Increased emphasis upon educational advancement for registered nurses entering the profession with an associate degree (ADN) or diploma is prevalent since the dissemination of landmark reports linking the level of nursing education to patient outcomes (Benner, Sutphen, Leonard, & Day, 2009; Institute of Medicine, 2010). The initial research that attempted to connect patient outcomes to the value of baccalaureate nursing (BSN) preparation (Aiken, Clarke, Cheung, Sloane, & Silber, 2003) contributes to this generally accepted relationship. National education leaders representing ADN and BSN entry-level programs have endorsed the movement to facilitate academic progression of RNs (American Association of Colleges of Nursing [AACN], American Association of Community Colleges, Association of Community College Trustees, National League for Nursing, & National Organization for Associate Degree Nursing, 2012).
Of 747 RN to BSN programs throughout the United States, 600 (80 percent) are offered at least partially online, as compared to 59 percent in 2015 (AACN, 2017). The number of RNs enrolled in RN-BSN programs increased by 69 percent from fall 2010 (77,259) to fall 2014 (130,345) and by 10.4 percent during 2013 to 2014 alone (AACN, 2015). The year 2016 marked the 13th consecutive year of growth by another 1 percent increase in enrollment (AACN, 2017). However, of all nursing programs in the United States, RN-BSN programs have the second lowest average graduation rate (83 percent), whereas ADN programs possess the highest (91 percent; National League for Nursing, 2012). The high rate of completion combined with the characteristics of ADN students speaks to their commitment and persistence in prelicensure education. However, their low rate of BSN attainment deserves further investigation.
Collaboration among leaders and experts in ADN/diploma and RN-BSN programs can help ensure that RN-BSN curricula build upon strong foundations to elevate nursing practice. The vital nature of the liberal educational component of the prelicensure BSN (Peirce, 2010) and evidence of its similar impact upon RN-BSN students (Debrew, 2010) are important to track if RN-BSN programs are to prepare well-rounded, well-educated individuals. An assessment of curricula by RN-BSN program directors and faculty is helpful (McEwen, White, Pullis, & Krawtz, 2014); however, involvement of ADN/diploma faculty familiar with this student population is essential.
In an effort to learn about elements of RN-BSN programs that may be related to student enrollment and persistence, the researcher initially sought to answer the question: What are the best practices of RN-BSN program curriculum and instruction? However, results of the literature search and consideration of the prevalence of distance/online/hybrid RN-BSN programs/courses moved the focus of the research to address the more specific question: What are the best practices for distance/online/hybrid RN-BSN program curriculum and instruction?
The application of the Matrix Method began this inquiry (Garrard, 2013). The integrative review method was chosen based on the freedom to include nonexperimental research (Whittemore & Knafl, 2005). By aligning the Matrix Method with the work of Whittemore and Knafl, the rigor of this review begins to address the lack of comprehensive guidelines and recommendations for distance/online/hybrid RN-BSN program curricula and instruction.
A variety of literature searches were accomplished utilizing numerous databases in addition to the snowball technique (Garrard, 2013) until the final strategy was determined. The inclusion of doctoral dissertations minimized the risk of publication bias. The final online search strategy utilized the CINAHL Plus With Full Text, ProQuest Dissertations and Theses, and PubMed databases. The search terms integrated key words and subject headings including “associate degree nurses,” “registered nurses,” “diploma nurses,” “RN-BSN,” combined with the word “and” in an effort to glean papers that addressed curriculum development, post-RN education, and nontraditional education specific to RNs. The snowball technique (i.e., using references lists of retrieved papers, etc.) gleaned additional papers. Limitation on publication years reflected papers published or made available between January 1, 2010 and December 31, 2014. The total number of research papers retrieved through the final search was 226, eliminating the need to include works representing lower levels of evidence (Joanna Briggs Institute [JBI], 2014). (See Figure A, available as Supplemental Digital Content 1 at http://links.lww.com/NEP/A89.)
