REVIEW

Exploring the transition experiences of students entering into preregistration nursing degree programs with previous professional nursing qualifications: an integrative review Marion Tower, Marie Cooke, Bernadette Watson, Nick Buys and Keithia Wilson

Aims and objectives. This paper aims to investigate the transition experiences of students with previous nursing qualifications (nondegree qualifications) entering a nursing degree program. Background. Nurses with professional nursing qualifications (nondegree) are an important pool of professionals to draw on to help address nursing shortages through providing alternative pathways to becoming registered nurses. However, research suggests this cohort need higher levels of support and intervention to be successful. Design. An integrative review was conducted, guided by Whittemore and Knafl’s framework. A comprehensive search was conducted and 14 studies were included in the review. Methods. A five-stage approach was used to conduct the review: problem identification, literature search, data evaluation, data analysis and presentation of results. Constant comparative analysis was used to identify commonalities, differences and themes in the relevant literature. Results. Themes emerged that suggested students struggled with academic and institutional challenges, becoming learners, managing conflicting demands of outside life, developing a student identity and experienced threat to their sense of professional identity. Additionally, the cohort did not view themselves as ‘the same’ as traditional students. Holland’s framework provides a useful framework from which to conceptualise these students’ experiences. Conclusion. There are challenges for this cohort of students as they transition into degree level study. Supportive activities that extend and further develop students’ personality orientations may be a useful starting point in addressing some of the challenges and providing a more positive transition to university. Relevance to clinical practice. The demand for health care is growing and there remains a shortfall of registered nurses. Nurses with professional qualifications

Authors: Marion Tower, PhD, RN, Director, Undergraduate Studies, School of Nursing & Midwifery, Mater Clinical School, University of Queensland, South Brisbane, Qld; Marie Cooke, PhD, RN, Professor of Nursing, School of Nursing & Midwifery, Griffith University, Nathan, Qld; Bernadette Watson, RN, BN, Lecturer, School of Nursing & Midwifery, Griffith University, Nathan, Qld; Nick Buys, PhD, Dean, Learning & Teaching, Griffith Health Executive, Southport, Qld; Keithia Wilson, PhD, Portfolio Leader,

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What does this paper contribute to the wider global clinical community?

• Information about the experi-

•

ences of pre-registration nursing students with previous professional nursing qualifications as they transition into nursing degree programs. Provides a framework from which to view these experiences to support this cohort to be successful at nursing degree level qualification.

Student Success & Retention, Centre for Learning Futures, Griffith University, South Brisbane, Qld, Australia Correspondence: Marion Tower, Director, Undergraduate Studies, School of Nursing & Midwifery, University of Queensland, Mater Clinical School, Raymond Tce, South Brisbane, Qld 4101, Australia. Telephone: +61 7 3163 7870. E-mail: [email protected]

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1174–1188, doi: 10.1111/jocn.12756

Review

Transition experiences of nursing students

(nondegree) are an important pool of professionals from which to increase registered nurse numbers and address workforce sustainability issues.

Key words: alternative pathways, diploma qualified nurses, enrolled nurses, integrative review, nursing shortage, transition experience Accepted for publication: 26 November 2014

Introduction The demand for health care is growing due to an ageing population and increased burden associated with chronic disease management. This has resulted in significant challenges for the nursing workforce to ensure sustainable delivery of health care (Jeffreys 2007, Urwin et al. 2010, Cameron et al. 2011). Health Workforce Australia (HWA), (2012) projects that an increase of 16% in registered nurse graduates will be required in 2016 to meet the demands for adequate health care delivery in Australia. Similar shortfalls in registered nurses will occur in other countries, including 30% in Canada by 2016 (Little 2007), and 29 and 30% in the United States of America (USA) and United Kingdom (UK) by 2020 (Unruh & Fottler 2005, Buchan & Seccombe 2010). Recruiting and retaining students in University-level nursing programs must be addressed to meet these projected shortfalls, given the high attrition rates in such programs (Cameron et al. 2011). In 2008, attrition rates in Australian nursing programs were estimated to be between 9
7–41
8% (Turner et al. 2006), with reported figures in the UK of between 27–40%, Canada 28% and the US up to 50% (Canadian Nurses’ Association 2009, Buchan & Seccombe 2010, Fraher et al. 2010. Strategies aimed at increasing engagement and improving support of students have been implemented to address attrition and retention issues, particularly in the first year of study. These include developing academic capital, (such as literacy skills workshops) and social capital strategies (such as orientation and mentorship programs) (Kift et al. 2010, McIntyre et al. 2012). Much of this work has been based on students in traditional enrolment patterns, who commence study by enrolling into and studying primarily first year courses. To address the shortfall of registered nurses, it is imperative to consider effective alternative entry pathways to achieve registered nurse status (Greenwood 2000, Seibold et al. 2007, Porter-Wenzlaff & Froman 2008). Nurses with professional qualifications (nondegree1) are viewed as an

