ACCELERATED MASTER'S PROGRAMS IN NURSING FOR NON-NURSES: AN INTEGRATIVE REVIEW OF STUDENTS' AND FACULTY'S PERCEPTIONS KATHLEEN M. DOWNEY, PHD, RN, MBA*

AND

MARILYN E. ASSELIN, PHD, RN-BC†

Accelerated master's programs in nursing for non-nurses (AMPNNNs) are rapidly increasing in number. They offer accelerated entry into nursing practice for individuals with a baccalaureate degree or higher. An integrative review, based on Whittemore and Knafl (2005) was conducted to identify the characteristics of the students and the perceptions of students, graduates, and faculty who participate in these programs. A search of published literature yielded 15 sources with relevant data for this integrative review. Student characteristics indicate predominantly Caucasian females who are older, mature, and academically accomplished. There is a dearth of literature related to the perceptions of students and faculty as they experience the program. Student experienced role changes, and the demands of nursing education were notable. Faculty identified the need to develop innovative teaching strategies for adult learners. The gaps in the evidence base of AMPNNNs are highlighted, and areas for future research are recommended. (Index words: Accelerated master's program in nursing for non-nurses; Accelerated master's degree; Nursing education, Integrative review) J Prof Nurs 31:215–225, 2015. © 2015 Elsevier Inc. All rights reserved.

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URRENT HEALTH CARE systems continue to demand a supply of nurses in excess of the numbers of qualified nursing professionals available to meet this need. The U.S. Department of Labor, Bureau of Labor Statistics (2014) projects a 19% growth in the employment opportunities for registered nurses between 2012 and 2022. This demand, combined with the influential report “The Future of Nursing” (Institute of Medicine, 2010), calls from nurse leaders for education reform (Benner, Sutphen, Leonard, & Day, 2010), and an intimate understanding of the needs of the profession, has caused nurse educators to pursue innovative options for educating nurses. Accelerated programs in nursing for non-nurses with baccalaureate degrees or higher are among the nontradi-

*Dr., College of Nursing, University of Massachusetts Dartmouth. †Assistant Professor, College of Nursing, University of Massachusetts, Dartmouth. Address correspondence to Dr. Downey: P.O. Box 673, Mattapoisett, MA 02739. E-mail: [email protected] 8755-7223

tional approaches that nurse educators are promoting. Accelerated programs in nursing is a broad term covering a variety of nontraditional educational options for individuals seeking a second degree. In the case of non-nurses, these programs include those that offer a baccalaureate degree (Bachelor of Science [BS] or Bachelor of Science Nursing [BSN]), a master's degree (master of science [MS] or master of science in nursing [MSN]), or a nursing doctorate (ND) in a compressed time frame to candidates who begin their nursing education already having earned a baccalaureate degree or higher. Although the outcomes of these programs are different, they all originate from the desire to offer attractive nursing education options to non-nurses, and in the literature, they are often considered together as accelerated programs in nursing. Generic second-degree master's programs provide opportunities for individuals with non-nursing baccalaureate degrees to achieve entry into nursing practice at the graduate degree level. Some programs, but not all, offer an advanced practice nursing degree. Yale University introduced the first master's program for non-nurses in 1974 (American Association of Colleges of Nursing [AACN], 2013; McDonald, 1995; Slavinsky, Diers, & Dixon, 1983). In 1990, there were 12 master's programs

Journal of Professional Nursing, Vol 31, No. 3 (May/June), 2015: pp 215–225 © 2015 Elsevier Inc. All rights reserved.

