Accelerated second-degree nursing programs have proliferated in the last 25 years, driven in large part by global nursing shortages.1–3 Academic-practice pipelines—or the pipelines of students from admissions through graduation, licensure, and practice—depended on accelerated programs even before COVID-19 began. During the pandemic, almost every US hospital has had to rely upon travel nursing agencies to fill critical staffing vacancies and maintain daily operations,4 and nursing turnover is now the number one concern of hospital chief executive officers, according to a 2021 survey by McKinsey & Co.5 In this context, there is urgent need for accelerated second-degree nurses who can enter the workforce quickly and bring essential traits such as maturity, leadership skills, and resilience.2,6–9
Approach: Assess the Landscape, Present Strategies for Evaluation and Reform
Despite accelerated second-degree students representing a vital and growing component of emerging nursing cohorts, few publications have assessed the current second-degree program landscape or drawn comparisons among second-degree pathways.1,8 This article addresses this literature gap by discussing the second-degree program landscape, highlighting challenges in second-degree education, and comparing graduate-level second-degree entry against other pathway options. Based on their findings, the authors present 4 strategies to optimize and sustain accelerated second-degree nursing education, including by advocating for second-degree practice entry at the graduate level or above. Supplemental Digital Content, Table 1 (available at: https://links.lww.com/NE/B251) shows pathway differences at a glance.
Background
Second-Degree Students Offer Unique Value
Accelerated second-degree programs are designed to help students holding a bachelor's degree in another field transition efficiently to a nursing career.1,6,10,11 Programs are considered accelerated because they do not include non-nursing core curricula, offer limited academic recesses, and are typically around 24 to 32 months long.1,6 Accelerated second-degree graduates are deployed across a vast spectrum of practice roles from direct care to advanced practice to care management, and more. As with traditional bachelor of science in nursing (BSN) graduates, they are typically socialized into direct patient care roles first, before moving into formal leadership roles.
There is great variability in the scope, clinical practice hours, and graduation requirements of second-degree programs, plus offerings at the associate degree in nursing (ADN), BSN, graduate, and doctoral levels. This variability makes it difficult to draw blanket inferences about these programs.1,6,10 However, the literature on second-degree students is consistent: second-degree students bring unique value and are ideally suited to address pressing health care market needs.2,3,6,7,10
Second-Degree Students Bring Diverse Life Experiences
Second-degree students are known for their diversity, maturity, and rich spectrum of life experiences.6,10 Men are 3 to 5 times more likely to enroll in a second-degree program than a traditional program,6 for example, and 30% of graduate cohorts are composed of underrepresented minority (URM) groups.12 In one 2020 study, 30% of second-degree students identified as first-generation college graduates.13 Students in second-degree cohorts come from fields as diverse as art, agriculture, marketing, photography, business, criminal justice, construction, and more.6,11 These characteristics produce a distinct profile: with their professional experience, second-degree students fill specific niches at the intersections of nursing and countless other fields. Lived experience, and the human insight it affords, enables these students to make nursing care relevant (through cultural knowledge, empathy, tailored interventions, etc) to diverse populations and practice settings.6 Second-degree cohorts are known for their professionalism as well.6,10 For second-degree students, age and career experience afford emotional intelligence, creative problem-solving, and adaptability that can manifest as an ethos of professionalism, even during early clinical exposures.6,10,11,14
Second-Degree Students Address Market Needs
In today's health care landscape—characterized by rapidly shifting expectations, new technologies, and emerging threats—care teams need nurses who can lead effectively, regardless of the scenario at hand. The professionalism and emotional intelligence of second-degree students often make them well suited to clinical leadership roles.6,10,11,15 Because second-degree programs do not typically require a humanities and science core, credit hours may be dedicated to leadership and management competencies instead.1 (Although this opportunity is dependent on the credit hour requirements and curricular focus of the program at hand.) Furthermore, although second-degree students are new to nursing, they are further along in their careers compared with traditional students2,3,6; as such, they may be uniquely qualified to advance more rapidly into clinical and senior leadership roles.2,3
In addition, second-degree graduates tend to score higher in measures of resilience, which helps counteract staffing crises.7 Resilience translates to longer tenures in nursing roles and the ability to withstand the critical 6- to 12-month period after graduation.7 Meyer and Shatto7 cite several authors in describing how second-degree graduate students' experience, age, and self-esteem positively impact measures of resilience compared with traditional students. They describe how “survivor's pride,” or the ability to leverage lived experience to navigate hardships, functions in a positive feedback loop: pride in one's ability to survive has been shown to help second-degree graduates to successfully work through clinical challenges, further building self-esteem and resilience over time.7 On the other hand, low self-esteem among younger, traditional students has been associated with a negative feedback loop of depression and turnover.7
Findings
Second-Degree Pathways Need Evaluation and Reform
Nursing's need for accelerated second-degree graduates is clear, and calls to evaluate and compare these students' roads to practice are timely. After decades of proliferation, the dearth of literature on second-degree pathways is striking8 and national data collection mechanisms are lacking. Despite limited evaluative insights, programs continue to multiply with great variability. Based on a study of the literature, the authors present 4 strategies to evaluate and optimize second-degree pathways.
