Graduates’ Experiences of Transition and Transformation Following Completion of a Nursing Bridging Education Program

Background: Nursing bridging education (NBE) refers to educational programs that support learners to move from one level of educational preparation or practice to another. In the context of this study, NBE refers specifically to an educational focus that creates the opportunity for learners to move from practice as a college diploma prepared RPN to an RN through earning a Bachelor of Science in Nursing (BScN) degree.

Purpose: All participants were asked to respond to four questions that focussed on the impact and outcomes of the NBE program and their experiences transitioning into RN practice.

Results: Participants provided insight into their experiences as they were asked to reflect on the NBE program and their subsequent practice. NBE program graduates describe undertaking an external process of role transition as they become employed as RNs, while undergoing an internal process of personal and professional transformation through the experience of RN role enactment.

Conclusion: Understanding the transformational nature of an educational program is important in harnessing the potential for education to impact not only the learner, but potentially the profession into which students enter upon graduation.

Introduction

The structure and options associated with nursing education in Ontario, Canada are changing. Within this jurisdiction, the College of Nurses of Ontario is the regulatory body for Registered Nurses (RNs), Registered Practical Nurses (RPNs) and Nurse Practitioners (RNECs). This paper focusses on an innovative type of educational offering that creates the opportunity for bridging between RPN and RN preparation. RPN education has been offered in North America for more than 85 years, with Ontario as the site for the first Canadian program in 1941 [1]. Since that time, RNs and RPNs have been educated in parallel streams, often with very little intersection between the two types of program offerings. This situation became further pronounced with the 2005 implementation of a degree entry to practice requirement for registered nurses in Ontario, moving RN education to university settings or to colleges offering RN education in collaboration with a degree granting university.

Nursing bridging education (NBE) is a term that refers to educational programs that support learners to “bridge” or move from one level of educational preparation or practice to another. In the context of this study, NBE refers specifically to an educational focus that creates the opportunity for learners to move from practice as a college diploma prepared RPN to an RN through earning a Bachelor of Science in Nursing (BScN) degree. Growth in NBE program enrolment has been exponential over the past decade in Ontario. In 2003, the NBE program from which this research was conducted admitted its first students. It was the first NBE program of its kind in this jurisdiction. By 2005, an additional three government funded pilot programs were initiated. Today, six colleges and ten universities are involved in collaboratively offering NBE programs. Student enrolment across the province is estimated to be somewhere in the range of 2000-2500 students.

Despite the growth in programs, there remains little evaluative data to point to program outcomes. Research by Coffey et al. [2-4], examining student performance, behaviours, and outcomes in NBE programs and by Purdy et al. [5], describing program outcomes and student success strategies in bridging education remain two of the few empirical studies examining NBE with robust data analysis. This article adds to this research base, in presenting results of qualitative analysis of data collected from graduates of one NBE program in Ontario. The study explores the impact of completing the NBE program and graduates’ experiences of transition into practice as RNs.

Background

The core of nursing education in this jurisdiction fosters continuous, life-long learning and personal and professional development [6]. NBE provides registered practical nurses (RPN) educated through college diploma programs the opportunity to build upon their college education and workplace experiences to attain a bachelor of science in nursing (BScN) and write the examination to practice as a registered nurse (RN). Through this process, NBE recognizes that RPNs already have valuable skills, knowledge, and experiences that can be leveraged to streamline their educational requirements to practise as an RN in less time than it would take to complete the traditional BScN pathway [4,5,7].

Despite the multiple models NBE in this jurisdiction, all nursing programs require accreditation. Currently, the accreditation process has been delegated by the CNO to the Canadian Association of Schools of Nursing (CASN) [8]. Accreditation Program (CASN, n.d). However, while program quality for all nursing degree programs, including NBE programs, is assured through this process, there remains a dearth of relevant literature related specifically to NBE. Most concerning, there is very little research-based evidence available. In a systematic review of available literature, Suva et al. [9], looked at 39 papers that focused on the transition from RPN to RN through bridging education. They identified that learner experiences were influenced by personal, community, and social conditions. These influences extended beyond the period of time in which learners were enrolled in educational programs, to their experience of transition into professional practice. It is important to note that, overwhelmingly, these references were from outside of Canada, with very little research or even commentary from the Canadian context. While recommending the potential for benefits to learners to be gained through the addition of transition supports, the authors of this systematic review note that more research is required to fully appreciate the transition process.