Inclusion/Exclusion of Papers
Of the original 226 papers retrieved, 136 were eliminated through exclusion criteria, and seven were eliminated as duplicates, revealing a topically based subdivision. The subdivisions were rank-ordered based on the number of papers within them. The greatest number of papers were of a general nature (n = 29), referencing topics addressed by prior research (Perfetto, 2015). The second most numerous category (n = 19) addressed distance/online/hybrid RN-BSN programs/courses. Considering the prevalence of online RN-BSN programs and the variety of studies represented, this specific focus was deemed worthy of synthesis. (See Supplemental Digital Content 2 at http://links.lww.com/NEP/A90 for Figure B.)
Levels of Evidence
In an effort to objectively ascertain the strength of studies included based on their design, commonly accepted levels of evidence were assigned to each applying the Australian JBI (2013) criteria. Per JBI recommendations, the levels of evidence did not serve as a substitute for critical appraisal and reasoning (JBI, 2014; see Figure 1).
A matrix (available as Supplemental Digital Content 3 at http://links.lww.com/NEP/A91) facilitated the comparison and consistent assessment of each study in accordance with commonly accepted research review categories (Garrard, 2013) and enables more in-depth review of each study by the reader. The scientific rigor of each study is rated using the JBI criteria. Table 1 shares the four emergent themes.
The background information and literature reviews that precede each paper/study consistently acknowledge the need to support RN-BSN advancement. The common need to improve RN-BSN pathways serves as the foundation for the research, inquiries, or reports. Discussions within the papers commonly relate to agreement on the convenience, accessibility, and flexibility of online RN-BSN programs for this busy student population. Comprehensive reviews of the literature in online education, within and outside the discipline of nursing, provide the backdrop for the studies and help determine variables measured.
Research problems/questions for the 19 studies emerged from a concern with the proliferation of enrollment in online RN-BSN programs absent substantiating guidance, best practices, or evidence (see matrix in supplemental digital content). Other questions on the rigor of online education, a general unease with the lack of perceived human connection in online courses, and a prevalence of student and/or faculty incivility in the online environment raised additional concerns. The common purpose of the authors related to the value of online approaches to RN-BSN education and the goal to add to their research and evidence base.
Theme 1: The Relationship of Online Course Design to Achievement of Learning Outcomes and/or Student Satisfaction
Close to 90 percent of the studies explored online course design in relation to student success and/or student satisfaction, some with more rigor and specificity than others (Cobb, 2011; Cummins, 2011; Hsu & Hsieh, 2011; Lindley, 2014; London, 2013; Rebar, 2010). Though students who are satisfied with a program are typically meeting learning outcomes (Davidson, Metzger, & Finley, 2014; Davidson, Metzger, & Lindgren, 2011; Hsu & Hsieh, 2011; Johnson & Smith, 2011; Sikma & Prentice, 2012), these two measures are distinct and addressed independently by some studies; others address the measures together.
For the purposes of this theme, student satisfaction, persistence, and/or the level of achievement of learning outcomes are defined by the studies included (see Matrix in supplemental content). Online course design reflects type and structure of learning activities integrated into the course, the physical design of a course within a learning management system, the number of students enrolled in a course, and/or the level of technology integrated.
STUDENT ACHIEVEMENT OF LEARNING OUTCOMES
Two studies revealed strong, statistically significant positive relationships between online student engagement and course performance (Cummins, 2011; Hsu & Hsieh, 2011). Cummins described structured discourse rather than disjointed online dialogue as a deliberate, vital component of online course design that increased student engagement. A multiple linear regression model showed as engagement (as measured by the frequency of online dialogues and time spent on the internet) increased, individual student course scores increased (Hsu & Hsieh, 2011). The inverse was true for individual students who spent less time online engaged in structured online discussions (Cummins, 2011). Interestingly, at the group level, no statistically significant relationships were discovered between the highest levels of interaction and mean final course grades.
