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Adult Nursing Students Persisting Toward Degree Completion: A Case Study of an RN to BSN Accelerated Program

Student persistence is a substantial concern to many postsecondary institutions. Colleges and universities across the World are paying close attention to retention rate data and other outcome measures centered on the issue. Premature student departure is especially distressing for nursing programs that are under pressure to supply and replenish the nursing workforce, which, in the United States, is projected to need an additional one million nurses by 2020. Therefore, supporting nursing students’ progression is an essential ingredient required to aid workforce capacity and to refill the nursing pipeline to meet the growing demand for healthcare. The purpose of this qualitative case study was to investigate the experiences of adult students who overcame challenges commonly found in this student population and were able to graduate from a registered nurse (RN) to Bachelor of Science in Nursing (BSN) completion program. Aspects were explored that surrounded RN to BSN student retention at this facility and the components that helped these students reach completion. This examination also focused on the external factors affecting these participants and the particular program and institutional components that contributed to their successful completion. The findings of this qualitative case study produced six major themes and 41 subthemes. The main themes uncovered in the case study are: Institutional and Program Fit, Role of Current Professional Climate and Decision to Pursue BSN, Institutional Support Systems and the Role of Critical Bonds, Critical Bonds Formed Among Peers, Family Support and the Role of the Critical Insider, and the Personal Characteristics that Contribute to the Students’ Ability to Complete. The findings of this study add to the limited RN to BSN nursing retention literature and help illustrate why this student subpopulation persists to degree completion rather than depart an institution.


Introduction
Student attrition is one of the greatest issues facing postsecondary institutions. It is especially a concern for nursing programs, where premature student departure has a direct impact on the country's overall health. To complicate matters, the United States Bureau of Labor Statistics [1,2] and AACN [3] project the RN workforce will need to grow to 2.71 million between the years 2012 to 2022, equating to 3.24 million, or 19% in just 10 years. Advocating, many more nurses will be needed to meet the nation's growing demand for healthcare, as well as to replenish the baby-boomer nurses projected to retire [3][4][5][6]. To fulfill these recommendations, the American Association of Colleges of Nursing and AMN Healthcare 2017 Survey of Registered Nurses [4,5-7] fully support academic progression to prepare a robust nursing workforce.

Statement of the Problem
In reaction to the anticipated nursing shortage, nursing schools are being burdened to grow their programs rapidly, admit as many qualified applicants as possible, streamline curricula, and ultimately graduate as many nurses as possible [8,9]. Weitzel and McCahon also pointed out that nursing programs are required to foster strategies to help students reach completion [9]. However, it is important to note that the pathway to educational advancement for the Registered Nurse to Bachelor of Science (RN to BSN) completion student still continues to be filled with obstacles [10] and as a result, there still remains a sizable percentage of adult RN to BSN students where completion is never obtained.
In addition, there is significant evidence affirming the barriers that commonly prevent adult students from finishing their degrees and these include: family responsibilities, career or job demands, lack of financial support, loss of social support, community commitments, poor previous academic performance, foreign education, English as a second language, adverse educational experiences, loss of tuition reimbursement (and time for reimbursement), financial aid issues, poor institutional fit, and poor health or ill family member [11][12][13][14]. However, there is less research that exclusively identifies the particular characteristics of a successful RN to BSN accelerated adult student and what components of a program most helped them succeed. In addition, limited research was uncovered specifically addressing factors that solely lead to understanding what constitutes successful completion in this particular student subpopulation.
Stolder, Rosemeyer [15], and Zorn further emphasized that nontraditional nursing students are often isolated by various circumstances such as single parenthood; parenting children who are physically, cognitively, socially, or academically challenged; domestic violence; and inadequate housing with poor transportation. More specifically, most RN to BSN students are additionally responsible for a family while working full time with extended and nontraditional hours in order to further their education. This makes retention a major issue for institutions because if and when a "crisis" occurs, typically, school obligations are the first responsibility that must be dropped or postponed for the adult RN to BSN student [16]. Making sense of how these adult students overcome such challenges is of tremendous benefit to a program. Quality improvement initiatives may be generated from the information collected from the participants as well as spur future research studies. Results from this study can also be used to revise policy or scheduling challenges to meet the needs of the adult RN to BSN student and identify specific situations that may place adult students at risk for non-completion.
In order to improve student retention and advance nursing scholarship, nurse educators will need to be substantially more prepared to address the contemporary attrition issues facing their students. More specifically, although institutions are experiencing tremendous growth in RN to BSN completion programs, it has been recognized that "the RN to BSN student population has been understudied" [16]. This gap in the literature provides an opportunity to conduct future retention research centered on adult RN to BSN students. Therefore, this study adds to the growing nursing retention literature, which further allows nurse researchers and educators to place themselves in a strategic position to make a greater impact on improving nursing student retention at large.