Description of the study and participants

In this paper, we present data collected from graduates of one NBE program in Ontario, Canada. Data were collected through the fall of 2012 into the winter of 2013. Funding for the study was secured from the Ontario Council on Articulation and Transfer (ONCAT). Research ethics board (REB) approval for the study was granted by the one university and two college REB boards where the program was offered collaboratively. Graduates of the program were contacted by email and invited to participate in the study either by taking part in a telephone interview or by completing an online qualitative questionnaire. A total of 30 graduates of the program responded to this invitation to participate in the study exploring their experiences after completion of the program. All telephone interviews were conducted by one member of the research team who had not previously taught any of the graduates of the NBE program. All confidential responses from these interviews were transcribed verbatim and the audiotapes were subsequently destroyed. For participants who preferred to respond via online questionnaire, the data were collected using LimeSurvey, a secure online data collection tool housed at one of the participating academic institutions. No identifying information was collected and there was no recorded connection between the email address to which the research invitation was sent and responses uploaded by participants to LimeSurvey. All participants were asked to respond to four questions that focussed on the impact and outcomes of the NBE program and their experiences transitioning into RN practice. Responses to each of the four questions were analyzed using Nvivo9/10. Responses were coded and themes were identified through analysis to 3 levels of abstraction. Within this manuscript, each of the quotes used to explicate the themes is taken from separate interviews or online responses, such that the exemplars are reflective of the 30 participants.

A total of eleven graduates completed a telephone interview, with an additional 19 graduates responding online. This number represented approximately 20% of the total graduates of the program to that point. Year of graduation ranged from 2009-2012. All participants had successfully passed the national registration exam (at that time it was the Canadian National Registration Exam – CRNE) upon completion of the program, currently holding RN registration at the time of data collection. Length of time to program completion for all respondents, which can range from three to seven years depending upon individually constructed program maps, was three to five years. The majority of participants (23 of 30) reported completing the NBE program on a full-time basis through the standard three year program map.

Results

In responding to four qualitative questions, participants provided insight into their experiences as they were asked to reflect on the NBE program and their subsequent practice. Specifically, participants were asked to consider the outcomes of completing the NBE program for them, their experience of transition into professional practice within the first six months, more generally their transition into practice over the longer term, and finally their perceptions of the impact on their lives of becoming an RN.

Question one: Outcomes of the program

Graduates were asked to describe outcomes of the NBE program for them. Through thematic analysis, three areas of change were identified. In the first theme, graduates described experiencing greater freedom, choice, and flexibility within their work life. Comments such as “Now I have steady income and good hours with as much overtime as I want” and “Working part-time – this was my chosen work hours” reveal that there was not one common work pattern that graduates were seeking, but rather that they were appreciative of greater opportunity to tailor their work life to their needs. In addition to flexibility in work hours, graduates identified flexibility more broadly in terms of job opportunity. Examples include comments such as “You have more opportunities for work, in every way” and “Jobs that are offered in hospitals are limited for RPNs. For RNs, it’s unlimited...But for RPNs there are limits.”

For the second theme, graduates identified as an outcome of the program greater opportunity to work within their chosen nursing specialization. Statements such as “I ended up in a field I wanted to… I am doing a 6-month spot in the Emergency Department and I am happy where I am!”, “Now I am an RN and I am a supervisor and nurse in charge”, and “It really opened up some opportunity, like to have a job in a float pool and work in the ER or ICU” reflect this theme.

Finally, when referring to the impact of the NBE program, a third theme was identified as graduates spoke of the growth they experienced on both personal and professional levels. Comments such as “...the skills and the preparation needed to enter into the workforce” and, “Personal growth. It is more complex than it looks at first. You improve yourself” were included in this theme.

