out and re-imagining to independence: LPN's transitioning towards BNs and beyond. Int J Nurs Educ Scholarsh 2013;10 (1):107–113.
13. Hylton J. Relearning how to learn: enrolled nurse transition to degree at a New Zealand rural satellite campus. Nurse Educ Today 2005;25 (7):519–526.
14. Dowswell T, Hewison J, Millar B. Enrolled nurse conversion: trapped into training. J Adv Nurs 1998;28 (3):540–547.
15. Prindle RM. A narrative inquiry of licensed practical nurse (LPN) returning students: implications for transformative pedagogy and curriculum [dissertation]. Moscow, ID: University of Idaho; 2005.
16. Suva G, Sager S, Mina ES, Sinclair N, Lloyd M, Bajnok I, et al. Systematic review: bridging the gap in RPN-to-RN transitions. J Nurs Scholarsh 2015;47 (4):363–370.
17. Jones C, Toles M, Knafl G, Beeber A. An untapped resource in the nursing workforce: licensed practical nurses who transition to become registered nurses. Nurs Outlook 2018;66 (1):46–55.
18. Melrose S, Gordon K. Overcoming barriers to role transition during an online post LPN to BN program. Nurs Educ Pract 2011;11 (1):31–35.
19. Parzen M, Janzen K. Facilitation of disorientating events for the RPN to BScN learner. Qual Advan Nurs Educ 2019;5 (2):3.
20. Coffey S, Lindsay GM, Cochrane M, Cummings K, Macdonald K, Mairs S, et al. Making the grade through the front door: evaluation and innovation in a registered practical nurse to bachelor of science in nursing program. J Educ Train Stud 2016;4 (1):32–38.
21. Mthimunye K, Daniels F. Predictors of academic performance, success and retention amongst undergraduate nursing students: a systematic review. S Afr J High Ed 2019;33 (1):200–220.
22. Mitchell K, Chorney M, Gural D, Simmons-Swinden J, Picheca L, Baxter C. Social and academic integration strategies for retention of nursing students: a scoping review protocol. JBI Evid Synth 2019;17 (1):28–36.
23. Schultz PR. The lived experience of licensed practical nurses enrolled in an upgrade associate degree nursing program [dissertation]. Nashville, TN: Peabody College for Teachers of Vanderbilt University; 1992.
24. Smith-Wacholz H, Wetmore J, Conway C, McCarley M. Retention of nursing students: an integrative review. Nurs Educ Perspect 2019;40 (6):328–332.
25. Mais Y. Registered practical nurses’ (in post RPN-BScN education) experiences of nurse-to-nurse conflict in the workplace [dissertation]. Oshawa, ON: University of Ontario Institute of Technology; 2017.
26. Lockwood C, Porrit K, Munn Z, Rittenmeyer L, Salmond S, Bjerrum M. Chapter 2: Systematic reviews of qualitative evidence. In Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis [internet]. Adelaide: JBI; 2020 [cited 2019 Nov 6]. Available from: https://synthesismanual.jbi.global
27. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71.
28. Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evid Based Healthc 2005;13 (3):179–187.
29. Munn Z, Porritt K, Lockwood C, Aromataris E, Pearson A. Establishing confidence in the output of qualitative research synthesis: the ConQual approach. BMC Med Res Methodol 2014;14 (1):108.