Taylor_608_Formatted Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 121 Exploration of Rural Nurses in Decision Making of Academic Progression Joyce M. Taylor, PhD, RN, CCRN-K1 1 Associate Teaching Professor, RN-BSN Nursing Program, Pennsylvania State University, Abington Campus, jtaylorrn23@gmail.com Abstract Purpose: To explore the meaning that academic progression has for rural RNs and their decision to pursue or not pursue a BSN or higher levels of education. Background: Mounting evidence has linked a higher educated nurse with improved patient outcomes and decreased patient mortality prompting leaders in healthcare to call for a bachelor of Science (BSN) degree as baseline preparation for nursing practice Yet, the majority of the nation’s registered nurses (RNs) continues to be educated at the associate degree (AD) level. These numbers are even higher in rural areas of the country, where social determinants of health for rural populations places higher demands on rural nurses to provide quality of care. Sample: Nine (n=9) AD RNs from a rural community hospital in Pennsylvania who met inclusion criteria were selected. Methods: A qualitative phenomenological approach was the research design choice which captured the lived experiences of how rural RNs think and feel about pursuing a BSN or higher degree. Findings: Findings from this study revealed that rural RNs are motivated by the need for a BSN specifically in regard to job security, professional identity, professional development, personal enrichment, and career mobility and feeling prepared for the demands of 21st century nursing practice. The participants conveyed they want their voices to be heard regarding the unique challenges that rural nurses face in pursuit of a BSN. Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 122 Conclusion: Higher education in nursing is now a key imperative. Understanding academic progression in relation to RNs practicing in rural healthcare institutions should serve to disseminate the identified gaps of knowledge in rural nursing education. This study has direct implications for curriculum development and educational strategies focused on producing a more educated rural nursing workforce to meet the growing needs of rural populations. Keywords: academic progression, associate degree, bachelor degree, nursing education, role transition, rural health, rural nursing, rural RN workforce. Exploration of Rural Nurses in Decision Making of Academic Progression Mounting evidence has linked a higher educated nurse with improved patient outcomes and decreased patient mortality prompting leaders in healthcare to call for a bachelor of science in nursing (BSN) degree as baseline preparation for nursing practice (Aiken, Clarke, Cheung, Sloane & Silber 2003; Harrison et al., 2019; Institute of Medicine [IOM], 2011). Yet, the majority of the nation’s registered nurses (RNs), approximately 54%, continue to be educated at the associate degree (AD) level (Probst, 2019; Spetz, 2018). These numbers are even higher in rural areas of the country, which is significant as social determinants of health for rural populations places higher demands on rural nurses to provide quality of care. (Amponsah, Tabi, & Gibbison, 2015; Fahs, 2012; Molanari, Jaiswal, & Hollinger-Forrest, 2011). This study addressed the following research question, “How do associate degree prepared RNs working in a rural facility describe and interpret academic progression and their decision to pursue or not pursue a BSN degree?” Understanding academic progression and rural nurses begins to fill the gap of the under researched rural nursing population regarding appropriate educational attainment for rural nursing practice. Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 123 Academic Progression Despite calls for a more educated RN workforce, academic progression has seen slow progress (IOM, 2011). It is now widely recognized that the 80% BSN goal by 2020 will most likely not be met as only 66% of RNs are projected to have a BSN+ education by 2025 (Spetz, 2018). Moreover, a huge disparity in educational attainment exists for rural RNs. In fact, recent analysis showed only 46% of the rural RN workforce holds a BSN as compared to the 57% of urban RNs (National Council of State Boards of Nursing [NCSBN], 2019; Probst, 2019). Correspondingly, rural nursing students are usually first-generation college students with little or no support or expectations of academic progression (Snyder, Jensen, Nguyen, Filice & Joynt, 2017). Noteworthy, educational levels for most adults in rural areas remain below the national average; the more isolated a rural RN the less likely they will have achieved a BSN degree (Medves, Edge, Bisonette, & Stansfield, 2015; Molanari et al., 2011; Snyder et al., 2017). Marilyn Chow in the Future of Nursing Education report asserted, “The future is here, it just isn’t everywhere” indicating that the goal of increasing the proportion of BSN RNs to 80% by 2020 is particularly challenging for rural healthcare environments where nurses need to be adequately prepared as frontline caregivers (IOM, 2011, p. 317). There are a myriad of factors contributing to the undereducated rural RN pipeline such as quality of education, lack of educational access, and return on investment for higher degrees (Amponsah et al., 2015; Molanari et al., 2011; Murray, Havener, Davis, Jastremski, & Twitchell, 2011; Probst, 2019). Understanding Rural Nursing The uniqueness of rural nursing and nursing education is largely misunderstood (Yonge, Myrick, Ferguson & Grundy, 2013). Thus, it is important to have a basic understanding to the context of rural, rural health and rural healthcare education. The diversity of rural settings and Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 124 difficulties with definition and measurement of what is deemed rural have contributed to the lack of accurate description and understanding the needs of rural nurses. For the purpose of clarity in this article, Rural is defined as located outside a metropolitan statistical area or more geographically remote with a lower population density. Rural areas include some combination of: open countryside, rural towns (places with fewer than 2,500 people), and urban areas with populations ranging from 2,500 to 49,999 that are not part of larger labor market (United States Department of Agriculture Economic Research Service [USDA ERS], n.d.). Rural health refers to a unique combination of socioeconomic and geographic factors that create disparities in health care not found in urban areas (Rural Health Information Hub, n.d.). Rural nurses are viewed as rural generalists’ who require specific competencies and skillsets for care coordination, assessment and management of at-risk and underserved rural populations often in resource-poor environments (Burman & Fahrenwald, 2018; Medves et al., 2015; Molanari et al., 2011; Probst, 2019). Compared to their urban counterparts, rural RNs are challenged with providing care to rural populations who on average are older, sicker, poorer, more isolated and more likely to be uninsured or underinsured. Subsequently, rural residents are less likely to seek preventative care therefore experiencing higher rates of chronic illnesses and co-morbidities. Collectively, the aforementioned socioeconomics and health disparities among rural populations places higher demands and expectations on rural RNs who are often inadequately prepared for their expanded roles in providing healthcare (Amponsah et al., 2015; Fahs, 2012; Molanari et al., 2011; Murray et al., 2011; Probst, 2019; Snyder et al., 2017). Methods A qualitative phenomenological approach was the research design choice, and well-suited to capture the intense and often emotional human experience of what it is really like to experience Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 125 the phenomena in question (van Manen, 1990, 2014). The research design enabled a rare glimpse of how rural RNs really think and feel about their decision in academic progression. The theoretical frameworks of Schlossberg’s Transition theory and Knowles Adult Learning theory guided this study, specifically, capturing the needs of clinical RNs transitioning to the academic environment (Anderson, Goodman, & Schlossberg, 2012; Knowles, 2015). Ethics approval for the protection of human subjects was received from the Capella University Institutional Review Board #2015- 741 and from the Ethics Review Board at the local hospital where the research occurred. Upon approval, the recruitment phase commenced. Participants and Recruitment Sampling was drawn from the target population of RNs who were currently working at the rural acute care facility and met the following inclusion criteria. RNs who were currently employed at the facility who were actively pursuing a BSN; RNs who considered enrolling in a BSN program within the next five years; or RNs who were not considering moving beyond an associate degree in nursing. The five-year time frame was selected as it represented the recommended 80% BSN by 2020 (IOM, 2011). A final purposive unique sample of nine (N = 9) participants was sufficient in reaching the point of saturation and most benefited results of the study. Data Collection Prior to any further research activity, informed consent was distributed and explained to interested participants who met the inclusion criteria. Once informed consent signatures were obtained, the interview process began. The individual in-depth interviews were guided by semi- structured, open-ended questions and additional probing questions (see Appendix) that addressed the primary research question. The interviews were audio-recorded and lasted from 30 to 60 minutes. Recordings were transcribed verbatim within 48 hours of each interview for accurate Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 126 content analysis. The study participants were given a pseudonym to ensure the anonymity of the nurses and the hospital included in the research. The primary concern in phenomenological research is rigor or trustworthiness that the participants’ experiences are accurately represented (Lincoln & Guba, 1985). Therefore, to establish credibility, confirmability, transferability, and dependability, identify potential biases and develop confidence in the researcher’s interpretation of data collected, strategies deployed included: peer debriefing and member checks, audio- recorded and transcribed interviews, with summaries sent to participants for review (Polit & Beck, 2017). Nine (N = 9) nurses currently working at the facility were interviewed. All nine participants were female as no male candidates chose to participate in the study. However, there was variance in other areas, see demographics (in Table 1.). Although residency was not listed on the survey, the participants volunteered information. Seven of the nine participants were local rural residents, while two participants lived outside the rural geographic area. The furthest commute was 60 miles one-way from the hospital. Table 1 Participant Population Demographics Participant Pseudonym