Research Purposes and Questions
The purpose of this qualitative case study was to investigate the experiences of students who not only overcame the challenges commonly found in the adult student population but were also able to complete the adult RN to BSN accelerated nursing completion program at a Midwestern, private, faith-based institution. I explored the aspects surrounding RN to BSN student retention at this institution and the components that help these students to reach completion. The foci for examination were the external factors that impact successful completion rates, the unique individual characteristics of these students, and the particular program and institutional components that contribute to their ability to successfully complete an accelerated RN to BSN completion program.
The primary research question that guided this study is: What makes the students successfully complete an accelerated RN to BSN program at a Midwestern, faith-based, private institution? Additionally, I posed the following related research questions: 1. What are these students' personal characteristics that can be attributed, if at all, to their ability to successfully complete an accelerated RN to BSN program? 2. How do these students meet the challenges, if any, on the way toward their degree completion? 3. What are the facets of an accelerated RN to BSN program that can contribute, if at all, to the students' ability to reach completion? 4. What support do the department and institution provide for the students in order for them to succeed academically?

Literature Review
As reiterated by Jeffreys [17,18], understanding why students decide to leave a nursing program provides valuable information; however, it does not necessarily explain why other successful students choose to persist. Clearly, academic success is a complex phenomenon, and it has been extensively researched in higher education literature. For instance Jeffreys [18], explained that success has been defined in a variety of different ways, such as: reaching graduation, obtaining employment status, or earning more than minimal benchmarks in order to reach one's full potential. If success is "reached," then can we conclude outcomes have been optimized? If the answer is yes, then "optimizing outcomes benefits individuals, the nursing profession, the healthcare system, patients, organizations, and society at large" [18].
According to CCNE [12] Standards IV, in order to be compliant, the completion rate in a nursing program must be 70% or higher, excluding students who identified factors such as (a) family obligation, (b) relocation, (c) financial barriers, and (d) decisions to change majors or to transfer to another institution of higher education. Guiding students to move past these and other obstacles will improve graduation rates for any nursing program. It is reported that the program being examined in this study has a retention rate of around 85% [19]; which is above CCNE's 70% benchmark. However, this case study attempted to uncover some of the success strategies of completers with the aim of developing continual and contemporary retention policies that improve their overall retention rate, as well as meeting the strategic agenda written by the department chair and the retention plans of the University.
Undoubtedly, the RN to BSN adult completion student has unique issues that put them at risk for reaching the endpoint in a program.
Focused nursing student retention has been determined to be important; yet, it is clear the RN to BSN student subpopulation has been understudied [14], which makes studies such as this ever more imperative. Although enrollment rates are on the rise in all levels of nursing education [8], it is important to point out that retention remains an issue for adult RN to BSN students [14]. Therefore, more studies are needed that specifically focus on the RN to BSN adult student subpopulation to discover the factors that restrict and support their ability to remain in school as well as to review initiatives and strategies that aid retention throughout higher education in general [14].

Data Collection and Analysis Strategies
This case study explores the aspects surrounding RN to BSN student retention and the components that help students to reach completion. Typically, case study research involves extensive and multiple sources of triangulating data (Figure 1). The sources of data examined for this study included in-depth, semi-structured interviews with participants' who have successfully completed the RN to BSN program as well as analytic memoing, extensive field notes, and institutional survey data. Triangulation means making use of multiple sources of data and theories to corroborate all the evidence collected [20]. This process permitted me to substantiate the themes generated from the interviews and from the RN to BSN student body at large. The "student body" included all student cohorts from the past three years that responded to the exit survey and had successfully graduated from the RN to BSN program. The primary data for analysis collected from the 10 indepth, semi-structured interviews were supported by the analysis of the institutional documents (exit surveys) that contributed to triangulation and, therefore, strengthened the credibility of the research findings. An integrated data analysis allowed me to create a more holistic description of the participants' lived experiences and the components that helped them reach completion.

