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. Author manuscript; available in PMC: 2021 Dec 3.
Published in final edited form as: J Nurs Educ. 2020 Oct 1;59(10):557–565. doi: 10.3928/01484834-20200921-04

“A National Survey of RN-to-BSN Programs: Are They Reaching Rural Students?”

Melinda A Merrell 1, Janice C Probst 2, Elizabeth Crouch 3, Demetrius A Abshire 4, Selina H McKinney 5, Eboni E Haynes 6
PMCID: PMC8641547  NIHMSID: NIHMS1653201  PMID: 33002161

Abstract

Background

Increased representation of Bachelor of Science in Nursing (BSN) prepared nurses improves health and reduces costs. Fewer rural U.S. nurses have BSN degrees compared to the national average. RN-to-BSN programs provide an opportunity to increase the number of BSN prepared rural nurses. However, the number of these programs targeting rural students is unknown.

Methods

Directors of RN-to-BSN programs were surveyed regarding program characteristics and efforts to target rural learners. Using mail and online return options, the response rate was 31.3%.

Results

Only 38% of programs targeted rural RNs for recruitment. Supports for rural student recruitment and retention, including partnerships with community colleges, rural clinical placements, and online offerings were limited in number and/or scope.

Conclusion

RN-to-BSN programs with the capacity to recruit and retain rural learners may help increase the number of BSN prepared rural nurses. Increased collaboration among stakeholders will support rural nurses in continuing their education.

Keywords: education, nursing, rural nursing, rural health, workforce

Introduction

The nursing profession has been charged to increase the proportion of Bachelor of Science (BSN) degree prepared nurses to 80% by 2020 (Institute of Medicine (IOM), 2010). BSN degree preparation among nurses has been associated with improved outcomes, including reduced patient morbidity, mortality, and associated costs (Aiken et al., 2017; Hawkins et al., 2018; National Advisory Council on Nurse Education and Practice (NACNEP), 2010). Nationally, over half of nurses have earned a bachelor’s degree or higher (Health Resources and Services Adminstration (HRSA) Bureau of Health Professions National Center for Health Workforce Analysis, 2013). In rural areas, however, Census data from 2011–2015 indicated that only 46% of nurses were bachelor’s prepared or better (Probst et al., 2019). This proportion has been found to decrease as rurality increases (Skillman et al., 2006; Smith et al., 2019).

Rural areas may especially benefit from a more highly educated nursing workforce that is better equipped to address medically complex patient populations (Baernholdt & Mark, 2009; Bratt et al., 2014). Rural residents tend to be older and have complex health issues associated with higher rates of chronic diseases, such as diabetes, cardiovascular disease, cancer, and mental health disorders (Barton & Azam, 2017). Despite patient complexity, nurses working in rural areas have reported higher patient to nurse caseloads than nurses working in urban areas (Baernholdt & Mark, 2009). Further, health care services in rural areas are often under-resourced or absent, resulting in challenges to providing care across the spectrum of needed services (Cramer et al., 2009). In this environment, rural nurses also experience more interpersonal demands due to their connections to the communities where they work (Bratt et al., 2014). These demands, as well as greater professional isolation and practice autonomy in rural nursing, require leadership skills that are taught during BSN preparation (Bratt et al., 2014; Spencer, 2008).

Educational efforts to increase the number of nurses obtaining BSN degrees include registered nurse (RN)-to-BSN and other “bridge” programs, which fill educational gaps between diploma or associate level nursing preparation and baccalaureate education (American Association of Colleges of Nursing (AACN), 2008; IOM, 2010). Given the relatively high proportion of associate degree RNs in rural areas, RN-to-BSN programs are well-positioned for encouraging development of a more highly educated nursing workforce in rural areas (HRSA Bureau of Health Professions National Center for Health Workforce Analysis, 2013). Hospital-led efforts to hire bachelor’s prepared nurses for maintenance of accreditation or Magnet status increases the demand for a more highly educated workforce (Conner & Thielemann, 2013; NACNEP, 2010). As of late fall 2018, 777 schools in the U.S. offered RN-to-BSN programs (AACN, 2019a).

To date, there has not been an examination of if or how RN-to-BSN programs specifically target rural nurses for recruitment and retention in their programs. Although some RN-to-BSN programs reportedly focus on rural nursing, the overall number, distribution, and characteristics of these programs is unknown (Hawkins et al., 2018; Southwest Minnesota State University, n.d.). A previous national survey of RN-to-BSN programs did not examine this issue (McEwen et al., 2012). In addition, since the time this previous national survey was conducted, the total number of RN-to-BSN programs has increased 20%. An examination in both overall changes in the characteristics of RN-to-BSN programs over time, as well as their interest in and capacity for educating nurses in rural areas, is warranted.

Our study addresses this important gap, using a national survey of RN-to-BSN programs to better understand the potential role of these programs in addressing disparities in BSN prepared nurses between rural and urban areas. These results are needed to inform policy makers and stakeholders who are responsible for addressing the status and needs of nursing education.