Gender Age Ethnicity RN Practice Years RN Specialty Area Currently enrolled P 1 F 46 Caucasian 7 Med-Surg; LTC No P 2 F 51 Native American 29 ICU/CCU Yes P 3 F 56 Caucasian 30 ICU/CCU; Adm No P 4 F 29 Native American 5 Med-Surg Yes P 5 F 29 Caucasian 5 Telemetry Yes P 6 F 45 Caucasian 25 ED No P 7 F 44 Caucasian 6 Telemetry No P 8 F 50 Caucasian 27 ICU/CCU Yes P 9 F 51 Caucasian 29 Med-Surg, Telemetry, Adm No Abbreviations: Adm = Administration, ED = Emergency Department; ICU / CCU = Intensive Care Unit/ Cardiac Care Unit, Med-Surg = Medical Surgical, LTC = Long Term Care; Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 127 Findings Analysis of the findings revealed four primary themes: need for a BSN degree, challenges with the decision in pursuing a BSN, motivators for RNs to pursue a BSN, and support. Multiple sub-themes emerged in conjunction with the dominant themes. The themes and subthemes are identified and discussed in the analysis supported by excerpts from participant narratives. Table 2 Dominant Themes, Thematic Meaning units, and Thematic Frequencies Dominant Themes Thematic Meaning Units Frequency (N = 9) Percentages % Need for a BSN Feeling unprepared for expanded role 8 89 Job security 9 100 Entry level into practice 9 100 Professional identity 6 67 Challenges with the decision in pursuing a BSN Finances 8 89 Time and competing priorities 8 89 Motivators in the decision to pursue a BSN Tuition reimbursement 9 100 Flexibility 9 100 Accessibility and convenience 6 67 Career opportunities 5 56 Personal enrichment 5 56 Support Employer support 9 100 Peer support 9 100 Academic support 5 56 For most of the participants a career in nursing was prompted by altruism. Exemplars included “I enjoy caring for people” or “I really just like everything nursing has to offer regarding helping others.” Many chose a two-year program due to affordability, a quick timeframe to degree completion, and for some a BSN was not even an option, as the AD program was all that was available, especially in rural areas. The participants described how becoming a nurse, regardless of pathway to licensure, evoked “a sense of pride, a position of honor in their community”, and for most job security. For decades those tenets held true, until recently when mounting pressures to complete a BSN began to erode their sense of value and security. Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 128 Theme 1: Need for a BSN degree The first and most common theme derived from the data was the need for a BSN. The participants unanimously shared personal views of need to have versus nice to have a BSN. Several sub-themes emerged as most prominent: feeling unprepared for expanded role, job security, BSN as entry level into practice, and professional identity. Feeling unprepared. Magnified by calls from the IOM for a more educated nursing workforce, most participants described feeling unprepared for their expanded roles (IOM, 2011). Specifically, in regard to leadership, managed care, and systems thinking. Participants’ comments included, “My nursing program did a wonderful job in preparing for the actual hands- on, but I don’t think they could have even thought of how to prepare us for today’s role” or “I could see now why schools need to be different, as even my role has expanded. I am a clinical leader and was never prepared for my expanded role” and “I don’t feel the associate program I attended prepared you to be any type of leader.” Job security. Traditionally, RN positions, regardless of educational pathway were assumed to be recession proof, as one participant commented, “When I was a senior in high school my father said nursing was a stable job, the economy was going to crap and nursing meant job security.” The RNs who initially felt secure are finding themselves in a much different predicament, “We were recently notified that a degree would be mandatory in the near future, especially for management positions . . . so to have a job or the job I want in the next few years I will need to go back to school for my BSN.” The participants noted that hospitals are preferentially hiring newly licensed RNs with a BSN or if associate degree nurses do get hired, they are usually required to earn a BSN within a specified period. The idea of poor job prospects prompted a sense Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 129 of urgency. Several participants shared: “We are literally stuck without a BSN” or “In the BSN program they talk about the future of nursing 80% BSN by 2020 . . . it scared me. I thought, I better get this done because I am not going to have a job”. Another nurse shared, “Magnet hospitals won’t even interview you unless you have bachelor degree, education is becoming a big deal”. Entry level into practice. All of the participants unwaveringly expressed the need for a BSN as the sole entry into practice. The finding was particularly notable as it shed light on recent perspectives of the decades long debate on entry level into practice. Participants expressively described how they would advise someone interested in an education in nursing, “I would say a BSN because here I am now at my age trying to get my BSN, it’s challenging. I don’t think I want to see others go through that.” or “Do it all now (get a BSN). Go all the way.” Others described confusion over multiple pathways and being uninformed, one poignant response: They (magnet hospitals) now want a BSN . . . and for the present employees who don’t a have a BSN the hospitals now have a set period of time they want you to continue