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 specifi cally 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 refl ect 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. Conclusions: 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. Mini Review Graduates’ Experiences of Transition and Transformation Following Completion of a Nursing Bridging Education Program Sue Coffey1*, Gail Lindsay1, Katherine Cummings2, Shelley Bouchard3, Marianne Cochrane2, Karen Macdonald4, Sandra Mairs2 and Susan Sproul2 1University of Ontario Institute of Technology, Oshawa, Canada 2Durham College, Oshawa, Canada 3Trent University, Peterborough, Canada 4Georgian College, Barrie, Canada Dates: Received: 02 February, 2017; Accepted: 07 February, 2017; Published: 08 February, 2017 *Corresponding author: Sue Coffey, Associate Professor, University of Ontario Institute of Technology, Oshawa, Canada, E-Mail:


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 fi rst 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 specifi cally 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 fi rst students. It was the fi rst 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][3][4], examining student performance, behaviours, and outcomes in NBE programs and by Purdy et al. [5], 008 Citation: Coffey  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 specifi cally 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 identifi ed that learner experiences were infl uenced by personal, community, and social conditions. These infl uences 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 benefi ts 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 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 confi dential 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

Results
In responding to four qualitative questions, participants provided insight into their experiences as they were asked to refl ect on the NBE program and their subsequent practice.
Specifi cally, participants were asked to consider the outcomes of completing the NBE program for them, their experience of transition into professional practice within the fi rst six months, more generally their transition into practice over the longer term, and fi nally 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 identifi ed. In the fi rst theme, graduates described experiencing greater freedom, choice, and fl exibility 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, Finally, when referring to the impact of the NBE program, a third theme was identifi ed 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 fi rst. You improve yourself" were included in this theme.

Question two: Transition to RN practice within the fi rst six months
Graduates were asked to comment specifi cally on their experience of transition to RN practice within the fi rst six months following completion of the program. Analysis of their comments led to the identifi cation of three themes. For the fi rst 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 taskoriented", "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 refl ected 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 fi nd 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 evidencebased 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" refl ect this theme.
Finally, a third theme was identifi ed that refl ected 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 identifi ed. For the fi rst 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 confi dence piece, I think that I am gaining more confi dence 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 confi dent"; "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" refl ect this theme.
For the second identifi ed theme, transition to their new role as RNs was also identifi ed 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 confi dent and when I don't, I have my colleagues to confi rm things or inform me of new things I didn't know" reveal participants' thinking around this theme.
The third theme that was identifi ed 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 confl ict). 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" refl ect 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 fi gure out how to bring new knowledge and practice to an ongoing practice environment that may or may not welcome that change. 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 defi nitely 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 identifi ed. In the fi rst and most prevalent theme, there was a focus on increased self-esteem, confi dence, 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 satisfi ed to have accomplished this" refl ect 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 benefi cial 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 fi nd 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" refl ect 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 fi nding 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 fi rst 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].

Conclusion
The very signifi cant changes that graduates describe in relation to having completed their NBE program and moving into RN practice are refl ective of their educational experiences, their workplace exposure, internal refl ection, 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 fi ndings 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 fi ndings 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.