The impact of class size on individual student grades revealed a negative relationship; as online class size increased, course grades were likely to decrease (Cummins, 2011). This phenomenon leveled out at a class size of about 18 students. The difficulty to control for confounding variables (e.g., multiple faculty) was acknowledged.
Program persistence, performance, and completion appeared to benefit from the redesign of traditional/on-ground courses/programs to online/hybrid designs (Davidson et al., 2011, 2014; Gilmore & Lyons, 2012; Hsu & Hsieh, 2011). Hybrid designs that integrate face-to-face and online classes/meetings, described and/or “tested” by at least five studies, were found to promote individualization, access, and convenience associated with student success and satisfaction (Davidson et al., 2011, 2014; Hsu & Hsieh, 2011; Johnson & Smith, 2011; Sikma & Prentice, 2012). The use of strong researcher-developed instruments demonstrated that a blended/hybrid learning environment facilitated metacognitive and self-regulatory development that was associated with higher course performance (Hsu & Hsieh, 2011). Hybrid course designs appeared to maximize the advantages of online learning and minimize the limitations of traditional/face-to-face courses for RN-BSN students. An in-person orientation, in combination with transformation from an on-ground program to a fully online design, was associated with a near doubling of student enrollment and increased student satisfaction and persistence (Gilmore & Lyons, 2012).
The Community of Inquiry (COI) Survey, originally developed to study online education, was used to examine aspects of the technological design of online courses and their relationship to student success in two studies, facilitating their comparison (Lindley, 2014; London, 2013). The underpinnings of the COI framework established its utility to measure student engagement that can translate into persistence and program completion. Lindley examined student outcomes using the COI survey. Students who reported higher levels of cognitive presence were more likely to reenroll in subsequent semesters; high social presence related to student perception of group cohesion; and high teaching presence reflected students’ positive perception of course design, organization, and ability to facilitate discourse. Similarly, London utilized the COI framework to study the integration of audio feedback in online courses in an RN-BSN program.
The use of audio-text feedback versus text-only feedback as an online pedagogy revealed a lack of a statistically significant positive relationship with student success in one study (London, 2013). Conversely, the comparison of asynchronous audio-video and text-based instructor feedback with text-based-only instructor feedback showed statistically significant positive differences between the control and intervention groups on the same measures of the COI survey (Lindley, 2014). This study, because of its strong experimental design, very low attrition, and high power, promotes the use of asynchronous audio-video and text-based instructor feedback in online RN-BSN courses. In addition, because study participant demographics are similar to those of RN-BSN students in the United States, findings may be generalizable to RN-BSN students in online programs at other US colleges.
Not surprisingly, student comfort with technology such as computer-mediated communication was found to have a positive relationship with overall student satisfaction in an online course (Cobb, 2011). Interestingly, though Mann’s (2014) investigation did not focus strictly upon technological applications as a component of course design, students’ perception of the importance of instructor expertise with “high-tech” approaches in online courses is low. Though faculty often strive to adopt high-tech methods, evidence suggests that less complicated technology is aligned with greater student satisfaction (London, 2013).
Experienced online learners demonstrated the relationship between the six dimensions of the Distance Education Learning Environments Survey (DELES; Instructor Support, Student Interaction and Collaboration, Personal Relevance, Authentic Learning, Active Learning, Student Autonomy) with their satisfaction in a fully online program (Price, 2013). Personal Relevance shared a strong positive relationship with Student Satisfaction, and all but Active Learning (weak) shared a moderate relationship with the same. This study demonstrated the clear preference of RN-BSN students for constructivist approaches to teaching and learning that build upon their experience in nursing.
Students shared an almost unanimous lack of preference for group work as a component of online or hybrid courses (Clark, Ahten, & Werth, 2012; Clark, Werth, & Ahten, 2012; Davidson et al., 2011; Hart & Morgan, 2010; Price, 2013). A perceived lack of recognition for individual contributions and unfair grading practices underpinned these perspectives. An alternative may be the integration of group activities to build community, with the clear recognition of individual contributions (Clark, Ahten, et al., 2012).