education, even floor nurses. So why would schools offer two-year programs that are not going to be useful in finding a job” . . . “I believe it will begin to look bad on them (ADN programs) because their students won’t be getting hired.” Participants expressed feelings of regret and disappointment of not initially pursuing a BSN, “I wish I knew then what I know now, I would have gone all the way.” One participant felt misinformed by the concept of a 2-year program and shared, “by the time I graduated nursing school I almost had four years of training, I could have just went and got a BSN.” Professional identity. Several participants shared they felt less credible not having a professional degree, “I want us (nurses) to be respected . . . it is important for nursing to be looked at as a profession that is viewed beyond those who are just doing things such as emptying bedpans Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 130 or bathing someone.” Another shared, “As community nurses in a small rural hospital, we do so much and are given so much responsibility and frankly, never receive the credit we deserve. To get credit and be recognized we need to have more education.” Theme 2: Challenges with the Decision in Pursuing a BSN The RNs described overwhelming challenges with their decision in academic progression, especially regarding finances and time commitments. Evidenced by one response, “Believe me ... I have given this (a BSN) more than a second thought . . . and there is no easy way at this time.” Overwhelmingly, financial burdens, i.e. the cost of tuition was a major challenge. Adult learners have homes, families, and added responsibilities. Participants looked at tuition costs as an additional burden to everyday living expenses, “I have to work 12-hour days. I have three kids, two of them in school, attend classes, affording the classes while having your regular everyday life expenses, I would say these are huge challenges.” Another participant reflected, Finances is my number one (challenge). And it’s not that I don’t want a bachelor degree … I am a widow with two kids in college . . . the thought of going back to school is difficult for me because I just can’t afford it. I am looking at way too much debt with my own kids’ student loans. Several RNs did not see the advantage of a BSN when additional remuneration is not offered, “It’s a big financial commitment . . . and unfortunately, you are not guaranteed to make any more money.” Older RNs do not feel that they will see a return on their investment, “A BSN is not financially feasible” and “Cost is a big issue right now, we do get tuition reimbursement, but it is just a fraction of the cost” and a senior nurse noted, “Younger nurses can recoup their investment, but will I be able to?” Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 131 Time and competing priorities. Balancing their personal lives with workplace responsibilities with the challenges of a RN re-entry placed undo pressures on those RNs who have or are considering academic progression as described by several nurses, “Time was a huge factor in my decision”, “Family time is a big challenge” and “As a single mom, time is a big challenge . . . mainly between working full-time and raising my daughter.” Another participant articulated, “Time is a big challenge. I usually work three to four 12-hour shifts each week . . . I would need eight hour shifts to go to school . . . so time is a huge factor”. Theme 3: Motivators for RNs to Pursue a BSN The third theme revealed strong motivators such as employer-based incentives, academic incentives, and personal incentives of career opportunities and personal enrichment. Tuition reimbursement. A surprising finding was that when finances were not considered an issue 100% of respondents were prepared to seek a BSN and possibly a graduate degree, “the thought of going back is difficult for me because I just can’t afford it ... if I were offered to go to school for free I would go.” and “The hospital offered some tuition reimbursement so I enrolled ... tuition reimbursement really, really helped.” Flexibility. Flexible scheduling was significant as several participants described how flexibility has or would influence their decision: “I changed jobs so I could work three 12-hour shifts ... my new schedule will give me more flexibility and time for studying.” or “Flexibility is a big deal ... I need a schedule that accommodates my full-time schedule” and “If I would be allowed to have a more flexible schedule, I would be interested in going back.” Accessibility and convenience. The nurses acknowledged that they face additional challenges of being rural and long-distance commutes when considering RN re-entry. Several participants noted an alternative to travel is distance learning. Online options were particularly Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 132 appealing, “I chose an online program ... it’s perfect for me. I am older. I have kids. If I actually went back to school full-time and had to leave home for class, I think my husband would divorce me” and another revealed: “What really attracted me (to enroll in a BSN program) was that the program was entirely online. For me that was huge ... I have three children all still home in various activities. I work full-time. I could just not do it ... sitting in a class even one night a week. However, not all of the participants embraced online learning as one participant shared: Convenience is huge! One school conducted on-site classes at the hospital; but they are no longer