important pool of professionals to increase graduate numbers (IOM, 2011). This group of nurses have already achieved a certain level of competency in practice and are considered more ‘work ready’ (Seibold et al. 2007, Cubit & Leeson 2009). As such, affording accessible pathways for these students to transition into Bachelor level nursing degrees to become registered nurses is an important recruitment strategy (Kevern et al. 1999, Rapson 2000, Williams et al. 2005, Seibold et al. 2007, Goodwin-Esola & Gallagher-Ford 2009, IOM 2011, Raines & Taglaireni 2011). However, research suggests that students who transition with previous professional qualifications require high levels of support and intervention to succeed (Kevern et al. 1999, Williams et al. 2005, Boelen & Kenny 2009, Goodwin-Esola & Gallagher-Ford 2009, Cook et al. 2010). Challenges associated with supporting these students are related to their relative poor levels of academic capital. Local level quality assurance data from one University2 suggest that when compared to traditional entry students, alternative pathway students experienced a decreased sense of capability and connectivity to the School and, perceived themselves to be less resourceful. Additionally, these students demonstrated a further decline in their sense of capability at mid semester point, corresponding to the end of the ‘honeymoon period’ (Hill & MacGregor 1998a,b). A further challenge is that the cohort consists entirely of mature age students who most often have work and carer responsibilities.3 Other risk factors for their attrition include mode of enrolment (many enrol full-time), being first in family to attend university, and having a low socio-economic background (McKenzie & Schweitzer 2001, Young 2004, Willcoxson et al. 2011); and having English as a second language (Porter-Wenzlaff & Froman 2008). The majority of students who enter into nursing degrees with previous professional qualifications complete a combi2

At the authors’ university 26% of commencing traditional entry year 1

BN students work more than 17 hours/week compared to 56% commencing alternative pathway students; 31% commencing traditional

1

Non degree qualifications include Diploma (Australia, New Zealand,

year 1 students have carer responsibilities compared to 56% commenc-

US, Canada), Associate Degree (US, Canada) and hospital trained

ing alternative pathway students.

enrolled nurses (UK).

3

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1174–1188

Data retrieved from central university administration.

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nation of subjects from across the degree in 2 years of fulltime study. Whilst they are commencing into their first year of study at university they are, however, often not perceived by academics or peers to be first year students, and there is scant nursing literature to guide strategies for engaging with and supporting this cohort of students. Evidence from the US and UK emphasises that students who commence into programs with substantial credit are anxious and often struggle to bridge the gap between prior learning and what is expected at university (Barron & D’Annunzio-Green 2009). Indeed, Cree et al. (2009) describe how students feel a sense of dislocation and loss as they transition to degree level study. This is exacerbated by the experience of being a new student trying to integrate into a cohort of students who already learn together, and acclimatising to a new academic culture (Fotheringham & Alder 2012). Other research has identified the importance of help with getting started (e.g. induction programs); having an enabling study environment (e.g. accessible tutors), and support to become independent learners, through feedback on work, open communication channels with tutors and support to develop ICT skills (Dumbleton et al. 2008). In addition to this assistance, Gordon et al. (2010) argued the need for high quality learning resources and employer, colleague and family support as important for success in the transition to university study. However, despite the importance of such strategies there are few resources that inform how best to engage with, support and retain this cohort (Kevern et al. 1999, Hylton 2005, Rapley et al. 2008, Hutchinson et al. 2011, Ralph et al. 2013) and there is minimal research on the experiences of alternate pathway students in nursing degree programs.

Aims and method The purpose of this paper is to answer the question ‘What are the transition experiences of students with previous

nursing qualifications (nondegree qualifications) entering into a nursing degree program’. Gaining a comprehensive understanding of the topic, required a methodology that afforded the inclusion of diverse methodologies to synthesise findings (Cameron et al. 2011). An integrative review framework was adopted, informed by the work of Whittemore and Knafl (2005). The framework allows for the inclusion of quantitative, qualitative and theoretical evidence and has the potential to identify complex concepts (Whittemore & Knafl 2005). The approach adopted five stages: problem identification, literature search, data evaluation, data analysis and results. The review process is outlined in Table 1.