Findings
The participants' accounts produced a plethora of information that adds to a growing body of knowledge surrounding the adult nontraditional RN to BSN students. From the experiences that the participants shared with me, I learned that student retention  (Figure 2).   Did your nursing school provide a positive academic experience? 6.16 6.28 6.06

Subthemes: Faculty Uphold a High-Touch Environment (Faculty Support and Accessibility)
How satisfied are you with the accessibility of faculty and outside class? 6.11 5.61 5.40 How satisfied are you with the faculty responsiveness to student concerns? 6.11 5.64 5.42 How satisfied are you with the faculty's ability to interact with students? 6.20 6.36 6.41 How satisfied are you with faculty's ability to communicate effectively? N/A 6.30 6.17

Subtheme: Faculty Set-up Opportunity to Build Confidence and Transform Practice
To what degree did the program teach you to make effective presentations? 6.25 6.05 6.10 To what degree did the program teach you to demonstrate accountability for your own actions? 6.49 6.20 6.20 To what extent did the nursing program teach you to provide culturally competent care? 6.25 6.20 6.17 To what extent did the nursing program teach you to act as an advocate for vulnerable patients 6.39 6.26 6.20 To what degree did the program teach you to work with inter-professional teams? 6.02 6.02 6.14 How satisfied are you with the faculty's ability to relate concepts to the real world? 6.32 6.22 6.28 To what degree did the program teach you to apply research-based knowledge as a basis for practice 6.44 6.24 6.23 To what degree was the information you learned applicable to your future career? 6.27 6.20 6.05 To what degree did you learn valuable information? 6.12 6.16 n/a

Sub-Theme: Faculty Serve as Role Models
How satisfied are you with the faculty's ability to act as affected role models in clinical practice? 6.30 6.28 6.36

Sub-Theme: Faculty Motivate Students to Critically Think and Reach Completion
To what degree did the program teach you to integrate theory to develop a foundation for practice 6.22 6.06

6.19
To what degree did the program teach you to understand the effects of health policies on diverse populations 6.38 6.17

6.22
To what degree did the nursing program teach you to understand the global healthcare environment 6.02 6.09 6.14 To what degree did the program teach you to apply an ethical decision-making a framework to clinical situations? 6.20 6.20 6.18 To what degree were you motivated to do your best academic work? 6.12 6.29 6.18 To what degree were you challenged to do your best academic work? 6.20 6.22 6.17

Sub-Theme: Faculty Motivate Students through Engaged Learning Strategies
How satisfied are you with the faculty's ability to engage students in discussions 6.51 6.43 6.48 How satisfied are you with the faculty's ability to draw on experience of students? 6.32 6.30 6.37

Sub-Theme: Administration Support and Availability
How satisfied are you with responsiveness of the program administration to student concerns? 6.09 5.87 5.53

Sub-Theme: Academic Advisor Support and Availability
How satisfied are you with the quality of academic advising? 6.22 n/a n/a To what degree was your academic advisor knowledgeable about course requirements? n/a 6.23 6.16 To what degree was your academic advisor knowledgeable about degree requirements? n/a 6.22 6.15 To what degree was your academic advisor knowledgeable about campus referrals sources for personal, academic, or financial problems? n/a 5.95 6.02

Sub-Theme: Library Staff Support and Accessibility
How satisfied are you with Benedictine University's library services? 6.18 6.32 5.66

Sub-Theme: Diversity in Nursing Practice
Satisfaction with fellow students ability to work in study groups 6.24 5.85 5.98 Satisfaction with fellow students level of camaraderie 6.39 6.19 6.37 Satisfaction with fellow students academic integrity 6.45 6.28 6.43 Satisfaction with fellow students academic ability 6.27 6.13 6.26 How satisfied are you with the value you derived from your collaboration experiences? 6.13 5.64 5.64 How satisfied are you with the amount of collaboration required in your courses? 6.00 5.62 5.55 Satisfaction with fellow students amount of work experience 6.33 n/a 6.20 Satisfaction with fellow students quality of work experience 6.34 n/a 6.22 The analysis of Table 1 demonstrates that Institutional Fit plays a role in helping educators understand why students choose to stay at the university or in the program. Similar to the responses of the 10 study participants, respondents to the Exit Survey met the benchmark set by the department by reporting satisfaction when asked about the delivery model of the program, the course schedule, the tuition, and the expenses of the program compared to investment in the degree and having an accepting environment and an overall positive academic experience.
Another similar response from both the Exit Survey's remarks and those of the 10 participants was Institutional Support Systems and the Role of Critical Bonds. The Exit Survey responses compared to those of the 10 participants in the following themes: the Faculty Uphold a High-Touch Environment, having Faculty Support and Accessibility, having Nursing Administration Support and Accessibility, having Academic Advisor Support and Availability, in addition to having Library Staff Support and Accessibility.
Finally, there was a clear similarity between the responses from the survey and from the interviews regarding the satisfaction with peer relationships. For example, satisfaction was evident through the themes of Critical Bonds Formed Among Peers, the Collaboration, and Teamwork, as well as valuing Diversity in Nursing Practice in the classroom environment. It is important to note that the interview analysis themes of The Role of Current Professional Climate and Decision to Pursue BSN, Family Support and the Role of the Critical Insider, and the Personal Characteristics That Contribute to the Students Ability to Complete were not identified through the responses to the exit survey. This finding suggests that there is the need for more qualitative studies to be conducted in order to understand more fully the facets surrounding student retention in the RN to BSN program at Benedictine University.