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for non-nurses. There are now 66 master's programs offering entry to nursing practice in the United States (AACN, 2014). This relative proliferation of programs occurred in response to demand for both more advanced practice nurses (APNs) and educational opportunities in nursing for baccalaureate prepared non-nurses. There are a significant number of proposals from service and education suggesting that the accelerated degree option is a reasonable response to be considered and advanced in reaction to demands for more and better-prepared nurses (Renaud & Miller, 2003). Although there are multiple entry options to the nursing profession available to non-nurses seeking a second degree in nursing, there are two primary accelerated avenues, which are often grouped together and described singularly as accelerated options, the accelerated BSN and the accelerated master's degree. This blurring of the lines between accelerated BSN and accelerated master's programs is reflected in a review of the literature on accelerated programs (Neill, 2011a; Rico, Beal, & Davies, 2010; Wassem & Sheil, 1994). The body of literature specific to the accelerated BSN is more extensive than the literature specific to the accelerated master's. The focus of this review is the accelerated master's programs. As accelerated programs have developed, the naming of these programs has not been uniform. There are varieties of labels assigned to accelerated programs at the master's degree level, some that appear similar, yet, with some nuanced differences between them. “Graduate entry” refers to accelerated programs, primarily in Australia, and does not specifically refer to master's-level entry (Neill, 2011a, 2011b). However, at the master's degree level, programs include MS, MSN, and master in nursing (MN). Labels assigned to these programs include clinical nurse leader, generic MSN (G-MSN), entry level MSN, accelerated MSN, second-degree MN, direct entry MSN, accelerated prespecialty MSN, master's entry program in nursing (MEPN), graduate entry prespecialty in nursing (GEPN), alternate entry master of science in nursing (AEMSN) program, master's program in nursing for non-nurses (MPNNN) and graduate program in nursing for non-nurses (GPNNN; Cook, Becker, & Weitzel, 1996; Moore, Kelly, Schmidt, Miller, & Reynolds, 2011; Steib, 2005; Ziehm, Uibel, Fontaine, & Scherzer, 2011). For this review, accelerated master's programs in nursing for non-nurses (AMPNNN) will be used as the umbrella term referencing all accelerated master's-level entry programs in nursing for non-nurses. Candidates for accelerated programs are recognized as mature, diverse learners who have experienced educational success in a prior baccalaureate program and who possess strong decision-making skills influenced by prior life experiences (Cangelosi & Whitt, 2005; Wink, 2005). The literature reflects educational models, curriculum designs, curriculum modifications, course facilitators, teaching strategies, approaches, and challenges for faculty in accelerated programs (Neill, 2011a; Raines, 2007; Robert, Pomarico, & Nolan, 2011; Rodgers & Healy, 2002; Schreier, Peery, & McLean, 2009; Shiber, 2003;

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Suplee & Glasgow, 2008; Utley-Smith, Phillips, & Turner, 2007). Despite this developing body of evidence, a gap in the data exists in understanding participants' perceptions of accelerated nursing programs (Cangelosi & Whitt, 2005; Raines, 2007). AMPNNNs are developing and generating programmatic evaluations and are the interests of researchers conducting qualitative, quantitative, and mixed-methods research. The research supporting the development of these programs is limited but evolving. The National League for Nursing (NLN) identified the evaluation of methods to graduate diverse students from undergraduate and graduate programs as a research priority and the use of systematic reviews as a research design to advance nursing education science (2012). AMPNNNs offer a unique approach to nursing education, recognizing a common factor, that the students have achieved a non-nursing baccalaureate degree prior to matriculation in the nursing program. This approach implies that there are unique assets, challenges, or both in the background of those with a non-nursing baccalaureate degree that demand or warrant a nontraditional approach to their education as nurses. Understanding this educational approach from the perspective of those who experience it contributes to a broader understanding of this option. The purpose of this integrative review is to summarize and synthesize literature contributing to an understanding of the characteristics of students and the perceptions of students and faculty in AMPNNN.

Methods An integrative review is appropriate to examine and assimilate published theory, research, and studies to identify existing knowledge as it relates to the perceptions of those actively involved in AMPNNNs. This approach affords the opportunity to consider both qualitative and quantitative research and include divergent methodologies. Gaps in knowledge are evident when considering all relevant publications as a whole (Whittemore & Knafl, 2005). For this integrative review, the framework of Whittemore and Knafl (2005) was used. This approach involved five steps: problem identification, literature search, data evaluation, data analysis, and presentation.

Problem Identification For clarity with this integrative review, publications relevant to all forms of AMPNNNs, regardless of label, were considered. This included entry level MN, MS, MSN, MEPN, GEPN, G-MSN, accelerated MSN, MPNNN, and GPNNN. This review examined the AMPNNN experience from the perspectives of the students and the faculty and explored what is known about the diversity of the population participating in these programs. The perceptions of the educational experience for the students and the faculty were also examined. The development of the questions was guided by nursing education research priorities and previously conducted research (Cangelosi & Whitt, 2005; National League for Nursing [NLN], 2012) and informed by the reflections of a second-degree nurse (Hobbs, 2007).

ACCELERATED MASTER’S PROGRAMS IN NURSING

The guiding questions for this review were the following: What are the characteristics of learners enrolled in an AMPNNN? What are the students' and graduates' perceptions of the AMPNNN educational experience? What do faculty perceive as assets and challenges to teaching in an AMPNNN?