Question two: Transition to RN practice within the first six months

Graduates were asked to comment specifically on their experience of transition to RN practice within the first six months following completion of the program. Analysis of their comments led to the identification of three themes. For the first theme, many graduates described a dual transition involving transitioning from RPN to RN while also transitioning from nursing student to RN. Graduate statements such as, “It was nerve-racking in the sense that as an RPN I worked in a nursing home previously and the work was more task-oriented”, “I found the transition from student nurse to RN more challenging than RPN to RN”, and “I think the biggest part for me is going from a student into a full-time job role has been the hardest. It is different working than being in school” were the basis for this theme.

Graduates also reflected on an awareness of the heightened professional demands that they experienced as RNs, requiring greater critical thinking and a broader perspective than their past role as RPNs. Comments such as “A lot more critical thinking”; “…patients being more complex and I find it interesting to investigate and be in a place where I can think about their health issues and begin to care for them”; “I am using a lot of insight and knowledge in regards to the patient so it’s not only about getting tasks done, but rather looking at the patient as a whole”; and “…good understanding of evidence-based practice. Prior to the program I was just doing what I was doing. But starting as an RN, I was asking questions – why things are done the way they are done” reflect this theme.

Finally, a third theme was identified that reflected an awareness of and an acceptance of increased professional responsibility inherent in their new role as RNs. Statements such as “You have more responsibility…I have to make decisions by myself” and “The biggest difference was more responsibility…the responsibility was more on the RN” are the basis for this theme.

Question three: Overall transition to RN practice

In question three, graduates were asked to describe their overall experience of transition to professional RN practice. Through thematic analysis, four themes were identified. For the first theme, transition was portrayed as a process that takes time and occurs as a result of both new learning from their BScN degree and work experience as RNs. Comments such as “…still felt like an RPN for a while but am slowly adjusting to my new role”; “In terms of the confidence piece, I think that I am gaining more confidence in the RN role, slowly and gradually. But I still feel a little lost at times but I guess with more experience I will become more confident”; “I think this is sort of a misconception that this happens once you receive your registration by itself…the transition comes with years of very hard work and actually collaboration that is happening throughout our academic career and your connections with professional organizations…it does not actually happen only when you obtain your license”; and “I was nervous because I wanted to be careful that I didn’t step back into the role of an RPN so I had to get a very clear understanding of this new role and new responsibilities I had attained” reflect this theme.

For the second identified theme, transition to their new role as RNs was also identified as including a stronger focus on interprofessional collaboration and healthier interpersonal and interprofessional relationships. Statements such as “Respect for colleagues in our workplace as we problem-solve and share daily”; “Good interprofessional collaboration”; and “I have a great support system so I feel confident and when I don’t, I have my colleagues to confirm things or inform me of new things I didn’t know” reveal participants’ thinking around this theme.

The third theme that was identified was the requirement for greater leadership knowledge and skills as RNs than graduates had previously possessed as RPNs (and which they felt they had gained in the program). Comments such as “To get this position that I have now, you need more knowledge that I got from the program and you need more leadership skills. You need more management skills that I didn’t get from the college from my RPN program”; “Leadership – the program that we took and many other subjects that we have there (e.g., ability to deal with conflict). You can solve problems faster than RPNs and I feel the problem was in myself before university… I wasn’t so good before university, but now… it is much easier”; and “I think that I kind of feel more sense of responsibility or accountability just because I am going to have more of a leadership role as an RN” reflect this theme.

Finally, the fourth theme reveals that transition was sometimes experienced as challenging because the NBE program student/graduate had changed and had to figure out how to bring new knowledge and practice to an ongoing practice environment that may or may not welcome that change. Comments such as, “You have so many ideas and you have a certain mindset…You have a certain kind of expectation of your ability to change things, and you are learning the new cutting edge ways of how things are in health care and what it is to be a nurse and when you get out in the real world it is definitely a shocker”; and “I am finding that [practice environments are] not necessarily what we learned and you are met with a lot of resistance when you try to bring about your ideas…in some ways there are opportunities to change and I have definitely had that experience, but I have also been met with resistance” underscore this theme.