Strategy 1: Standardize the Nomenclature
A standardized nomenclature is essential to the evaluation and comparison of second-degree pathways. Numerous authors describe inconsistent nomenclature as a barrier to national data collection, comparative analytics, literature review, and more.1,6,10 To illustrate this point, Supplemental Digital Content, Table 2 (available at: https://links.lww.com/NE/B252) shows some of the labels used or identified by authors as referring to graduate-level second-degree programs alone. Such inconsistencies not only undermine data collection but also are important from a student, employer, and patient relations' standpoint1: a shared understanding of graduates' preparation is necessary to earn patient trust, hire effectively, negotiate salaries, manage scope of practice, uphold nursing's reputation, and more.
Strategy 2: Standardize Program Scope and Requirements
Like program names, second-degree program requirements vary widely among nursing schools.10 According to a review by Mark et al,1 second-degree programs have the following:
- Credit requirements ranging from 52 to 107 hours;
- Clinical requirements from 500 to 1395 hours; and
- And program lengths from 15 to 36 months.1
Several authors have commented on the impacts of program inconsistency on nursing careers. Mark et al1 discuss confusion among hiring professionals, duplicate or faulty investments of time and money by students, and eroded credibility among colleagues. Shatto et al11 describe bullying severe enough to impact nursing attrition, and Downey and Asselin6 share reports of second-degree graduates facing worse treatment from fellow nurses—who may be mistrusting or resentful of accelerated graduates—than from interprofessional colleagues.6
Although many agree on the need for second-degree pathway standardization, consensus on program design has been difficult to obtain. Debates surrounding prerequisites, clinical practice hour requirements, and program scope are ongoing. In an attempt to solve the standardization barriers, the American Association of Colleges of Nursing (AACN) has proposed an approach to help sidestep many of these debates. The 2021 AACN Essentials document describes a competency-based model, now endorsed by the organization's member deans.16 Under this model, students completing an entry-into-practice degree (regardless of BSN vs graduate) will be required to possess certain competencies and students entering advanced practice (regardless of graduate vs doctoral) will be expected to possess certain competencies.16 This is a significant disruption for a profession that has focused, for decades, on differences between degrees in nursing. It accounts for programs that have not yet transitioned from the graduate to doctoral model for advanced practice preparation.17 It also puts to rest the idea that one must earn a BSN degree to be prepared for practice. The new AACN Essentials allows RNs and advanced practice RNs to practice, if they are qualified, regardless of their education journey.16
As nursing schools adopt the new Essentials, second-degree students enrolling in prelicensure programs will have many of the same needs as first-degree (BSN) students who are developing the same competencies. Currently, there is no evidence that second-degree graduates require specialized programs to socialize them into nursing. However, the literature supports that they bring enhanced skills from previous careers that can emerge during residencies and first employment positions.6,11 These skills should be harnessed in clinical settings to strengthen the nursing workforce. To do so, health care systems must be socialized into the new nomenclature of prelicensure students (who may be receiving undergraduate or graduate degrees in their program of study). National health systems, for instance, may have hiring databases that require applicants check a box that they have a BSN degree. Such fields pose unnecessary barriers to graduate-degree holders completing job applications.