Literature Search A search of the literature was conducted utilizing computer programs, ancestry searching, and hand searching of journals. The search was completed between September and November 2012 using Medline and the Cumulative Index of Nursing and Allied Health Literature (CINAHL). Terms entered and results generated (using Boolean search method when appropriate) were G-MSN (9), accelerated MSN (49), MSN entry (43), direct entry and MSN (5), second-degree MSN (283), graduate programs in nursing for non-nurses (1), nontraditional MSN (5), MSN and faculty perceptions (1), master's programs in nursing for non-nurses (1), accelerated master's and nursing (71), generic master's and nursing (48), direct entry master's and nursing (12), second-degree master's and nursing (62), nontraditional master's and nursing (2), faculty perceptions and master's entry, and nursing (5). After reviewing abstracts, this search yielded 12 unique publications with relevance to this integrative review. Ancestry searching was conducted, reviewing reference lists from publications identified in the previously described CINAHL search. This yielded two additional articles. Hand searching was conducted by the Journal of Nursing Education, Nursing Education Perspectives, and the Journal of Professional Nursing. Hand searching revealed one additional article. From all sources, there were 15 articles identified for review. There was redundancy between the results of the search strategies employed, searching was terminated, and saturation was determined to have occurred when searching failed to produce new articles. Initial inclusion criteria included publications that were written in English, were peer reviewed, and reported on primary research or theories of students or faculty in AMPNNNs from 1974 to present. Because of the dearth of literature that met these criteria, the criteria were expanded to include program development reports or program evaluation studies of AMPNNN programs. This allowed for the inclusion of graduates' perspectives and resulted in a restatement of the question from “What are the students’ perspectives of the AMPNNN educational experience?” to “What are the students’ and graduates’ perceptions of the AMPNNN educational experience?” The time frame was selected because Yale University offered the initial AMPNNN in 1974 (American Association of Colleges of Nursing, 2013; McDonald, 1995), which made this time frame inclusive of all relevant AMPNNN research. Studies that considered accelerated programs inclusive of, but expanded beyond the definition of

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AMPNNN, were included if data and findings related to AMPNNN were segregated and identified. Inclusion criteria were amended to include peer-reviewed articles of program development after reviewing the lack of data available to answer the third guiding question of this review, “what do faculty perceive as assets and challenges to teaching in an AMPNNN?” Exclusion criteria included literature written in languages other than English, gray literature, unpublished research, nonpeer-reviewed literature, and published research findings lacking identified methodology. In addition, research related to curriculum and outcomes that did not include either demographics, students', graduates', or faculty's perceptions were excluded. Studies of accelerated programs that included AMPNNN programs but were not limited to AMPNNN programs were excluded unless the AMPNNN specific data and findings were clearly identified.

Data Evaluation Publications were evaluated for relevancy to the previously identified questions. Articles were removed that did not contribute to an understanding of the three identified questions. The common reasons for removal included the anecdotal inclusion of a search term that resulted in an article being included in the search but not having relevance to the search, grouping of AMPNNN with other accelerated programs without the ability to differentiate AMPNNN data and impact, and nonpeer-reviewed literature that advocated for AMPNNNs as entry options for second-degree candidates. The broad range of work contributing to this integrative review included case studies of program development; program evaluations using quantitative, qualitative, and mixed design studies; and surveys across programs. Programmatic data were from planning and intermediate program evaluations and postprogram evaluations with alumni. Reported methods included case study (Schreier et al., 2009), critical incident (Ezer, MacDonald, & Gros, 1991), phenomenological inquiry (McNiesh, 2011), grounded theory (Cook et al., 1996), ex post facto design (Munro & Krauss, 1985), evaluator-developed questionnaires, surveys and interviews (Boughton, Halliday, & Brown, 2010; Johnson & Johnson, 2008; McKenna & Vanderheide, 2012; Miller & Holm, 2011; Moore et al., 2011; Smith, 1989; White, Wax, & Berrey, 2000; Ziehm et al., 2011), and record review (Ventura, 1979). Although methodologically diverse, the contributions of each article to answering this review's questions were significant. The sources were not considered comparatively but rather synergistically, providing evidence to enhance understanding of the issues. Although the diversity of literature contributed to the completeness of the description of the existing knowledge, it also confounded the analytical approach because there was not a singular evaluative approach that could value and critically appraise the contributions of all sources of data of this review. For purposes of this integrative review, the approach described by Hawker,

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Payne, Kerr, Hardey, and Powell (2002) guided the scoring for methodological rigor of the contributing data sources. Publications were reviewed and assigned ratings on a 1–4 scale (1 = poor, 2 = fair, 3 = good, 4 = very good) for the methodological rigor of the article, considering nine items: title and abstract, introduction and aims, methods and data, sampling, data analysis, ethics and bias, findings/results, transferability/reliability, implications, and usefulness. Potential total scores ranged from 9 to 36. Publications contributing to this review had actual total scores ranging from 17 to 36. These scores were converted to a high or low weighting (scores between 17 and 26: low; and 27 and 36: high) that then was assigned to each publication contributing data to this review. This rating allowed for a weighting of the contribution of the data to this review, with data rated as high having a stronger impact and data rated as low having less impact on the description of findings (Whittemore & Knafl, 2005).