Question four: Impact on their lives of becoming an RN

Graduates were asked to describe the impact on their lives of becoming RNs. Three themes were identified. In the first and most prevalent theme, there was a focus on increased self-esteem, confidence, feelings of accomplishment, and pride in achieving an important goal. Comments such as “I feel like I am seen differently at work, more respected by some individuals having my degree”; “Overall, I just feel good that I have accomplished the CRNE exam and obtained my RN degree so my self-esteem has increased”; “I completed my goals so that has impacted me. It was rewarding”; “It has been a goal completed. It is something that I have set myself up to do, not really knowing if I would be able to achieve it. It means a lot to me personally and for my family”; and “My goal was to become an RN so I am proud of achieving this goal. I feel satisfied to have accomplished this” reflect this theme.

The second theme reveals that for some graduates, there was also a moderate increase in salary or a sense of job security. Statements such as “In terms of income, I am gaining more income which will be beneficial when I want to buy a house and such”; “I am also in a profession that is always going to be in demand so job security is a major thing which I believe I have”; “It’s going to be a bit more money for one thing”; and “I am actually being paid a better wage than the starting salary at a hospital so it means a lot to me” underscore this theme.

Finally, in the third theme, graduates described a heightened self-appraisal of professional freedom, autonomy, and satisfaction. Comments such as “I have more complex patients and more critical thinking to do at work and I find that rewarding”; “I have more interesting cases and not only bedside work”; and “Prior to being an RN, I constantly felt like I had my hands tied and I wasn’t able to do things so that was rewarding” reflect this theme.

Discussion

Results of the qualitative analysis of participants’ perceptions of the outcomes of completing an NBE program reveal that participants identify changes to the amount of freedom and choice they experience as well as personal and professional growth. While there are divergent preferences in terms of full-time or part-time work and area of specialization, having more opportunity to choose the most desirable work context was common among participants. This finding is common to other types of nurses who seek greater opportunity for choice in the workplace [10]. When focussing on transition to RN practice within the first six months, participants reveal many of the same transition challenges seen by other types of nursing program graduates, in which the practice setting may seem stressful and the professional demands daunting [11].

Following up the reflection on the first six months of transition to exploration of how participants experienced transition overall provides greater insight into the processes of professional socialization for this unique group of graduates. Having worked as one category of nurse (RPN) in Ontario, and subsequently transitioning into practice as another category of nurse (RN), the inherent difference in practice orientation comes into focus. Identifying elements such as the need for enhanced leadership skills and an appreciation of the challenges of bringing change to practice environments reflect the critical role of RN as both a leader at the point of care and a change agent in the practice setting [12].

The identification of the need for time to fully integrate into the role of an RN is interesting in light of the anecdotal feedback that faculty who teach in the early years of the program hear from NBE program students who enter the program feeling as though they are already doing the job of an RN, while not being acknowledged for it. To the contrary, these results suggest that fully enacting the role of RN, for nurses who had previously worked as RPNs, takes time and exposure to the role. Additionally, the recognition that support from and interaction with nursing and non-nursing members of the interprofessional team was a key element of transition is highly reflective of the healthcare culture in Ontario [13,14]. When asked about the impact of becoming an RN on their lives, participants focussed much more on their internal appraisal of themselves and their sense of accomplishment, than on their heightened earning power. This finding is interesting given the very significant difference in salary between RPN and RN in this jurisdiction. While improved earning power was identified, much more focus was directed toward personal and professional satisfaction than income.

Overall, analysis of qualitative data derived from interviews with graduates revealed two parallel foci. Graduates describe a very strong focus on the internal changes they experience as they transition to and enacted the role of an RN. At the same time, they reveal an awareness of and an appreciation for the changes to their practice that are both externally required of them and internally adopted by them. Graduates’ descriptions of their experiences of transition to the role of RN revealed a powerful, transformative experience. This personal and professional transformation takes place simultaneously within their role enactment as RNs and their own self-conception as they become RNs.

Graduates of the program describe experiencing internal and external change processes as a result of completing the program and becoming RNs. This process describes how NBE program graduates undertake an external process of role transition as they become employed as RNs, while undergoing an internal process of personal and professional transformation through the experience of RN role enactment. Understanding the transformational nature of an educational program is important in harnessing the potential for education to impact not only the learner, but potentially the profession into which students enter upon graduation.