Search method Having identified an aim for the review the second stage of the process is developing search strategies to locate all relevant literature (Whittemore & Knafl 2005). The keywords in the search were ‘diploma nurses’, ‘enrolled nurses’, combined with ‘transition’, ‘registered nurse’, ‘Bachelor of Nursing’, ‘university’ and ‘education’. Databases searched included CINAHL, ERIC, MEDLINE, Google and Google Scholar. Reference lists and dissertations were also used as sources of information for further references. Inclusion and exclusion criteria were applied to focus the problem. Included in the review was literature post 1993 (this year marked the completed transition to tertiary level study for nursing in Australia), peer reviewed qualitative and quantitative research and literature reviews and publications related to nurses (nondegree) with professional qualifications who commenced Bachelor’s level study. Publications from Australia, New Zealand, UK, USA and Canada were sourced. Excluded from the review were theses, commentaries, opinion pieces and editorials. Whilst it is acknowledged there are differences in levels of preparation and scopes of

Table 1 Integrative review process (Whittemore & Knafl 2005) Stage

Purpose

Application

Problem identification

Clear identification of the problem of interest

Literature search

Seek out all relevant literature sources to identify maximum number of sources Determine authenticity, methodological quality, informational value, representativeness Provide a thorough, unbiased interpretation and synthesis of evidence Capture the breadth and depth of the topic and contribute new understanding

Answer the questions: ‘What are the transition experiences of students entering into a Bachelor of Nursing who have a nonuniversity professional nursing qualification’? Searching of CINAHL, ERIC, MEDLINE, Google and Google Scholar CASP critical appraisal tool plus two reviewers

Data evaluation Data analysis Presentation

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Data reduction, data display, data comparison, conclusion drawing and verification Report prepared to demonstrate chain of evidence to support the conclusion

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1174–1188

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Transition experiences of nursing students

practice between countries with regard to nondegree nursing qualifications, the focus of the review was to establish nursing students’ experiences of transitions into higher education.

Search outcome Following the initial search generating 137 titles, the search was extended to include LPN (licensed practical nurse), which had initially not been included due to differences in licensing requirements and roles. This yielded a further 196 titles. Secondary searches included theses’ reference lists and journal articles’ reference lists. Duplicate papers were excluded. Papers were reviewed by two reviewers against the selection criteria. Where consensus was not clear a third reviewer was used until consensus was achieved. A total of 14 studies met the inclusion criteria and formed the basis of the integrative review. The evidence table was developed using guidelines developed by Kable et al. (2012) (Table 2).

Quality appraisal There is no gold standard by which to appraise quality (Conn & Rantz 2003, Whittemore 2005, Whittemore & Knafl 2005), but given the small but diverse body of literature that emerged from the search, a two stage approach (‘signal’ and ‘noise’) was used for the appraisal process (Edwards et al. 2000). ‘Signal’ prioritises judgement of qualitative and quantitative research in terms of ability to answer the study question over ‘noise’ (the inverse of methodological quality (Dixon-Woods et al. 2006, Edwards et al. 2000). Using this approach, assessment of ‘signal’ was undertaken by two reviewers (MT and BW) who analysed each paper and levels of agreement were examined. Informed by Kirkevold (1997), the assessment of ‘noise’

Table 2 Inclusion and exclusion criteria Included

Excluded

Literature post 1993(this year marked the completed transition to tertiary level study for nursing in Australia) Peer reviewed qualitative and quantitative research literature reviews and publications related to nurses (nondegree) with professional qualifications who commenced Bachelor’s level study Publications from Australia, New Zealand, UK, US and Canada

Theses, commentaries, opinion pieces and editorials Non-English publications

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1174–1188

appraised authenticity, methodological quality, informational value and representativeness. Appraisal tools developed by the Critical Appraisal Skills Programme (CASP) were used (CASP 2009). The tools contain comprehensive checklists to determine authenticity and methodological quality, validity of the results and applicability to the question under investigation (CASP 2009). While there was broad representation of research methods, the majority of studies used qualitative approaches. The authors were aware that the quality of qualitative research is often contested (Dixon-Woods et al. 2007). However, qualitative studies provide an important contribution to understanding research problems (Kuper et al. 2008). Furthermore, the ‘signal’ and ‘noise’ approach to quality appraisal provided a robust framework under which to consider quality (Edwards et al. 2000).

Data abstraction and synthesis The purpose of this stage of the integrative review was to reduce the separate data points to identify common threads (Cooper 1998). First, each article was summarised by recording setting, aim, sample, methods and findings to provide a means by which to organise the literature and systematically compare sources for coding by the reviewers without complicating the review process (Whittemore 2005, Whittemore & Knafl 2005, Cameron et al. 2011). This was then documented in a table to allow for constant comparative analytic processes to be used to identify patterns, commonalities and differences (Whittemore & Knafl 2005).