Data Analysis The 15 articles contributing to this integrative review included one that is a survey of 35 AMPNNNs (Miller & Holm, 2011). The remaining articles were specific to singular programs, either as program evaluation studies or as program development reports. There were 13 programspecific reports with 590 participants. The sample size on the individual reports ranged from 13 to 100. Data sources were entered into a grid alphabetically, noting source, type of data, study, sample, rigor, country of origin, aim, relevant findings, and contributions of data to the three research questions (Table 1). This allowed for the logical sorting of data and integration of relevant data from disparate publications to contribute evidence to the guiding questions. Characteristics of Learners Enrolled in an AMPNNN. To understand the range of student diversity in the AMPNNN programs, it is appropriate to examine both the characteristics and the demographics of the population. These programs attract adult learners, who, by requirement, are accomplished academically (Miller & Holm, 2011). These adult learners are slightly older, mature, highly motivated, goal-directed individuals (McNiesh, 2011; Vinal & Whitman, 1994). They have high academic expectations, excel in classes, have good study habits, prefer experiential and problem-oriented approach to learning experiences, and desire hands-on experiences (Vinal & Whitman, 1994). In clinical settings, these students demonstrate that their need for self-confidence and self-competency as a nurse overrides their common characteristic of selfdirectedness (McNiesh, 2011; Vinal & Whitman, 1994). Students participating in AMPNNN programs range in age from 21 years of to 60 years. The mean ages of participants in several programs, as reported through programmatic evaluations, ranges from 24.8 years to 31 years of age (Ezer et al., 1991; Johnson & Johnson, 2008; McKenna & Vanderheide, 2012; Miller & Holm, 2011; Smith, 1989). By design, the AMPNNNs target older, mature learners, and the evidence

reflects an older population. Although the range of ages is marked, there is a concentration of participants younger than 30 years of age (Ezer et al., 1991). Among students enrolled in AMPNNNs, 35–47% report marital status as single; 38.75–65% report as married. The percentage of students who are also parents ranged from 17 to 70% (Boughton et al., 2010; Ezer et al., 1991; Johnson & Johnson, 2008; Smith, 1989). Gender is addressed in multiple reports, with the number of males represented at higher numbers in the AMPNNNs than in the traditional educational option. In an Australian-based program, males represented 29.1% of enrollees (Boughton et al., 2010). In a U.S.-based study of 35 AMPNNNs, the mean number of males per program was 13 (Miller & Holm, 2011). In programmatic evaluations, the number of males enrolled in programs ranges from 3 to 5 or three times the average number of male enrollees in a traditional program (Johnson & Johnson, 2008; McKenna & Vanderheide, 2012; Moore et al., 2011; Smith, 1989; Vinal & Whitman, 1994; White et al., 2000). Data from a survey of 35 U.S.-based AMPNNNs indicate a predominance of Caucasian enrollees (Miller & Holm, 2011). Other sources report 93% Caucasian and 7–15% African American enrollment, whereas silent on other ethnicities of participants (McKenna & Vanderheide, 2012; Miller & Holm, 2011; Moore et al., 2011). Data from an Australian AMPNNN reflect language diversity, with 45.6% of enrollees from non-English-speaking countries (Johnson & Johnson, 2008). The nontraditional models of nursing education have encouraged diversity by targeting individuals with strong educational credentials. By definition, students participating in AMPNNNs have previously achieved a baccalaureate degree or higher in a non-nursing concentration. On admission to AMPNNNs, the percentage of students who have attained a non-nursing master's degree ranges from 12% to 44% and as many as 5% having achieved a non-ND (Boughton et al., 2010; McKenna & Vanderheide, 2012; Smith, 1989). The concentration of studies for prior degrees reflects a wide range, including accounting, agriculture, agronomy, art, biology, business, chemistry, criminal justice, dietetics, education, engineering, fashion merchandising, health, interior design, languages, law, literature, music, natural sciences, philosophy, psychology, religion, social sciences, sports medicine, and zoology (Boughton et al., 2010; McKenna & Vanderheide, 2012; Moore et al., 2011; Smith, 1989; Ventura, 1979; Vinal & Whitman, 1994). Some students begin studies immediately after completion of the first degree, but others do not resume studies for a number of years. The range of time between achievement of previous degree and commencement of studies in AMPNNN is immediate to more than 20 years. Sixty percent of those enrolled in an AMPNNN has achieved their last degree within 5 years (Johnson & Johnson, 2008; Moore et al., 2011). The grade point average in previous educational coursework of students admitted to AMPNNN range from 2.8 to 4.0 on a 4.0 scale, with many programs setting the lower limit at 3.0 (Ezer et al., 1991; Johnson & Johnson, 2008; Miller & Holm, 2011).