The Findings of the Study Discussion
The thematic analysis produced six major themes and 41 subthemes from the interviews of 10 participants who successfully graduated from the RN to BSN program at Benedictine University. Several valuable lessons can be learned from this study. First, understanding student retention is multifactorial. The findings of this study support some of the precepts that deal with the barriers that commonly prevent adult students from completing their degrees, as well as the factors that support academic success in nursing. However, little research is available that exclusively identifies the particular characteristics of a successful RN to BSN accelerated adult student and what components of a program most help them to succeed. Scarce to no research has been conducted that uncovers precisely the factors that solely lead to understanding what constitutes successful completion in this particular student subpopulation. The majority of the research addressing RN to BSN retention is conducted as quantitative studies and, therefore, is lacking in alternative ways of exploring the same issues in more depth and detail. For these reasons, the findings of this case study are deemed significant in terms of substantively contributing to the existing literature on the subject.

Conclusion and Recommendations
There is a plethora of retention studies in the literature. However, little is written about nontraditional students and even less focus is on the RN to BSN student subpopulation. What surprises me the most is that very little research solely investigates the "successful side" of retention and the components that contribute to an adult student's ability to complete an RN to BSN program. Although this case study identifies six major and 41 subthemes, there is still much to investigate concerning what contributes to the academic success of an RN to BSN students' ability to complete.
The opportunity to work with adult RN to BSN students is a great gift. The richness of class discussion along with the quality of their effort and work is unmatched. What is also amazing is their ability to balance other commitments, schoolwork, family, financial struggles, ill parents, sick children, being ill themselves, personal and family tragedy, all while working full time or more. My tremendous respect for this student population has in part guided my research interest. However, what I learned from my 10 participants was far more than I had imagined and these lessons will change my teaching practices forever.
First, lessons I learned from my participants is the importance of Institutional (program) Fit. Students should spend time investigating a program to ensure that it is compatible with student preferences. Moreover, programs should consistently evaluate the preferences of their stakeholders to make sure that what is being offered truly meets the needs of the students they serve. Another important lesson converged upon the Professional Climate.
Understanding the exact reason a student returns to school allows educators to recognize some of the motivation for why a student stays. More importantly, programs should foster relationships with community partners to ensure the program is preparing graduates for the professional climate mandates and beyond. Additionally important is the role of Institutional Support Systems and a High-Touch Environment. Faculty must be mindful that a nursing student makes the decision to remain in school at the conclusion of each course [17,21]. With that said student retention is more likely a faculty-driven indicator and should not to be considered a senior administrative problem. Faculty and staff must be cognizant that every interaction we have with a student is of vital importance to the student's decision to remain at the University. Setting policy that promotes easy access to faculty, administrators, advisory, and library staff is essential in helping students to problem solve and de-escalating some of the stressors they experience along the way to completion.
Another important lesson aimed at fostering student success is to support the Critical Bonds Among Peers. Promoting peer relationships and creating networks through collaborative learning opportunities is a recipe for student success. One more important lesson is to recognize and appreciate Family Support and the Role of a Critical Insider. Doing so is supporting what Jeffreys calls "the whole student." The final lesson learned from this case study is to recognize the Personal Characteristics That Contribute to a Student's Ability to Complete. Understanding the student's unique personal characteristics will better prepare faculty and staff to determine needs and strengths and help identify those who are at risk [17].
Using a qualitative case study approach, I had an opportunity to uncover new and valuable information about the lived experiences of the Registered Nurse (RN) to Bachelor of Science in Nursing (BSN) Completion students. From the lessons learned in this case study, it is evident that student retention is multifactorial and creating an environment that promotes student success is complex.
Although a significant amount of literature has discovered why students depart from a university, research has not fully explored the role institutions play in an RN to BSN student's decision to stay through degree completion. Therefore, I believe that the findings of this study contribute to the limited RN to BSN retention literature as well as bring about a deeper understanding of nursing student retention in a program that provides support and opportunity for the students to succeed and graduate.