Theme 2: Academic Integrity in Online Teaching and Learning
A suspected relationship between the proliferation of online RN-BSN programs and academic dishonesty served as the foundation for two studies (Hart & Morgan, 2010; Morgan & Hart, 2013). The initial descriptive research utilized the self-report Academic Integrity (AI) Survey to compare RN-BSN students in online and traditional programs and did not support concerns that cheating is more prevalent in online courses (Hart & Morgan, 2010). When an intervention providing more intense exposure of RN-BSN students to AI policies was integrated into an online course in a quasiexperimental study, no statistically significant differences between the intervention and control groups were found related to reports of cheating and perception of its seriousness (Morgan & Hart, 2013). Despite this, faculty may promote a culture of enhanced awareness and value of AI through positive discussion and related learning activities. Diligent awareness of the possibility of academic dishonesty is the responsibility of all faculty at all times.
Assessment of AI gathered through the research studies in this review was by self-report (Hart & Morgan, 2010; Morgan & Hart, 2013), an inherent limitation. Even considering this limitation, the researchers dispelled concerns of any disruption of AI in online RN-BSN programs that might dictate aspects of course design. RN-BSN students reported higher levels of AI than their undergraduate/prelicensure counterparts and those in other disciplines (Hart & Morgan, 2010). The researchers concluded that the high level of AI reported by online RN-BSN students may be related to their professional role and ethical comportment (Morgan & Hart, 2013). Moreover, the researchers posited that online RN-BSN students diligently strive to minimize any belief that academic dishonesty is prevalent in online courses in an effort to promote the integrity of the program and credentials earned (Hart & Morgan, 2010).
Theme 3: The Experience of Community and Caring in Online Courses
Nursing is a team sport; accordingly, the important role of camaraderie and its effects on persistence, satisfaction, and success in the online and hybrid learning environment is clear for nurses returning to school (Cobb, 2011; Cummins, 2011; Lindley, 2014; London, 2013; Mann, 2014; Rebar, 2010). The acknowledgment that unproductive feelings of isolation can often occur among online learners (Brahe, 2013; Clark, Ahten, et al., 2012; Clark, Werth, et al., 2012) can be motivation for faculty and students to address scenarios that promote incivility before it begins.
An alarming exposure of incivility in the online teaching and learning environment pointed to the importance of trust and open communication among students and faculty. Clark et al. (Clark, Ahten, et al., 2012; Clark, Werth, et al., 2012) explored the prevailing faculty belief that inherent anonymity of the online environment encourages uncivil faculty and student behavior that is related to fear, uncertainty, and distrust. Their studies emphasize the importance of clear norms, expectations, student engagement, and relationship building for the prevention of incivility online.
According to Brahe (2013), students related that online communities of peers who don’t work or live together promote liberal sharing based on anonymity, a positive effect of the anonymous nature of online learning. Students’ own construction of informal online communities and their contribution to emotional support and success may minimize the potential for incivility and motivate continued engagement and satisfaction. Convenience and ease of online communication methods emerged as vital to time-constrained lives and aided the swift development of relationships, despite geographical separation that normally encumbers human connection. In contrast to the potential for incivility, liberal sharing, lack of competition, and free-flowing empathy among classmates contributed to partnerships and resulted in synergy, empowerment, mutual respect, and reciprocal learning.
The “skills” of instructors appeared less important to students than the sense of community they associated with deep learning in the course/program (Cobb, 2011; Mann, 2014). Similarly, student satisfaction shared a stronger positive relationship with the COI variable Social Presence than it did with Perceived Learning (Cobb, 2011; Davidson et al., 2014). Like other aspects of design, studies on the importance of caring online communities to student success all emphasized the vital role of faculty and instructional designers in the establishment of community (Brahe, 2013; Clark, Ahten, et al., 2012; Clark, Werth, et al., 2012; Cobb, 2011; Cummins, 2011; Davidson et al., 2011, 2014; Lindley, 2014; London, 2013; Mann, 2014; Rebar, 2010).
