Accelerated second-degree baccalaureate nursing (ABSN) programs are proliferating rapidly as a strategy to address the critical nursing shortage.1 In addition to the nursing shortage, the Institute of Medicine and Robert Wood Johnson Foundation set a goal to increase baccalaureate-prepared nurses to 80% by 2020. These priorities have led to a significant growth in ABSN enrollments.2 The profile of the ABSN student has been shown to be more diverse than traditional entry-level nursing students in terms of age, gender, race and ethnicity, and life experience.3 Accelerated second-degree baccalaureate nursing students have been found to be academically stronger than students in the traditional bachelor of science in nursing (BSN) program, although no differences have been noted in terms of clinical competence, NCLEX-RN pass rates, and transition to the professional nursing role.4 Some studies have reported higher attrition rates for ABSN students than for traditional entry-level nursing students related to both academic and nonacademic factors,5,6 whereas other studies have reported conflicting findings.7
A 2010 National Advisory Council of Nurse Education and Practice report to Congress posited that health care knowledge required for all health care professions, including nursing, doubled every 5–8 years and was predicted at that time to begin doubling annually.1 Although the academic strength of the ABSN students in our program was increasing based on entry grade point average (GPA) and prerequisite course grades, attrition rates were continuing at a concerning rate. Because second-degree students have already earned a baccalaureate degree, they are not eligible for federal financial aid and must often use higher-interest private loans.2 Costs associated with program extension or dismissal, or an inability to become licensed to practice, can be high for students. The nursing program also must invest additional resources, such as clinical placements and remedial courses, to accommodate students requiring extended time to successfully complete the program. In addition to costs, the prolonged course progression delays or prevents the student's entry into the workforce, hindering efforts to alleviate the nursing shortage. Therefore, it is important that academic risk factors are identified and strategies are developed to promote student success for timely progression to graduation and licensure.
Consecutive descriptive correlational studies were conducted with 2 sequential ABSN cohorts. The purpose of the initial study was to identify academic risk factors through an admissions assessment that could potentially disrupt progression and lead to prolonged program completion. Once academic risk factors were identified in the first study, the aim of the second study was 2-fold. First, the efficacy of targeted interventions developed to promote the success of ABSN students identified as at-risk was examined. Second, admissions assessment results and student curricular performance were analyzed to explore additional risk factors that could interfere with program completion.
The studies were conducted in a nursing program within a college of health professions in northern New England. This ABSN program is a fast-paced, 16-month, second-degree program for students who have a previous bachelor of arts/bachelor of science degree and have met prerequisite requirements. The program currently begins in the spring semester and continues for 4 consecutive semesters. Student admission is based on the strength of transcripts from students' previous baccalaureate degree and prerequisite courses, particularly the science courses, as well as a personal essay and letters of recommendation. No interview or admission testing is required. The first cohort of ABSN students was admitted in the spring of 2012; 6 cohorts have now completed the program, the seventh cohort will complete the program in the spring, and the eighth cohort just entered the program. Since the first class was admitted in 2012, the program has now more than tripled in size and continues to expand.
Standardized testing is a common practice for nursing program admission decisions.8,9 The nursing program's contracted standardized testing vendor offers an admissions test, which is designed to be used as either a preadmission assessment or as a postentry evaluation for identification of at-risk students. It is a validated 91-question, online, multiple-choice test that generates an overall percentage score, a critical thinking score, and subscores on reading, writing, math, and physio-based science. The vendor suggests that students with a composite score of less than 60% meet with academic resources to formulate an individualized study plan (K. Haidemenos, personal communication, November 11, 2015). The nursing program had evidence of factors predictive of success for the traditional 4-year baccalaureate students, such as high school GPA, scores on standardized college admissions tests, and grades in the core laboratory sciences. These factors were less apparent for the ABSN students, and anecdotal evidence indicated a need for further inquiry.
The admissions test was administered as a pilot to a cohort of 37 ABSN students during the first week of the program in January 2016, followed by a brief overview of nursing school study strategies and available academic support resources. During the first semester of the ABSN program, faculty observed that struggling students who had low course examination grades also had low admission test scores. A retrospective descriptive correlational study, approved by the university's institutional review board (IRB), was then conducted on data from that student cohort. Several variables were identified as putting a student at risk of interrupted program progression, including the writing subscore on the admissions test. When comparing final course grades between students with low (less than 60%) and high (60% and above) writing subscores, 2-sample t tests showed that students with low writing subscores significantly underperformed those with high writing subscores in each of the 5 first-year nursing courses. Attendance and remediation variables were flagged as needing further definition and exploration and therefore were not included in the final statistical model.