Results The literature spanned four countries – Australia, Canada, New Zealand and the UK. Appraisal of the 14 publications revealed theoretical and methodological weaknesses (see Table 3). All papers had clearly written aims and study questions, and the study methods chosen to achieve these were appropriate. However, the quality of some of the studies was ‘thin’. In some qualitative studies the link between the study aim and theoretical framework was not clear and primary data had not been returned to sources to enhance rigor of findings. Additionally, many studies collected retrospective data from students that may have impacted on their perceptions of the transition experience. However, these studies were not excluded as the purpose of this paper was to review the available literature more broadly. Although there is only a small body of literature examining the question under investigation, the findings identify the emergence of five themes that highlight the experiences

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1178 Explore and critique literature regarding experiences of ENs undertaking a BN degree and conversion into RN status

Use an FSS (five senses of success) model to explore the EN experience of transition into the second year of a BN program

Identify factors that assisted with transition to university

Ralph et al. (2013) From EN to RN: An exploration and analysis of the literature

Hutchinson et al. (2011) The transition experience of Enrolled Nurses to a Bachelor of Nursing at an Australian university.

Hylton (2005) Relearning how to learn: Enrolled nurse transition to degree at a New Zealand university.

n = 10 purposefully selected participants at end of second semester Qualitative study interpretive Focus group interview Deductive content analysis by three team members n = 10 students, six academics Qualitative, grounded theory, exploratory, descriptive design. Focus group interviews (second focus group with students for rigor) Constant comparative analysis

Difficulty adjusting to higher education Challenges with achieving academically Challenges to becoming critical thinkers Challenges with transition to the RN role

n = 10 grads, within six months of graduation Qualitative study Open-ended interviews used Grounded theory approach to data analysis Literature review

Describe the transition experiences of enrolled nurses undertaking external tertiary course.

Rapley et al. (2006) EN to RN: The transition experience pre- and post-registration

Relearning how to learn Developing adult learning skills Finding their voice Improving self-esteem/ self-efficacy Learning how to reflect

Challenges experienced at university: lack of time, unprepared for study, scepticism about value of information, lack of computer literacy, poor critical thinking skills, previous knowledge devalued Supportive experiences: bridging course, orientation, begin feeling excited and confident, support from academics, colleagues, family Sense of purpose not clear Low sense of capability Low sense of resourcefulness Low sense of connectedness Unable to develop a sense of culture

Results

Sample/design/methods

Aim

References

Table 3 Evidence table

Reports on Maori students Students enrolled in a rural area Not clear when data was collected Methodologically weak

Experiences ‘applied’ to framework – ‘making a fit’ How interview topics related to FSS not clear

Theoretically weak

Comments

M Tower et al.

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1174–1188

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1174–1188 Determine relationships between prior education, length of experience as an EN and geographical location of the student to course completion

Rapley et al. (2008) Enrolled nurse to registered nurse: Is there a link between initial educational preparation and course completion?

Students were enrolled off campus Source of data unclear Supports literature that prior education experience is important Retention rate low at 75%

Applies findings to theory about mature age students returning to study Doesn’t differentiate well between the needs of the EN students and general study population Relevance to difficulty with sciences not well explored

Low confidence around returning to study Inverse correlation between the number of years of experience and confidence levels, both pre- and post-bridging. Confidence decreased with the number of years of experience (years-pre-rs (65) = 0
316, p < 0
05 and years-post -rs (55) = 0
316, p < 0
05) Increased confidence pre- and post- regarding returning to study (z = 5
863, p < 0
001), pre- and post-AP&C regarding anatomy (z = 6
027, p < 0
001), pre- and post-AP&C regarding physiol ogy (z = 6
195, p < 0
001), and pre- and post-AP&C regarding chemistry (z = 6
578, p < 0
001) Self-directed learning issues Unfamiliar learning styles No significant difference between rural and metropolitan students’ prior educational qualification or years as EN and whether student completed (v2 {1, n = 100} = 7
50, p = 0
01 Fisher’s exact) Hospital certificate students more likely to complete (particularly rural students) (OR = 4
090; 95% CI = 1
11–15
05) Sense of isolation n = 70 students Questionnaire on first and last day of one week bridging program Descriptive statistics

Identify confidence levels regarding return to study before and after bridging program Identify confidence levels regarding knowledge around sciences before and after bridging program Consider delivery of bridging program and overall impact on confidence

Boelen and Kenny (2009) Supporting enrolled nurse conversion – the impact of a compulsory bridging program

n = 112 students (56 rural) with either hospital certifi cate or technical college qualification Exploratory correlation study Descriptive statistics

Comments

Results

Sample/design/methods

Aim

References

Table 3 (continued)

Review Transition experiences of nursing students

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1180 Investigate students’ experience of the process of transition whilst completing a conversion course Describe an articulation program from ADN to BSN

Dearnley (2006) Knowing nursing and finding the professional voice: A study of enrolled nurses converting to first level registration.