Students believed that online instructors can create a caring teaching and learning environment that demonstrates respect for the learner (Mann, 2014; Rebar, 2010), where practices like the creation of online “spaces” for informal networking promoted and strengthened the learning community (Brahe, 2013). When providing feedback to students, an instructor’s professional attention to detail, timeliness, organization, and clarity were all seen by students as important aspects of a caring online community that they believed supported their success (Mann, 2014; Rebar, 2010) or was even essential to it (Rebar, 2010).
The COI framework emerged again to demonstrate the importance of caring learning communities in online courses/programs (Lindley, 2014; London, 2013). Group cohesion and discourse enhance the educational experience and align naturally with relationship-centered professionals like nurses while playing an important role in RN-BSN student success. However, the dichotomy between students’ need for a sense of community and their distaste for group work is challenging for faculty who rely on group activity to help students establish relationships in online courses (Clark, Werth, & Ahten, 2012; Davidson et al., 2011; Hart & Morgan, 2010). Creative ways to glean the benefits of group work and minimize aspects that lead to student frustration with lack of individual recognition can evolve with instructor experience. Clark, Ahten, et al. (2012) concluded that a positive online environment requires deliberate planning.
In summary, students who perceived a sense of community in online courses and programs were likely to be more satisfied with their experience (Brahe, 2013; Clark, Werth, et al., 2012; Cobb, 2011; Cummins, 2011; Davidson et al., 2011; London, 2013; Mann, 2014; Rebar, 2010). Concurrently, satisfaction with this sense of community and caring can translate into higher individual performance in the course/program (Cobb, 2011; Cummins, 2011; Rebar, 2010) and subsequent success, persistence, and completion (Lindley, 2014; London, 2013; Mann, 2014). Challenges with the establishment of a supportive online community promoted faculty uncertainty (Clark, Ahten, et al., 2012; Clark, Werth, et al., 2012) and established the need for professional development for those new to online teaching.
Theme 4: Learner Characteristics as They Relate to Success in Online Courses
No statistically significant relationships were identified between RN-BSN student demographics (i.e., years as RN, age, race/ethnicity) and measures related to their learning such as social presence (Cobb, 2011; Hsu & Hsieh, 2011). For the most part, research demonstrated that most RNs returning to school have considerable experience in the profession (Cobb, 2011; Price, 2013). Not surprisingly, a multivariate analysis showed that attitude, motivation, and specific capacities for learning (e.g., analytical ability) were significant independent predictors of course scores (Hsu & Hsieh, 2011). This supports the idea that if RNs who are motivated and committed are provided with an opportunity to engage in learning that fits with their life, they are more likely to succeed (Hsu & Hsieh, 2011). Beyond further demonstrating the need for online RN-BSN education, this theme supports the necessity of the integration of best online teaching and learning practices.
The themes of this synthesis provide research-based guidance for distance/online/hybrid RN-BSN program development and improvement. The studies reviewed applied the general, extant research in online teaching and learning to the RN-BSN student population to illuminate what works and what does not.
Analysis of Theme 1 demonstrates the importance of deliberate planning for distance/online/hybrid RN-BSN programs. The robust integration of technology into online courses, though exciting, is best integrated once fully tested. Group projects require careful attention to design and grading, with even greater zeal in the online setting. Collaboration among faculty and online instructional designers on course design and research efforts holds great potential for evidence-based direction. Overenrollment in the context of increased demand for online courses, though tempting, was associated with diminished quality of the educational experience. The positive impact of a thorough student orientation, as well as the construction of hybrid learning environments, may improve student retention and completion.
Concern for AI in online teaching and learning is minimized through this review and appears directly related to the ethical comportment of nurses. Additional evidence is needed to adequately justify any conclusion that concern is unfounded, however, due to the limited availability of research on the topic and the reliance on self-reporting instruments. Evidence presented through this review supports the value of related faculty-initiated discussions with students to foster a culture of academic honesty (Morgan & Hart, 2013). With this concern minimized, more student-centered, relaxed online learning environments can result.