Data source location

Type of data, sample size rigor

Contribution to integrative review

Boughton et al., 2010 University of Sydney Australia

Qualitative, pilot programn = 17Rigor: 31, high

Characteristics of learners

Cook et al., 1996 University of Texas, Austin United States

Qualitative, program outcomes grounded theoryn = 13Rigor: 32, high

Graduate experiences

Ezer et al., 1991 McGill University, Montreal Canada

Qualitative, program outcomesn = 48Rigor: 29, high

Characteristics of learners

Johnson & Johnson, 2008 College of Mount St. Joseph United States

Mixed-methods program outcomesn = 25Rigor: 31, high

Characteristics of learnersGraduates' perceptions

McKenna & Vanderheide, 2012 Monash University, Australia

Quantitative, program evaluationn = 79Rigor: 33, high

Characteristics of learners

Aim To facilitate improved student satisfaction by addressing the academic, communication, and relational challenges identified as having a significant impact on culturally and linguistically diverse students' academic achievement and their performance on clinical placement To study the socialization process of graduates of the University of Texas at Austin's AEMSN program To document the characteristics of incoming university graduates and track their career paths in nursing following program completion and to explore the extent to which the model of nursing being taught in McGill University's nursing program was evident in the professional practice of the graduates To validate what was being done well in the program and what needed changes and to understand how the MN program impacted the graduates after graduation. To describe and analyze the student enrollment in the first two cohorts of an accelerated, preregistration, master's-level nursing course in Melbourne, Australia

Findings The experience of culturally and linguistically diverse graduate entry MN students was enhanced with teaching support strategies.

A grounded theory, “Finding a Place and Forging an Identity,” was identified as a social psychological process experienced by AEMSN students transitioning to practice. The theoretical basis used in McGill University's generic master's program was evident in the practice of the graduates.

ACCELERATED MASTER’S PROGRAMS IN NURSING

Table 1. Summary of Data Sources

Examination of the outcomes of one MN program. Graduates validated that obtaining an advanced degree and completing the program in 15 consecutive months were the biggest draws of the MN program. Revealed higher male participation than traditional program. Students originated from a wide range of cultural and disciplinary backgrounds. Previous education ranged from bachelor to doctorate degrees. 219

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Table 1. (Continued) Data source location

Type of data, sample size rigor

Contribution to integrative review

Aim

Qualitative phenomenologyn = 19Rigor: 36, high

Characteristic of learnersStudents' Perceptions

To articulate the lived experience of students in an accelerated master's of nursing entry program learning the practice of nursing within a clinical setting

Miller & Holm, 2011 United States

Quantitative surveyn = 35Rigor: 31, high

Characteristics of learners

To describe GPNNNs nationwide and to delineate real and potential regulatory issues

Moore et al., 2011 United States

Qualitativen = 14Rigor: 36; high

Characteristics of learnersStudents' perceptions

To explore second-degree prelicensure master's graduates' attraction to the nursing profession, views on nursing, and thoughts regarding their contribution to nursing

Reasons for moving to nursing career were career stability, being part of a caring profession and previous personal or family experience with the health care setting. Themes from student's perceptions of learning the practice of nursing: entering a foreign world; novice again in a new world; physical demands of nursing work; pace of learning for clinical assignments; what is at stake; and being part of an intense learning community. The characteristics of GPNNNs in the United States include prerequisites, admission criteria, program modifications, NCLEX results, characteristics of students enrolled, and those who withdraw. Regulatory issues impacting GPNNNs. Explicated themes of perspectives of nursing and the GPNNN experience. Participants felt the following: drawn to nursing because of opportunities and caring nature of nursing; prepared and excited to start a second career; previous education enhanced communication abilities and views; difficulty integrating previously held perspectives into a nursing world view; surprised by poor nurse-to-nurse relationships and the difficulty of nursing education; liked helping others and the people for whom they provided care.

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McNiesh, 2011 United States

Findings

Quantitative design ex post facton = 98Rigor: 33; high

Characteristics of learners

Schreier et al., 2009 East Carolina University US

Program developmentRigor: 16; low Quantitative program evaluationn = 79Rigor: 24; low

Characteristics of studentsPerception of faculty Characteristics of the learnerPerceptions of students

Ventura, 1979 Pace University US

Quantitativen = 100Rigor: 21; low

Characteristics of the learner

Vinal & Whitman, 1994 University of Virginia US

Program evaluationRigor: 17; low

Characteristics of the learnerPerceptions of faculty

White et al., 2000 Virginia Commonwealth University US Ziehm et al., 2011 University of California, SF US