Conclusion

The very significant changes that graduates describe in relation to having completed their NBE program and moving into RN practice are reflective of their educational experiences, their workplace exposure, internal reflection, and the changing context of their personal and professional lives as a result of becoming RNs. Recognizing these changes may enable educators to focus more explicitly on change processes and the phenomena of transition and transformation in order to prepare students for these life-altering experiences upon graduation. Within our program, appreciating the very positive experiences of graduates has encouraged us to work more effectively with students throughout the program around these phenomena. The findings of this study are important both as we consider how to advise students coming into the program and as they progress through it. Bringing more graduates back to the classroom to speak to new students and to information sessions to meet with prospective students enables learners to begin to prepare for their own experiences of transition. Importantly, these findings provide insight into ways that we may more effectively support our students both during their time in our NBE program and in preparation for their careers beyond it.

1. Pringle D, Green L, Johnson S (2004) Nursing education in Canada: Historical review and current capacity. Ottawa, ON: The Nursing Sector Study Corporation Link: https://goo.gl/LxRVvU
2. Coffey S, Lindsay G, Vanderlee R, Anyinam C, Woodend K, et al. (2013) Multi-Site Examination of Student Performance, Behaviour, and Experience in Nursing Bridging Programs. Scholarship of Teaching and Learning Conference, Mount Royal University. Banff Alberta Link:
3. Coffey S, Lindsay G, Sproul S, Cochrane M, Cummings K, et al. (2014) Transition and transformation as key concepts in bridging from registered practical nurse to registered nurse. CASN Canadian Nursing Education Conference – Anticipating and Shaping the Future of Nursing Education. Halifax, Nova Scotia Link
4. Coffey S, Lindsay G, Cochrane M, Cummings K, Macdonald K, et al. (2016) Making the grade through the front door: Evaluation and innovation in a Registered Practical Nurse to Bachelor of Science in Nursing Program. Journal of Education and Training Studies 4: 32-38. Link: https://goo.gl/zJ8vM2
5. Purdy N, Santa ME, Mastrilli P, Tucker-Scott K, Murphy S, et al. (2012) RPN bridging to BScN: Program outcomes and student success strategies. In Registered Practical Nurses Association of Ontario (Ed.), 54th Annual General Meeting and Conference. Symposium conducted at the meeting of the Registered Practical Nurses Association of Ontario, Toronto, Ontario, Canada Link:
6. College of Nurses of Ontario (2014) Entry-to-practice competencies for Ontario registered practical nurses. Retrieved from Link: https://goo.gl/CzZRdx
7. Coffey S, Lindsay G, Anyinam C, Vanderlee R, Woodend K, et al. (2015) Meaningful Lifelong Learning in Nursing Education: Barriers, Facilitators, and Outcomes (pp. 7910). In INTED2015: 9th International Technology, Education and Development Conference Proceedings. (ISBN: 978-84-606-5763-7) Link: https://goo.gl/DVaZPn
8. Canadian Association of Schools of Nursing (nd) CASN and Accreditation. Retrieved from: Link: https://goo.gl/QuJJR7
9. Suva G, Sager S, Santa Mina E, Sinclair N, Lloyd M, et al. (2015) Systematic review: Bridging the gap in RPN-to-RN transitions. Journal of Nursing Scholarship 47: 363–370. Link: https://goo.gl/IhLvUu
10. Upenieks V, Valda MPH, RN (2000) The relationship of nursing practice models and job satisfaction outcomes. Journal of Nursing Administration, 30: 330-335. Link: https://goo.gl/DSjU76
11. Cubit K, Lopez V (2011) Qualitative study of Enrolled Nurses transition to Registered Nurses. Journal of Advanced Nursing 68: 206-211. Link: https://goo.gl/7vyqpZ
12. Weberg, Dan MHI, BSN, RN, CEN (2010) Transformational leadership and staff retention: An evidence review with implications for healthcare systems. Nursing Administration Quarterly 34: 246-258. Link: https://goo.gl/QfZcuv
13. Coffey S, Anyinam C (2014) Interprofessional practice. Pearson: Toronto Link: https://goo.gl/GO0cTb
14. Limoges J, Jagos K (2015) The influences of nursing education on the socialization and professional working relationships of Canadian practical and degree nursing students: A critical analysis. Nurse Education Link: https://goo.gl/1Qt9ZK

© 2017 Coffey S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.