Williams et al. (2005) The collaborative track option for BSN education

Explore barriers for LPN students in university education while transitioning to RN and what strategies help overcome the barriers

Examine change/transition process for ENs converting to RN

Hill and MacGregor (1998a,b) Charting the course for change

Melrose and Gordon (2011) Overcoming barriers to role transition during an online post LPN to BSN program

Aim

References

Table 3 (continued)

n = 10 students Longitudinal study Interviewed at beginning, middle and end of program Personal construct theory and repertory grid methodology

Isolation made it difficult to apply learning to practice Limited academic capacity prior to program Lack of informal dialogue with teachers and peers prohibited opportunities to apply theory to practice Balancing employment with practicum requirements Time to complete assignments Workplace policies that prevented absence for study

Intervention well described Evaluation methods not well described Theoretically weak Attrition of almost half of students from course Orientation provided at two points prior to articulating, covering course work and introducing academics at university On line program with clinical practice component Paper reports on midpoint Articulation is a cost-effective way to transition to BSN studies from college Additional time needed for curriculum assessment and adjustment Students dissatisfied with academic advisement and university processes Schedules dictated participation Students need additional counseling Liaison role essential

Pilot study conducted to validate instrument Study aim not clearly articulated Data analysis unclear Methodologically weak

Focus on practice Sampling method unclear Followed over time Methodologically weak

At three months perceptions of confidence in practice and new knowledge emerged strongly, family and colleagues support less important

n = 100 students from one cohort Stratified convenience sample Open-ended questionnaires. Data collected at 3, 6, 14 and 24 months. Thematic analysis and categorisation of data Consensus sought around validity of categories and interpretation of meaning n = 18 students Qualitative phenomenological study Semi-structured interviews at five stages over a two year period. Inductive analysis and coding n = 40 students who participated in an articulation program from community college to university. Surveyed Survey included open-ended questions. Analytic methods not reported

Comments

Students transitioned from silence and hesitancy to a liberated and dynamic approach to practice

Results

Sample/design/methods

M Tower et al.

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1174–1188

Aim Describe LPN to BSN program

Investigate the transitional experiences of LPNs as they entered a university degree

References

Porter-Wenzlaff and Froman (2008) Responding to increasing RN demand: Diversity & retention trends through an accelerated LVN-BSN curriculum

Melrose and Gordon (2008) Online post LPN to BN students’ views of transitioning to a new nursing role.

Table 3 (continued)

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1174–1188

n = 10 students Qualitative, constructivist. Draws on andragogy, role transition and personal construct psychology Open-ended interviews Thematically analysed

Discussion paper

Sample/design/methods

No citations in front end of paper regarding LPN students’ attitudes/needs

Achieve lower pass rates than generic students Do not see themselves as baccalaureate students – describes educational strategies to deal with professional role as RN Workplace issues in supporting study Diverse demographics – helping faculty understand LPN students’ affective behaviours Post LPN to BN students appreciate recognition for previous accomplishments – felt undervalued, poor role differentiation Post LPN to BN students value affirmation of their unique access challenges – financial disadvantage, external commitments Poor academic capacity

Online program Methodology well described

Comments

Results

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Becoming a learner

Threat to professional identity

Developing student identity

Academic writing skills

Discovery learning rather than taught

Responsibility differences ‘hit home’

Limited exposure to concepts/advanced vocabulary/critical thinking

Challenge of changing thinking from task oriented

Difficulty accepting need to complete a graduate program

Reluctance to persevere with gaining IT skills

Would not participate unless directly asked

Amount of reading required

Rarely put forward point of view Dependence of teachers for answers Poor critical thinking skills

Frustration with scope of practice/expectations on placement/articulation of how roles differed Viewed current LPN role as very similar to RN role Lack of confidence in professional ability Believe they are already functioning at registered nurse level Felt previous experience was undervalued

Other students already developed networks – feeling excluded Tension with other students over their previous nursing status Do not see themselves as baccalaureate students

Lacked tertiary study skills Limited academic capacity prior to program Learning computing

Difficulty conceptualising information

of students entering into nursing degrees with a previous nursing qualification and these will now be discussed Table 3 outlines the supporting texts for these, while table 4 highlights the themes emerging from the literature.