Quantitative program outcomesn = 29Rigor: 28; low Mixed-methods; program outcomesn = 52Rigor: 33; high

Characteristics of learner

Smith, 1989 University of Tennessee US

Characteristics of learner

To determine if there is any difference in success among groups at Yale University (non-nurse college graduates, BSNs, and nurses with a non-nursing baccalaureate degree) To describe one school's curriculum for a direct-entry master's nursing program To determine the effectiveness of the non-nurse MSN entry program at the University of Tennessee Knoxville; to discover the type of practice in which graduates are engaged

To show that an undergraduate background in the liberal arts provides as good a foundation for graduate education in nursing as does a specialized background in the biological social or psychological sciences To examine the similarities and differences between nontraditional and traditional students and implications for program planning To examine how program graduates are faring as APNs To assess employment performance outcomes of students who completed the prelicensure segment of an accelerated graduate entry program, master's entry program in nursing at University of California, San Francisco (UCSF)

There is no difference between MSN entry, BSN to MSN, and RN with BS to MSN on clinical and theoretical course grades at the end of the first and second year of the MSN program. Description of program development for GPNNN Graduates perceive that they were well prepared for their practice roles and they received high levels of acceptance from supervisors, colleagues, and physicians. Over 50% assumed beginning staff positions and over 50% began career working in hospitals after graduation. There is no relationship between concentration of prior baccalaureate degree and success in nursing courses in GPNNN.

ACCELERATED MASTER’S PROGRAMS IN NURSING

Munro & Krauss, 1985 Yale University US

Description of one GPNNN planning and implementation. Academic and clinical achievements were noted. Sociodemographic profile of advanced practice graduates of GPNNN. Managers of employed GPNNN students rated clinical skills favorably. Students with less than 1 year experience rated themselves as performing not as well as the managers rated them. Self-ratings of those with more than 1 year experience were congruent with manager's ratings.

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Academically within nursing, Munro and Krauss (1985) conducted an ex post facto study examining the theory and clinical course grades at the end of the first and second year of MSN coursework. They compared the AMPNNN with traditional MSN and found no statistical difference between the groups with regard to the grades. A reasonable early intermediate assessment of a student's aptitude in nursing is National Council Licensure Examination (NCLEX) success. NCLEX first-time pass rates range from 73 to 100%, in a survey of 35 programs with a mean of 96.2% (Miller & Holm, 2011). Programmatic evaluations report NCLEX pass rates at 87.5% to 100% (Johnson & Johnson, 2008; Ziehm et al., 2011). NCLEX success is critical within these programs as all AMPNNNs require licensure after successful completion of prelicensure coursework for continuation in the programs. One study reported the graduation rate of one program at 80% (Johnson & Johnson, 2008). The published characteristics of students clearly indicate a mature, academically accomplished population. Diversity within this population is reflected in the number of male participants, the age of the students, and the wide range of majors of previously earned degrees. Studies have documented the academic aptitude and NCLEX success of those participating in AMPNNNs. Students' and Graduates' Perceptions of the Educational Experience. McNiesh (2011) conducted a phenomenological study examining the lived experience of students in one AMPNNN program. Data were collected from 19 participants via interview and focus groups, and the analysis contributed to the identification of themes of the lived experience of the AMPNNN student. Themes that emerged were (a) entering a foreign world, (b) novice again in a new world, (c) physical demands of nursing work, (d) pace of learning for clinical assignments, (e) what is at stake, and (f) being part of an intense learning community (McNiesh, 2011). This study reflects both the unique attributes of the students and the unique challenges and transitions that they face in an AMPNNN, largely driven by their prior achievements and expectations of self and the expectations of the program. A qualitative study conducted in a midwestern university with 14 graduates of an AMPNNN described aspects of the process that students experienced, from when and what attracted them to nursing, the experience of getting a second degree, and how the first degree adds to nursing practice and to reactions to nursing (Moore et al., 2011). Themes that emerged were (a) that the majority of the students felt called to nursing recently; (b) that connections and caring and limitless opportunities were factors in attracting the students to nursing; (c) that the students felt that they were never really established in their prior career and, in the AMPNNN they had to overcome challenges, be prepared and ready, and were looking forward with excitement to their new career; (d) that their first degree broadened their perspective in nursing and enhanced their communication skills in nursing; (e) that they were most surprised by the difficulty of nursing education, the lack of