Based on contemporary literature, core nursing faculty and the Student Academic Success Center (SASC) learning specialist collaboratively developed targeted interventions for potentially at-risk students. Evidence shows that systematic, targeted, and multifaceted remediation supports student success.10 Students at risk of interrupted progression should be identified early, and individualized interventions should be developed as a contract between student and faculty to include monitoring and accountability.11,12 Remediation was operationally defined and informed the development of a formalized, structured algorithm (Rx for Success). Rx for Success is triggered by academic performance below benchmarks or concerning student behaviors, such as lack of class preparation, late or missing assignments, and absenteeism. An abbreviated Rx for Success algorithm is provided in the Figure. The full algorithm is shown in Figure 1, Supplemental Digital Content 1, http://links.lww.com/NE/A690. Once the Rx for Success algorithm is triggered, students complete a self-assessment checklist (see Figure 2, Supplemental Digital Content 2, http://links.lww.com/NE/A691). Collaboratively, faculty and the student discuss the results of the checklist and develop an individualized remediation plan based on identified risk factors, such as meeting with the SASC learning specialist and/or tutors, developing a study schedule, or working on time management and prioritization.
The admissions test was again administered to the next cohort of 56 ABSN students at the beginning of the semester in January 2017. After the admissions test, all students were encouraged to meet with faculty to discuss the results and develop a remediation plan based on identified weaknesses. The ABSN program coordinator, several nursing faculty members, and the SASC learning specialist then delivered an extensive Nursing School Success seminar focusing on nursing school study skills, time management strategies, and academic support resources. This value-added educational opportunity introduced students to best practices for studying during the nursing program gleaned from the literature and stressed the importance of being proactive learners by accessing SASC resources and meeting with faculty before significant challenges arise.13
During the 2016–2017 academic year, the 22 students identified as academically at-risk based on a writing subscore of less than 60% on the admission test, as well as any student triggering the Rx for Success throughout the semester, received more intensive, targeted interventions to support academic success. Data on academic performance from 5 nursing courses in the first 2 semesters, student behaviors (class preparation, assignment completion, attendance, and participation), and remediation were gathered and then analyzed for evidence of efficacy of those interventions. The second study was deemed exempt from review by the university's IRB.
A 2-sample t test concluded that students in the second study with combined reading and writing subscores less than 150% on the admissions test were found to be at risk of failing the first-semester foundational nursing course, with examination averages significantly lower than that of the students who had a combined score of at least 150% (P < .0001). Student success in that foundational nursing course was predictive of success in other courses during the first 2 semesters. Students identified as needing targeted remediation, and then seeking academic support through tutoring or learning specialist consultation, tended to earn satisfactory grades. In addition, students identified as at-risk who accessed SASC services only once tended to remain at-risk. The students who accessed SASC services were sent an anonymous questionnaire via an electronic survey software asking about the frequency of SASC usage, modification of study practices, and perceived academic progress; results revealed that 100% of students using SASC services indicated modification of their study techniques, critical reading, and test-taking strategies, and two-thirds of the students felt that these improvements were significant to their success.
Since the implementation of the Rx for Success algorithm, overall SASC usage increased from an average of 2.69 visits and 4.65 hours per student in the 2017 cohort to 4.82 visits and 8.93 hours per student in the current cohort. For students identified as at-risk, percentage of students accessing SASC resources increased from 57% to 88%. Use of SASC by students who successfully completed the program with their cohort increased from 58% to 89%. Increased SASC use was also noted for students who experienced delayed progression (56% to 83%); however, up to half of those students visited the SASC only once, whereas up to 83% of students without delays in progression accessed SASC resources on multiple occasions for more than 1 course. Program completion without delayed progression for at-risk students increased from 75.7% to 87.5%. At-risk students needing extra semesters to complete the program decreased from 21.6% to 6.3%, and students leaving the program due to persistent academic challenges decreased from 5.4% to 4.2%. First-time pass rates on the NCLEX-RN for these students increased from 87.9% to 97.9%.