Theme 1 – Academic/institutional challenges Eight studies highlighted academic and/or institutional challenges faced by students when they commenced at university (Hylton 2005, Williams et al. 2005, Rapley et al. 2006, 2008, Melrose & Gordon 2008, 2011, Porter-Wenzlaff & Froman 2008, Hutchinson et al. 2011). Hutchinson et al. (2011), Rapley et al. (2006) and Melrose and Gordon (2011) found that students had little understanding of academic expectations and in particular felt they did not have the academic writing skills required. In a further study by Rapley et al. (2008), no difference was found between rural and metropolitan students with regard to likelihood of completion, however, all students felt similarly unprepared for university academic expectations. Three studies also reported how Diploma prepared students struggled with information technology at university level in that they found that learning computing and navigating the Internet were significant issues for them (Williams et al. 2005, Rapley et al. 2006, Hutchinson et al. 2011). As well as struggling with academic expectations, many students were challenged by elements of the academic

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Perceived as ‘different’ to generic students Feeling overwhelmed and ill-prepared Out of their comfort zone Adjusting to student role

Conflicting demands Time and space

Time and juggling multiple roles is a major issue for study Poor work flexibility to negotiate university demands Trying to manage multiple roles Financial disadvantage of going back to study Time managementwork/life balanceattending placement Trying to get time off work for study was difficult

environment. Dissatisfaction related to what students considered poor advisement and complicated processes to navigate in the system, Williams et al. (2005). Late return of assignments (Rapley et al. 2006) and lack of support from academic staff (Hutchinson et al. 2011) were also related to student dissatisfaction. In contrast, one study reported transition experiences that built capacity, such as learning to skim read and having academic mentorship (Rapley et al. 2006). Similarly, Melrose and Gordon (2008, 2011) found that opportunities to engage in academic writing support, email forums and discussing course content with peers were helpful in the transition process. Porter-Wenzlaff and Froman (2008) recommend Faculty receive support to understand students’ behaviours. Williams et al. (2005) described the importance of academic orientation to demystify course work and promote engagement with supportive academics to facilitate a positive transition experience.

Theme 2 – Becoming a learner Several studies reported on students’ previously developed learning styles as problematic in the transition experience, (Hill & MacGregor 1998a,b, Hylton 2005, Dearnley 2006, Rapley et al. 2006, Boelen & Kenny 2009). Boelen and Kenny (2009) found that students reported issues around self-directed learning and were unfamiliar with learning © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1174–1188

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styles expected. Hill and MacGregor (1998a,b) and Hylton (2005) described how students developed as learners over the course of study, becoming reflective in their practice and embracing critical learning by the end of their degree program. Rapley et al. (2006) reported similar findings and also noted students struggled to develop from being task oriented to self-directed in their learning. Dearnley (2006) reported that many students had only one type of learning and had little confidence in their ability to learn and described the transition experience as one of relearning how to learn (Hylton 2005). Hill and MacGregor (1998a, b), Hylton (2005) and Rapley et al. (2006) identified factors that enhanced the transition experience for example, perceived faculty support, including academics’ praise and validation of previous professional experiences. They also highlighted students’ dependence on teachers for knowledge acquisition, and their reluctance to persevere with gaining information technology skills necessary for study.

Theme 3 – Conflicting demands of outside life An important theme concerned the impact of conflicting demands on University studies. The most frequently cited challenge was finding time to attend university, complete the study requirements and undertake assessment (Hill & MacGregor 1998a,b, Williams et al. 2005, Rapley et al. 2006, Melrose & Gordon 2008, Porter-Wenzlaff & Froman 2008). Melrose and Gordon (2008) highlighted students’ experience of financial disadvantage, with little prospect of financial assistance available for support. Compounding this were reports of workplace inflexibility to support time off, or managers who refused students time off to attend university study (Hill & MacGregor 1998a,b, Porter-Wenzlaff & Froman 2008, Melrose & Gordon 2011). Correspondingly, students highlighted how gaining a range of support from workplace managers, family and academic staff had a positive impact on how they transitioned into the BN program (Hill & MacGregor 1998a,b, Melrose & Gordon 2011). Other authors suggested more flexible learning opportunities would help students’ transition into university and alleviate some of the external stressors (Rapley et al. 2006, Porter-Wenzlaff & Froman 2008).