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passion in some experienced nurses, and the poor nurse– nurse relationships; and (f) that the people and the patients with whom they interact and the concept of helping people are what they most like about nursing (Moore et al., 2011). In a report of the experience of the University of Virginia with an AMPNNN, it was noted that students in the clinical situation indicated that their need for self-confidence and self-competency overrode the ingrained tendency toward self-directedness (Vinal & Whitman, 1994). In a mixedmethods study of 29 graduates from Virginia Commonwealth University, the most important and clinically useful experiences that prepared respondents for their role were clinical experiences with nurse practitioners (NPs), physicians, and preceptors as well as the quality of the practicum (White et al., 2000). Students perceived that their experience preparing them for roles as APNs could have been improved with more coursework in pharmacology and more information on tests, suturing, and completion of a formal residency or internship program (White et al., 2000). MN graduates of the College of Mount St. Joseph participated in a program evaluation and reported a difference between themselves and other new graduates. Themes that were identified in their responses included that they were more professional; that they were developing leadership/management skills; that they had a broader vision of the profession of nursing beyond patient care; that they had an understanding of evidence-based practice; and that they had a better understanding of research (Johnson & Johnson, 2008). Smith (1989) also noted that AMPNNNs rated themselves higher on research than non-AMPNNN peers. Although graduates of some programs actively sought out staff nurse positions to gain experience (Johnson & Johnson, 2008; Smith, 1989), other graduates described feeling well-prepared for practice roles (Smith, 1989; White et al., 2000). One study reporting on graduates of the AMPNNN at the University of Tennessee, Knoxville, noted that over 50% began their careers as staff nurses, whereas 43% began their careers as NPs (Smith, 1989). In another study, 77% felt adequately prepared for NP role, whereas 23% felt that they were not adequately prepared (White et al., 2000). The majority intended to practice as NPs; however, they rated themselves less than traditional students on issues related to advanced clinical practice (Smith, 1989). Eighty-three percent of graduates believe that the Registered Nurse (RN) experience is not necessary to function as an NP, but 25% believe that it would be helpful. Seventeen percent believe that the RN experience is necessary to function in the role as an NP (White et al., 2000). Challenges for AMPNNN graduates include the resistance from nurses who believe that they have not paid their dues; the lack of exposure to operational procedures of health care organizations; and finding a career with little or no nursing experience (White et al., 2000). A difficult realization is that they are accepted less by nurses than they are by physicians. Graduates note that physicians view them as having a scope of practice similar to a physician's assistant (White et al., 2000). An additional perspective conflict that adult learners in

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AMPNNNs have expressed is that they desire to be treated as a peer by faculty (Vinal & Whitman, 1994). Postgraduation employment offers an opportunity to evaluate outcomes from a different perspective. Seventy to 88% of first nursing positions for graduates of AMPNNN are in hospitals, with the majority in direct patient care (Cook et al., 1996; Ezer et al., 1991; Johnson & Johnson, 2008). Graduates of one program practice in a variety of clinical areas including family health (41%), children's health (31%), adult health (14%), and women's health (10%; White et al., 2000), whereas graduates of another program report working primarily in medical–surgical settings, with smaller numbers employed in obstetrics, intensive care units, psychiatric services, and hospice (Johnson & Johnson, 2008). In one program evaluation, recent AMPNNN graduates consistently rated their clinical practice less than the ratings assigned by their nurse managers (Ziehm et al., 2011). Graduates have concerns about the financial burdens associated with the costs of the AMPNNN program (Smith, 1989). Attrition can be viewed as a clear statement of a student's perspective of participation in a program. One program had experienced high attrition of 50%, which recovered to 8% the following year with programmatic intervention (Vinal & Whitman, 1994). There is a rich diversity of experiences of students and graduates in AMPNNNs. This may be because of the unique population but also may be a reflection of the variety of AMPNNN programs because much of the data are culled from program specific studies. Perceptions of Assets and Challenges to Teaching in an AMPNNN. There was a dearth of literature on faculty perceptions of teaching in an AMPNNN. As a result, faculty perceptions of assets and challenges were gleaned from the literature in an indirect way. Literature addressing AMPNNN planning and program evaluation contained decisions and evaluations that reflected perceptions of the faculty. Although these perceptions were identified, they were not supported by any research method. The literature, then, provided insights, which, although limited, were used to address this question. The new curriculum is seen as an opportunity for innovation where adult learning principles of individuality and self-directness are used to guide educational experiences (Schreier et al., 2009; Vinal & Whitman, 1994). A need to change from teacher centered to a concept driven, student-centered model was identified (Schreier et al., 2009; Vinal & Whitman, 1994). Faculty with specific interest in adult learning and working with nontraditional students are actively involved with these programs (Schreier et al., 2009; Vinal & Whitman, 1994). Faculty enthusiasm and interest are stimulated and high. Challenges and rewards are inherent in teaching in this program and are attractive to faculty. (Schreier et al., 2009; Vinal & Whitman, 1994). Scheduling is an issue that faculty confront, and it impacts the coordination of classroom content, clinical experiences, and laboratory experiences (Schreier et al., 2009). In addition, facilitating the mastery of clinical experiences for AMPNNN students is a