There were several unexpected findings from the studies related to predictors of academic success. Faculty assumed that the science subscore on the standardized test would be predictive of academic success. Science GPA has been a strong predictor of success in our traditional BSN students, which is consistent with findings of other studies.14,15 Likewise, previous studies have shown correlations between science GPA, science subscores on standardized examinations, and academic performance in nursing programs.9 However, this was not the case in either of the present studies.
Findings from the 2 present studies are similar to those of previous studies. Scores on standardized prenursing examinations have been shown to be predictive of academic success in associate degree nursing programs as well as prelicensure nursing programs in other countries.8,16,17 According to the literature, in the ABSN student population, reading subscores on a standardized baseline assessment test and grades in a first-semester health assessment course were found to be predictors of graduation and NCLEX-RN first-time pass rates.18 In the present study, grades in the first-semester foundational adult health course were more strongly correlated with performance in subsequent semesters than the health assessment course.
One study noted an association among ABSN course grades, motivation, and learning strategies, such as time management, controlled study environment, rehearsal, peer learning, and seeking help from peers and faculty, consistent with practices endorsed by the faculty and SASC learning specialist.19 Similarly, another study found that ABSN students perceived personal study skills and faculty advisement as positive influences on retention.20 There is also evidence that asking students to self-reflect on their learning behaviors, a key component of the Rx for Success, can contribute to the students' sense of pride and competency in nursing, thereby supporting academic persistence, progression, and retention.21
The nursing program continues to administer the admissions test to ABSN cohorts early in the program, and the Nursing School Success seminar has been further refined and expanded in response to anecdotal student feedback. A formal mentorship program has been established, whereby senior ABSN students are paired with junior students to offer advice and support for managing the demands of a rigorous program. This strategy has been found to be successful in previous studies.5
The structured algorithm, Rx for Success, has become part of the culture of the program, with faculty more consistently incorporating the strategies in courses for both ABSN and traditional BSN students. Although formal statistical analysis of data has not continued, the admissions test results and first-semester academic progress are closely monitored. A more proactive advising approach is taken with students identified as potentially academically at-risk; the ABSN program coordinator and course faculty intentionally reach out to these students on a regular basis to address concerns early, following the action steps in the Rx for Success. For example, if a student is identified as at-risk or demonstrates one of the triggers, the faculty member contacts the student for a meeting. The student completes the self-assessment checklist, either in advance or at the beginning of the meeting, and results are reviewed to identify habits that may be hindering success. The faculty member reviews recommended practices with the student, such as regular access of SASC resources, effective study strategies, test-taking tips, and time management. The student and faculty then collaboratively develop a remediation plan to modify those habits, with mutually agreeable checkpoints as needed to monitor progress. This practice has been found in previous studies to be influential in mitigating factors placing students at risk of delayed or interrupted program progression.13,22
Limitations and Recommendations
Several limitations of these studies can be acknowledged. The relatively small sample sizes precluded meaningful inferential statistical analysis of the data. The impact of nonmodifiable factors (previous degree/GPA, English language proficiency on program entry, demographics) was not included in the statistical analyses and needs further exploration. More accurate and precise data collection is needed, as not all faculty recorded attendance. In addition, more prospective and qualitative data are needed to better understand student perceptions of factors that may support or hinder their success. Class attendance and quantity/quality of remediation continue to need further exploration. Remediation was not required for students identified as being at-risk; compulsory remediation has been explored in previous studies and found to improve retention and academic success.12 The first-semester health assessment course has been substantially revised based on course evaluations and may offer predictive validity in the future.
The findings from this study have contributed to early identification of academically at-risk students and to the development of a formalized, structured, evidence-based algorithm, Rx for Success, to support academic success. Outcomes for students in the ABSN program are improving as a result; attrition rates are decreasing, and fewer students are experiencing delayed progression or dismissal from the program. We are learning that consistency in implementation of Rx for Success for all triggers is essential. Most faculty in the nursing program are following the algorithm, although mostly for academic triggers (eg, low writing subscore on the admission assessment, course examination scores). More work is needed to promote consistent student notification for triggers related to concerning student behaviors. Given the high stakes of delayed or halted program progression, the risk assessment and response strategies described in this article serve as an impetus for further inquiry.
The authors gratefully acknowledge Nora Krevans, MA, SASC Learning Specialist, for her contributions to the project and unwavering support of the students, and Lori Koban, PhD, for her statistical analysis and assistance with interpretation of the findings.
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