Theme 4 – Developing student identity It was apparent that this cohort of students faces challenges associated with the university student ‘identity’ (Williams et al. 2005, Dearnley 2006, Porter-Wenzlaff & Froman 2008, Rapley et al. 2008, Boelen & Kenny 2009, © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1174–1188

Transition experiences of nursing students

Hutchinson et al. 2011). Porter-Wenzlaff and Froman (2008), Dearnley (2006) and Boelen and Kenny (2009) described how this cohort did not see themselves as baccalaureate students because they lacked confidence in their ability to undertake the student role. At times, students reported hiding the fact they had nursing experience (Hutchinson et al. 2011). Other studies suggested that the difficulty experienced with integrating into the main student body was because students had already developed networks which resulted in new students feeling excluded and isolated (Porter-Wenzlaff & Froman 2008, Rapley et al. 2008, Hutchinson et al. 2011). Williams et al. (2005) described how Diploma prepared students needed more time to adjust to the student role and needed additional counselling. Students themselves requested more help to develop social networks through university although it was cautioned that students’ schedules dictated how much they would be able to participate (Williams et al. 2005). Boelen and Kenny (2009) identified that making early contact in orientation with academic staff and other students was beneficial in helping students transition into university. A possible supportive strategy identified was helping faculty understand the cohort’s needs (Porter-Wenzlaff & Froman 2008). Williams et al. (2005) suggested this could be achieved by introducing students to faculty members during orientation.

Theme 5 – Threat to professional identity An important theme was that students with previous Diploma level professional qualifications struggled with the challenge to their sense of professional identity (Hill & MacGregor 1998a,b, Dearnley 2006, Porter-Wenzlaff & Froman 2008, Hutchinson et al. 2011, Melrose & Gordon 2011). Many students reported feeling that they were just doing ‘more of the same’, and when they commenced at university did not recognise that the program required a transition to a different role (Hill & MacGregor 1998a,b, Porter-Wenzlaff & Froman 2008, Hutchinson et al. 2011). Students also reported feeling frustrated with the constraints on their scope of practice (Hutchinson et al. 2011). The academic work also challenged their professional identity and some students were unable to see the relevance of some degree content to ‘being a nurse’. This was also reflected in their reports about assessment of their knowledge (Hutchinson et al. 2011). Dearnley (2006) also reported that when Diploma students commenced at university, they lost confidence in their professional ability as a nurse. Melrose and Gordon (2008) also suggested that students experienced a sense of mourning as they felt the

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transition was associated with losing their role as ‘hands on’ bedside nurses.

Discussion Recruitment of students with previous nursing qualifications is viewed as a critical strategy to ensure sustainability of the future workforce (IOM, 2011). IOM, 2011 suggest that healthcare organisations offer tuition support to students who are within 5 years of completing primary qualifications and that organisations work to establish supportive environments in which to study is encouraged and a career pathway is articulated. However, this may be difficult to drive in current times of fiscal constraint. Retaining students once enrolled is a further issue. The struggles and challenges encountered by students without nursing qualifications, transitioning into first year university study are widely researched and in many ways parallel the experiences of students who enter into a nursing degree with prior professional nursing qualifications. However, students with previous nursing qualifications also cite lack of funded places and managerial support as factors in enrolling into university (Webb 2001). Personal, institutional and social issues are frequently cited as presenting challenges for all commencing students (Bowden 2007, Mulholland et al. 2008, Andrew et al. 2009, Hamshire et al. 2012). There is similarity in the academic and institutional challenges for students from both cohorts, and many students from both struggle to become independent learners with the ability to think critically. Further, a large number of students in both cohorts struggle to manage conflicting demands such as work and/or carer responsibilities. This may in part be due to students underestimating the demands required of completing a nursing degree, and overestimating the support available (Jeffreys 2007). The literature is replete with suggested interventions aimed to support students as they transition into university when confronted with the above challenges and is important for universities to increase student retention (Purnell et al. 2010). These interventions include orientation to university sessions, academic skills workshops, mentoring by high achieving students, supportive presence of academics and early identification and support of failing students (Poorman et al. 2002, Andrew et al. 2007, Jeffreys 2007, 2012, Shelton 2012, Lizzio & Wilson 2013). Whilst there is some work to suggest the need for specific interventions to support students with a previous professional nursing qualification, it should be remembered that