at our site anymore. I am not sure why ... having classes at the hospital is very convenient ... most of us actually live in the area ... I am not driving 40, 50 or more miles to go to class ... and I am not ready for online learning yet ... I am not computer savvy. Conversely, for one participant limited band-width was another obstacle to web-based programs, “I don’t have good internet access at home; being in this rural area I am in a dead zone ... so internet is an issue for me at home”. Career opportunities. Several of the participants are at the point in their careers where they are evaluating future prospects and responded with an optimistic tone when relating the possibilities of opportunity and options with a higher degree: “Having a BSN is a motivator as in when the opportunity comes and I want to do it ... I can!” and “With a BSN you have choices, you’re not limited ... I would like to do clinical teaching with nursing students”, another commented, “I am looking for some type of leadership role ... I want to mentor young nurses in a role that will make a difference.” The participants commented that having a BSN would make it easier for obtaining promotions, leadership positions, and possibly an educator role. Several of the older participants talked about career mobility and career options in the context of advancing age Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 133 and the possibility of not being able to continue to physically perform in their current staff positions, “I am close to fifty, and at work, it is becoming physically harder to be on your feet. It is a lot of physical labor in which I am getting too old to do.” Another participant shared similar feelings, “Will I be able to continue the kind of nursing that I am doing now, it is physically challenging ... lugging, and lifting, and pulling, I am feeling my age ... I will need at a BSN degree to change that.” Personal enrichment. Several nurses talked about a BSN in terms of personal growth and enrichment as intrinsic incentives that influenced their decision, “I enrolled in a BSN program because it is more of a self-growth type of thing that I feel I need to do this” or “I know that my children are watching me as I go to school and I am hoping they see a good mentor.” Other’s shared, “I wanted to pursue my career further just for personal achievement and personal pride” and “Since I started the BSN program, I am more open-minded, I am learning to look beyond the obvious simple answers and understand the reasoning that goes into the process of nursing” or “I especially like research and evidence-based practice and I know that I will need additional education to make that happen ... I was never satisfied with just doing!” Theme 4: Support Overwhelming responses expressed the need for some type of support in the decision for academic progression. Support ranged from the most basic of how to get started in a BSN program, choosing a program, program availability, and the application process, to other types of support from family, employers, academic advisors, and participants’ peers. Professional isolation was of particular concern as the participants reported there are few nurses at the BSN or graduate level at the hospital. The nurses noted they are often self-encouragers since there are few mentors or positive role models and they would like that to change, “That (RN- BSN) will be an uphill battle Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 134 for me. I believe we need mentors, which we don’t have at our hospital at this time.” Others indicated that they “Don’t feel supported” regarding continuing education and strongly expressed the desire for more guidance and support in their decision for RN re-entry. Employer support was viewed as encouragement for lifelong learning, one participant noted, “My last employer started asking me when you are going to go back to school ... that actually gave me the confidence that prompted me to eventually start a BSN program.” Support and encouragement from contemporaries influenced the final decision to go back to school as one RN recounted: I actually considered going back due to my peers prompting me. I work in such a small little hospital where everyone knows who’s going to school or wants to go to school ... we are all supportive of each other. We all trade textbooks, notes ... there’s not much support from administration so we try to support each other ... we’re all part of the sisterhood. Limitations Limitations includes participant diversity. The setting was a small rural community hospital which limited the ability to recruit a more diverse participant pool specifically regarding gender differences. Discussion Academic progression can be a challenge for most associate degree RNs (Burman & Fahrenwald, 2018; Molanari et al., 2011; Probst, 2019; Jones-Schenk, Leafman, Wallace & Allen, 2017). The rural nurses in this study felt particularly challenged when considering RN-BSN program reentry. Findings revealed that system and community support for educational attainment including tuition reimbursement, mentoring, accessibility and flexible scheduling were key factors in their decision. Noteworthy, are rural hospitals who for the most part remain under sourced and understaffed which in turn limits the ability to offer much needed incentives for rural RNs to Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 135 engage in higher education (Burman & Fahrenwald, 2018; Jones-Schenk et al., 2017; Probst, 2019). Implications for practice include rural hospitals to