Strategy 3: Refine National Data Capture Mechanisms
National data sets on second-degree pathways are few and limited. The current leading source of national, up-to-date academic data is an annual report by the AACN. The 2021-2022 report, Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing, reflects survey responses from 964 US institutions.18 This report initially mentions the percentage of accelerated baccalaureate for non-nurses and entry-level/second-degree master's programs included in the AACN's database (and their breakdown according to AACN membership vs nonmembership). However, the remainder of the report does not offer that level of program specificity when sharing enrollments and graduations data. Instead, data are given for the umbrella categories of baccalaureate, master's, and doctoral programming. For select tables, baccalaureate and doctoral categories are divided into subcategories, though no table explicitly mentions accelerated or second-degree pathways. Similarly, when the master's category is subcategorized, it is only divided according to nurse practitioner, clinical nurse specialist, and other majors.18(p87, Erratum)
Because the AACN's database includes 97.8% of the nation's accelerated baccalaureate for non-nurses programs and 96.1% of entry-level/second-degree master's programs, it is feasible that more specific data on prelicensure programs exist (or could be gathered).18 The AACN's report offers critical insights, such as data on enrollments and graduations according to race and ethnicity, number of qualified applications admitted versus enrolled, number of vacant program seats, and others.18 Offering greater specificity in future reports will enable academic nurse leaders to leverage much-needed insights into the planning and development of second-degree programs.
Strategy 4: Encourage Graduate-Entry Pathways
The following sections advocate for promoting second-degree entry at the graduate level or above. Recommendations for graduate entry or above are meant to account for doctoral pathways to an extent, as doctoral options can be viable for some (not all) of the same reasons that graduate pathways are preferred. Meaningful discussion of second-degree doctoral pathways does not fall within the scope of this article, due, in part, to doctoral program variability, though it can be a subject for future analyses.
Graduate Pathways Support Nurses' Financial Health
Enrolling in a second-degree program can mean living without full-time income for 2 years or more.2 Consider the gravity of this commitment for students who already have student loans and/or may be caring for dependents (up to 70% of second-degree students have children).6 Lost wages may be felt more acutely due to historic economic challenges: tuition costs have more than doubled since 2001 and, in June 2022, the Consumer Price Index rose 9.1% to a 40-year high.19–21 The rising gulf between salary and cost of living is becoming unlivable for many nurses with student loan debt.11,20
Second-degree students typically carry debt from 2 or more degrees. According to 2018 reporting based on 2014 data, the average principal loan amount for a first degree is $28 950 (likely much higher today); 25% of individuals take out an additional $100 000 in loans for their second degree; and 10% of second-degree students borrow more than $150 000.11 Between interest, fees, and multiple loans, some students will enter practice with a monthly salary lower than their combined monthly loan payments. This financial pressure is a source of significant stress for second-degree graduates.11 Effects of second-degree debt include career despondency, depression, regret of career choice, declining to choose nursing again if given the chance, material hardship, inability to cover their own health care costs, inability to make housing payments, negative credit, and exclusion from home and auto loans.11
In this context, graduate-entry students are able to access significant financial advantages compared with those who follow other pathways. For instance, compare the financial restrictions on second-degree graduate versus BSN students: second-degree BSN students are disproportionately impacted by debt because the financial aid system is designed to support progressive education attainment (ie, earning a BSN degree first, then a graduate degree, and then a doctoral degree). Students pursuing an accelerated bachelor's degree have restricted access to many of the opportunities afforded to both graduate and traditional BSN students.22 They may not qualify for low-interest federal loans; they may be barred from state and local financial aid lotteries, and they may have limited access to grants and scholarships.22,23 When it comes to federal support, once a student reaches their lifetime funding cap for undergraduate education—$31 000 for dependent students and $57 500 for independent students23—they are no longer eligible for government loans. If a student reaches these limits during their second-degree BSN program, they may be left with unfavorable options including: (1) having to secure a private loan with high and/or variable interest to cover remaining tuition, and (2) being compelled to delay courses or withdraw from nursing school (if unable to secure a private loan).
The first option, taking out a private loan, is the most expensive way to fund higher education, with variable interest rates up to 14.96% (according to limited data from private lenders).24 This is in stark contrast to federal loans, which offer rates as low as 5.30%.25 The second option, having to delay coursework or withdraw from nursing school, can increase risk of not graduating. When students who take out loans do not graduate, they often face a lifetime of compounding debt with no advanced degree to help negotiate higher salaries.26
Graduate-entry (or above) pathways are far more financially accessible. Graduate-entry students can access up to $138 500 in federal loans,23 along with state and local grant and scholarship opportunities. They may focus on studies without the burden of the lifetime federal loan cap. By reducing financial barriers, graduate pathways help promote recruitment, retention, and academic success for gender diverse, URM, and independent students.12,27 To support students further, schools can consider part-time graduate offerings. Doing so would afford students access to loans, while enabling them to continue employment in their first career during schooling.