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challenge for faculty (Schreier et al., 2009; Vinal & Whitman, 1994). Philosophically, faculty is divided over awarding APN recognition to graduates without demonstration of experience as nurse (Vinal & Whitman, 1994). The relationship between faculty and students has potential for conflict. Students have given faculty poor evaluations, yet this appears to be consistent with faculty not responding to this group as adult learners (Vinal & Whitman, 1994). Students expect to be treated as colleagues, but faculty generally prefer for that to occur after completion of programs (Vinal & Whitman, 1994). Although the data are limited, faculty recognize that adult learning principles have particular relevance in AMPNNNs. A student-centered approach by the faculty may be an important contributor to student success within AMPNNNs. There is a potential for conflict between student and faculty expectations of the educational approach of AMPNNNs.

Discussion In 2007, a cohort of representatives and practice partners from 28 accelerated nursing programs met, recognized the need for research-specific to accelerated nursing programs for non-nurses, and identified research priorities specific to this group (Beal, 2007; Ziehm et al., 2011). This review examined literature specific to AMPNNNs that informed the three guiding questions. The evidence specific to the characteristics of students in AMPNNNs is developing with publication of program-specific studies. Evidence of student's and faculty's perceptions is limited, and this impacts the depth of the responses to the guiding questions. The dearth of literature specific to AMPNNNs constrained the responses to the guiding questions, yet supports the call for research within this type of accelerated nursing program for non-nurses. The body of evidence identifying the characteristics of students who participate in AMPNNNs is developing. The demographics and characteristics indicate that all of the participants are educated at the baccalaureate level or higher on admission. They are mature older students who are predominantly Caucasian and female. The evidence indicates that male participation rates in AMPNNNs exceed the rates in traditional programs. There is significant diversity in the area of academic concentration of prior educational accomplishments, and this diversity does not seem to impact success in the AMPNNN. These learner characteristics are challenges to nursing faculty because traditional nursing education models have targeted a younger, less accomplished student. Knowledge of the characteristics of the students attracted to and participating in AMPNNNs is essential to educators and administrators for the development and flourishing of AMPNNN. These older, mature, and academically accomplished students require innovative teaching strategies, consistent with adult learning theory to guide their development as nurses. Valuing these characteristics as strengths, AMPNNNs should be learner focused, with students assuming an active role that encourages selfassessment and allows them to draw on prior experiences

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to enhance and support their development as master'sprepared nurses. Cangelosi and Whitt (2005) reviewed existing researchbased literature to identify the state of the evidence of nursing education as it relates to all accelerated programs. They identified a gap in the evidence as it relates to how students and faculty experience accelerated programs. This review considered peer-reviewed literature between 1979 and 2012 in an effort to assess the evidence of the perceptions of students and faculty within one type of accelerated program, the AMPNNN. With the exception of one phenomenological study (McNiesh, 2011), there have not been any published works directed at the student's perceptions of the accelerated AMPNNN. There are no published theories or research that contributes to the evidence leading to an understanding of faculty's perceptions of an AMPNNN. Expanding the inclusion criteria and expanding the question that framed this integrative review allowed for consideration of more evidence but resulted in evidence that arguably informs different questions than the ones originally considered. Although graduates were once students and they were the individuals who experienced AMPNNNs, their perceptions are no longer from the student perspective but rather from the graduate's perspective. This perspective is important; however, it does not address the evidence gap that remains in understanding the student's perspective of the AMPNNN educational experience. Evidence of graduates' perceptions of the AMPNNN educational experience is developing as a result of publication of program evaluations. This evidence is limited in that it is specific to individual AMPNNNs and not reflective of the broader population of graduates of AMPNNNs. There is a gap in the evidence that informs our knowledge of how graduates of AMPNNNs in general perceive their educational experiences in nursing. In addition, a gap remains in the evidence examining successful transitions from student to nurse or APN. These identified gaps provide an opportunity for future research. There is limited literature related to faculty perceptions of AMPNNN educational experience. This was also identified by Cangelosi and Whitt (2005). There is a need for evidence identifying and describing faculty's perceptions of their experience teaching in the AMPNNNs and evidence demonstrating best practices in the classroom and in the clinical setting. These gaps in the evidence are critical in this era of rapidly developing accelerated AMPNNN programs. The evidence related to NCLEX and the AMPNNNs is positive and affirming. However, it remains unknown how the principal participants, the students and faculty, are experiencing the program. Best teaching practices have not been elucidated or supported by evidence in the literature. This lack of evidence has the potential to undermine the credibility of these innovative programs. The gaps identified in this review provide a window into the potential for future research.

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