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additional factors such as supportive managers and supportive working cultures are also important for students with previous nursing qualifications (Webb 2001). However, the available literature appears to suggest ‘more of the same’ and does not engage with how to engender such supports. At university level, a suggested priority is to capture data about the student cohort, for example, how many hours worked outside of study and students’ family commitments to guide appropriate academic advice and enable effective mentoring by academic staff, working together to develop a study plan (Miller & Leadingham 2010). Faculty engagement is also considered essential. In particular, it is suggested that faculty acknowledge students’ previous education and nursing status (Rapson 2000). Importantly, this review revealed an additional significant factor that impacts on the transition experience of students who enrol in nursing degrees with prior professional nursing qualifications. This is related to the fact that the cohort has already developed a professional identity as nurses and do not view themselves ‘the same’ as students who commence with no nursing qualifications. This has not been well explored or conceptualised, and the effectiveness of current interventions is therefore largely untested. For these students, who have already developed a strong professional identity, expanding that identity to include the role of student nurse may compete with or threaten their sense of professional identity as nurses. This sense of identity is shaped by how they perceive themselves as related to their environment (Hall 1972). The review findings suggest that their current professional identity might not sit comfortably with the identity they believe ‘should’ be inherent in a nursing student role. This suggests that these students experience role conflict. Role conflict exists when pressure experienced in one role becomes incompatible with pressure that arises from another role (Coverman 1989). Applied to this cohort of students, role conflict is evident when students feel marginalised and report that they do not see the purpose to what they are doing with regard to expanding their professional role. More specifically, this occurs as person-role conflict. Person-role conflict occurs when there is incompatibility between what a person perceives to be expected and what the person believes they are doing, and results in decreased satisfaction and commitment to work and is related to increased anxiety and propensity to leave the situation (Kahn et al. 1964). This relates to students’ reporting in studies that they did not feel they were traditional baccalaureate students and they failed to see how what they were learning was different from their current professional role. © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1174–1188

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According to Latack (1981) there are three dimensions of role that may impact on individuals. First, person/role consensus which is the degree to which a person’s expectations of the role match the role of the ‘role sender’s’ expectations (in this case the university are the role senders who determine the student role). Second, person/role congruence, which is the degree to which a person’s professional self-identity matches the received role (again, determined by the university) and third, person/role overload which is the extent to which time and available resources are perceived as inadequate to meet set expectations (Latack 1981). It is suggested that this cohort of students is more likely to struggle with person/role consensus and person/role congruence because of their already existing strong sense of professional role identity. A useful framework to conceptualise these students’ experiences is Holland’s person/environment congruence typology (Holland 1996). Holland (1996) assumes that career and job choice reflect personality orientation and that a state of congruence or balance exists if the person’s orientation and environmental orientation are the same, resulting in stability and feeling of satisfaction. In contrast, when there is lack of congruence it leads to dissatisfaction and sometimes low performance (Holland 1996). Applied to these students, the personality orientations most closely associated with the professional identity of nurses who have completed Diploma level studies relate to what Holland (1996) describes as social and realistic personality orientations, where congruence is achieved through people-oriented and explicit activities. In contrast, congruence with regard to university based preparation for nursing requires students to draw together threads of several personality orientations (including social and realistic) to incorporate investigative, artistic, enterprising and conventional personality orientations, evidenced by scientific investigation, creative thinking, showing leadership and using systematic analysis. A key strategy to addressing the transition experiences of students who have a previous professional nursing qualification is in developing support that meets the cohort’s needs, as opposed to the university’s needs (Home 1998). Applying Holland’s framework to transition experiences of students commencing into a nursing programme with a previous professional nursing qualification affords the opportunity to better tailor support. Further research could include devising transition programs using Holland’s framework to further focus current strategies by developing activities to extend personality orientations. For

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1174–1188

Transition experiences of nursing students

example, orientation activities that explore the differences between Diploma prepared nurses, Bachelor’s prepared nurses and the RN role to enhance creative thinking may address the perception of ‘doing more of the same’ as an RN. Leadership development activities could be developed to assist with social integration. This might include working with current students to develop peer relations, and development of activities that require skills of exploration and critique, such as group problem solving a nursing or study related scenario. Interviewing current students about their experiences of being at university, or their understanding of nursing roles, and analysing this information could extend thinking around activities to develop academic capacity.

Conclusion This review has explored the transition experiences of students entering into nursing degrees with previous professional nursing qualification and highlights several challenges at professional and personal levels. While these challenges parallel those faced by students without a prior nursing qualification there are further challenges, related to workforce support and threat to students’ already developed sense of professional identity. Current strategies to enhance transition experiences are poorly conceptualised and offer more of the same, however, Holland’s framework is useful to conceptualise experiences to enhance transition.

Relevance to clinical practice The demand for health care is growing and there remains a shortfall of registered nurses. Nurses with professional qualifications at Diploma or Associate Degree level are an important pool of professionals from which to increase registered nurse numbers.

Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/eth ical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content and (3) final approval of the version to be published.

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