seek funding and scholarships from local, regional, and statewide entities in an effort to support rural RNs in pursuit of academic progression. The findings also revealed that in comparison to urban areas, rural nurses have limited opportunities for professional development which impedes efforts to remain current. Supported by the literature, when interacting with larger, metropolitan facilities, rural RNs described feeling that they are perceived as under educated and incompetent as compared to their urban counterparts (Medves et al. 2015, p. 24). The study findings indicated that by necessity rural nurses often rely on their colleagues for support and information regarding higher education. Likewise, social capital through shared experiences and resilience are perceived as powerful bonds for rural nurses (Burman & Fahrenwald, 2018; Younge, Myrick, Ferguson & Grundy, 2013a). Implications for nursing education includes nursing programs to develop or revise curricula making higher education for rural nurses affordable, relevant and accessible. Similarly, findings revealed that the RNs felt misinformed when initially choosing an associate degree nursing program. Early advisement and mentoring would facilitate their educational journey for higher education. Current efforts for unique academic partnerships and distance learning options are steps in the right direction but remain isolated and need to expand (Burman & Fahrenwald, 2018). Perhaps findings from this study will provide new developments in bridging the ongoing entry level into practice debate. Lastly, it is hoped that these findings send a compelling message to legislative bodies and nursing education policy makers for the need to be cognizant to the realities of rural nursing practice and education. A rural lens can assist in developing relevant policies and practices to promote a higher educated rural nursing workforce. Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 136 Conclusion Higher education in nursing is now a key imperative. Findings from this study revealed rare up close and personal perspectives from rural nurses to the struggles and rewards they experience in their decision in academic progression. Clearly evidenced from the findings was rural RNs have a strong interest in higher education and are motivated by the need for a BSN specifically in regard to job security, professional identity, professional development, and career mobility. Still, they want their voices to be heard regarding the unique challenges that rural nurses face in the pursuit of a BSN, especially regarding the need for mentoring, employer support and financial resources. Health care employers and academic administrators have the responsibility to assure that all nurses are prepared for the challenges in healthcare for the 21st century. Educating and supporting practicing nurses as well as those entering the profession of the appreciable benefits to higher education is paramount in providing a more qualified rural nursing workforce equipped to meet the growing healthcare needs of rural populations. Recommendations for further research This study provided the foundation for further research to quantify and analyze the efficacy of academic progression and the effect on patient outcomes in rural areas. Further research is needed on the efficacy of academic progression in increasing the numbers of advanced practice nurses in rural areas. Considering the importance of finances, research to explore the relationship between financial assistance for higher education and the impact on enrollment for rural nurses in RN-BSN programs would be beneficial. 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Retrieved from https://rnojournal.binghamton.edu/index.php/RNO/article/view/216 Online Journal of Rural Nursing and Health Care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 141 APPENDIX A Each interview began with social greetings, which created a warm, friendly atmosphere inviting casual conservation. What followed was a review of the informed consent that had been previously distributed. It was stressed that the interview would be audio-recorded to preserve the integrity of the data and that the interview would last up to one hour; each participant reconfirmed consent to be recorded. 1.“Tell me about your decision to choose nursing”. The broad statement was intended to yield rich information on the participants lived experience in the decision to choose nursing as a career. Probes, “What influenced your choice on nursing school”? “Tell me how you feel the nursing program prepared you for the expanded roles in nursing”? “Can you give me a for instance? Probing helped unfold implications and dynamics of the initial question. 2. “What are your thoughts on moving forward in your nursing career”? “Can you give me an example”? “Tell me about where you see yourself as a nurse in the next five years”? 3. “What are your thoughts on furthering your nursing education”? “What does back to school mean for you”? “Tell me about your personal view of obtaining a BSN degree”? “How would you describe personal challenges, if any, in pursuing a BSN”? “What would motivate you to go back to school”? Can you tell me how you would direct someone interested in a nursing career”? Can you explain why? The researcher adjusted throughout the interview process such as “can you tell me more about ... or can you expand on that point?” ending with 4. “Is there anything else you would like to share?” Participants were invited to share thoughts, reflections, or feelings on nursing.