Graduate-Level Entry Promotes Career Growth
Graduate-level or above practice entry is associated with positive career outcomes for second-degree nurses. First, graduate entry avoids redundancies in financial and time investments that can delay career advancement. For instance, ADN pathways are often seen as a faster option than graduate pathways, but second-degree ADN programs may still require 60- to 90+-semester hours (depending on prior credit acceptances).1,28 The time and cost required to complete a second-degree ADN are likely to at least double when employers say nurses must return to school for additional degree(s).29 If an ADN nurse does not return to school, they may be denied pay increases and promotions. Those who do work toward another degree may see promotions delayed until graduation—on top of a lower starting salary, working hours lost to schooling, and stacked tuition/loan commitments.
Second, for students who already hold a technical or undergraduate degree, graduate pathways help advance the nurses' academic credentials beyond the undergraduate level—whereas ADN and BSN pathways do not. This is particularly an issue for a diverse workforce, many of whom face systemic barriers to upward career mobility at baseline.30 Insisting that a workforce composed of gender, race, and economically diverse individuals repeat degree levels or complete redundant degrees stands to reinforce professional glass ceilings, pay gaps, inequitable debt-to-income ratios, and other disparities. Furthermore, it is rare among the health professions for students to repeat degree levels. Prospective students could instead apply to pharmacy, physical therapy, or physician assistant programs and obtain a graduate or doctorate degree, as well as higher-paid career opportunities. It is therefore more competitive for nursing to encourage second-degree pathways at the graduate level or above. Finally, graduate pathways are more aligned with other professions from an interprofessional education (IPE) standpoint. Nursing is often the only profession in IPE scenarios with students training at the technical level and peers training at the graduate or doctoral levels; this mismatch limits the extent to which students can be taught together.2
Graduate Pathways Produce Effective Nurse Leaders
Although the positive traits described earlier—such as life experience and professionalism—are associated with second-degree cohorts in general, the combination of such traits with graduate-level (or above) programming tends to produce highly effective nurse leaders. Macdiarmid et al2 describe how graduate-level second-degree students often leave first careers in search of a combination of opportunity, career stability, and an altruistic role authentic to their values. This motivation gives rise to graduates who are simultaneously attentive/caring and self-motivated/determined to succeed.2,6 Shatto et al11 refer to a “structured way of thinking” that enables second-degree graduate students to critically assess and lead during clinical crises; others have used the term “graduateness”31 to refer to this student profile.2,11,31 Preliminary studies demonstrate positive clinical leadership outcomes associated with “graduateness” in practice. Clinical nurse leaders (CNLs), a type of second-degree prepared nurse, for example, are associated with improved patient satisfaction, length of stay, number of falls and pressure ulcers, and frequency of nosocomial infections.3 The presence of a CNL on nursing units has been found to be associated with improved “measures of happiness” and less nursing staff depression and potential turnover.3
Conclusion
Second-degree students are a growing proportion of emerging nursing cohorts, and they are distinct from traditional students in important ways. Despite this, second-degree students are often grouped with other categories of student in national data sets. This limits the ability of nurse educators to comparatively evaluate second-degree pathways. Diverse program names and varying program designs compound evaluation challenges further. One of this article's most important implications for follow-up is the need to ensure that national data systems capture second-degree program data. Insights from these capture mechanisms can help nurse educators to evaluate, refine, and standardize programs.
Nurse educators can partner with organizations such as the AACN to lead this effort. The AACN ought to add fields for second-degree programs across its member survey sections and include these data in its annual enrollments and graduations report. This will enable more meaningful and useful data collection on a national scale. In addition, nursing schools will need to work with the AACN to standardize program names using AACN verbiage for competency-based programming. Implementing the 2021 Essentials can help disparate programs to uphold consistent education standards, and adopting AACN verbiage can help ease nursing label confusion.
Finally, nurse educators can prioritize nurses' financial health when advising students and building programs. In addition to encouraging second-degree pathways at the graduate level or above, this support can include offering part-time programming, transparency about costs, financial advising, and support services. Such steps would help maximize return on investment for nursing degrees and promote workforce sustainability.
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