The importance of the experience of community and caring in online courses should not come as a surprise; however, its vulnerability to uncivil faculty and/or student behaviors may. The possibility of incivility online demands that faculty maintain an awareness of its subtle beginnings and act quickly to intervene if detected. The same anonymity that promotes incivility appears to support greater bonding among classmates that can prevent incivility. Onground community-building skills transition to the online environment, but the importance of professional development for faculty new to online teaching is noted.
Learner characteristics as they relate to success in online courses match to motivation and commitment, rather than demographics. Direct application of the knowledge, skills, and attitudes of experienced nurses can have a profound ability to extend student engagement that can support program persistence and completion.
RECOMMENDATIONS FOR FURTHER RESEARCH
Further opportunities for the investigation of the relationship of online course design to achievement of learning outcomes and/or student satisfaction have materialized through this review. Emergent themes related to student success can provide direction for further research into best practices in enrollment management and student retention, disciplines unto themselves.
Studies that compare hybrid with fully online course designs are needed to glean the benefits of both. Hybrid courses may limit the ability to transcend geography; however, if students are within reasonable proximity to the university, this is not a concern. Team-taught courses may hold great potential for expansion of faculty capacity. Partnering with experts in distance learning in the design of studies that explore the impact of technological applications may extend the reach of RN-BSN education. Dissemination of successful practices is essential.
Analysis of the research specific to RN-BSN students related to AI in online teaching and learning brings forth instrumentation that could be applied to explore related concerns. The exposure of students to exercises designed to promote AI seems applicable for use by faculty in an effort to foster a culture of honesty. Limited by little related research and self-report instrumentation, the concern about academic dishonesty in RN-BSN programs is not fully dispelled and deserves further attention. Astute monitoring of all students with respect to AI is a must.
Specific approaches to enhance the experience of community and caring in online courses, considering its importance to RN-BSN students, need development and dissemination. The COI survey can be applied to measure student engagement, supporting research-based approaches for the construction of strong online learning communities. Evidence-based approaches to group work are needed to extend its utility and value.
In an effort to identify learner characteristics as they relate to success in online courses, the importance of student comfort in the online environment emerges. To further evidence the lack of relationship between individual learner characteristics and their success demonstrated here, additional research is necessary. With the exception of one study (Hsu & Hsieh, 2011), none focused on recent ADN graduates enrolled in RN-BSN programs; this may be worthy of further study based on the current emphasis on expeditious educational advancement of RNs.
Though results of this work are notable, all studies reviewed, with the exception of one (Lindley, 2014), are mostly applicable to the specific program investigated, limiting their generalizability to others. Replication of some of the studies would extend the good work begun.
Although only 13 boards of nursing have regulatory authority over RN-BSN programs (National Council of State Boards of Nursing, 2016) and specific guidelines and recommendations of national accrediting bodies are lacking (McEwen et al., 2014), RN-BSN program planning should engage ADN/diploma curricular experts. The secondary analysis of a survey of RN-BSN program directors seeking their input on essential content for their programs (McEwen et al., 2014) serves as a beginning for work that must engage those intimately familiar with ADN/diploma curriculum. Collaborative curricular planning, assessment, and evaluation of RN-BSN programs that utilize online approaches and apply themes discovered here have the power to extend program resources to reach more RNs. Gap analyses among practice, ADN, and RN-BSN program partners utilizing contemporary nursing competency frameworks can further align RN-BSN programs with the needs of practice settings (Sroczynski, Gravlin, Route, Hoffart, & Creelman, 2011).
Deliberate curricular planning and faculty professional development can propel enrollment and support persistence in online RN-BSN programs. Combined with the systematic evaluation of program outcomes, thoughtful expansion of distance education options that work might address some of the challenges for RN-BSN learners. Providing quality, expeditious RN-BSN pathways to achieve educational milestones promises to enhance the education, richness, and diversity of the profession, vital for optimal patient outcomes.
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