Methods

Study Population

A survey was mailed to all U.S. RN-to-BSN program directors in 2018, using a mailing list of accredited programs obtained from the American Association of Colleges of Nursing (AACN) (n = 758). Three mailings were conducted that included a cover letter, the survey, and a pre-addressed stamped envelope for survey return. The survey also included an online completion option using a website or QR code for mobile devices. Fifteen duplicate responses were received with only the first response retained.

Responses were submitted by 247 of the 758 RN-to-BSN programs, yielding a survey response rate of 32.6%. Ten surveys were dropped either when respondents noted that the RN-to-BSN program had been dropped or had zero enrollment, or when program data was incomplete or missing. The final sample included 237 responses for a survey completion rate of 31.3%. This rate is comparable to the response received for the previous survey of programs (McEwen et al., 2012). Physical location of the program in a rural versus urban area was not established for the study.

Survey Instrument

Survey development was based on prior literature about RN-to-BSN programs as well as an informed review by a panel of external nurse-educators. These educators were recruited to review draft questions and provide content suggestions and recommendations. The survey addressed overall characteristics of RN-to-BSN programs as well as their interest in and capacity for serving rural nursing students. Overall characteristics queried included general program information (e.g., institution type, size of program) and program requirements (e.g., student time to completion, GPA requirements).

Under the subhead “about your program and rural learners,” program leaders were first asked “does your program specifically target rural RNs in its recruiting efforts?” with possible responses of yes or no. Given the educational gaps between rural and urban RNs, we wished to ascertain the proportion of RN-to-BSN programs with this focus. Subsequent questions addressed the proportion of rural students among all learners, rural health curricular content, student learning challenges, interprofessional education opportunities, and distance learning. Questions about rural-specific curricular content were asked to assess the proportion of programs that were addressing this topic area (Holland et al., 2019). In the areas of recruitment, retention, online learning, and clinical placement, program leaders were asked to evaluate potential student barriers separately for rural and urban learners.

Analyses

Study staff transcribed written questionnaires. Data were exported into Excel and subsequently analyzed using Stata version 16 (StataCorp, 2019). Descriptive statistics were used to report survey findings. Chi-square and one-way ANOVA were used to analyze bi-variate results by programs’ self-reported status of their efforts to target rural RNs for program recruitment. The study was declared Not Human Subjects research on December 18, 2017 by the University of South Carolina Institutional Review Board.

Results

Characteristics of programs

RN-to-BSN programs were primarily housed in public university settings (52.7%), followed by private university settings (37.1%) (Table 1). In addition to RN-to-BSN program offerings, 176 institutions also offered traditional BSN programs (74.3%), 154 offered Master of Science in Nursing (MSN) programs (65.0%), 93 offered PhD/Doctor of Nursing Practice (DNP) programs (39.2%) and 39 offered Associate Degree of Nursing (ADN) programs (16.5%). Twenty-eight responses for “other programs” included five institutions with an LPN/LVN-to-BSN offering.

Table 1:

Characteristics of RN-to-BSN programs responding to survey

Characteristic All Programs (n=237) [Mean (SD)] Targets Rural RNs for Recruitment (n=90) [Mean (SD)] Does NOT Target Rural RNs for Recruitment (n=144) [Mean (SD)] p-value
Institution Type Public university 52.7% 56.7% 49.3% 0.209
Private university 37.1% 32.2% 41.0%
Community or technical college 5.1% 7.8% 3.5%
Public medical center 0.8% 2.2% 0.0%
Private medical center 0.8% 0.0% 1.4%
Other/Missing/Blank 3.4% 1.1% 4.9%
Programs Offered* RN-to-BSN 100% 38.0% 60.8% ---
BSN 74.3% 72.2% 75.7% 0.802
MSN 65.0% 60.0% 68.8% 0.202
PhD/DNP 39.2% 33.3% 43.1% 0.326
ADN 16.5% 18.9% 13.9% 0.037
LPN/LVN 6.3% 10.0% 4.2% 0.184
Other 11.8% 7.8% 14.6% 0.238
Number of Students Currently Enrolled 161.1 (502.3) 193.0 (748.0) 139.7 (253.2) 0.672
Number of Students Accepted on Average Past 5 Years 119.3 (672.5) 178.2 (1077.7) 80.4 (138.8) 0.480
Number of Students Graduating Each Year 65.2 (145.0) 63.6 (167.4) 65.6 (129.8) 0.839
Collaborate with Community Colleges Yes 41.4% 50.0% 36.8% <0.001
No 57.8% 50.0% 63.2%
Missing/Blank 0.8% 0.0% 0.0%
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*

Multiple response option

Bolded / italicized: significant p-value at < 0.05

Current student enrollment in RN-to-BSN programs ranged from one student to 7,027 with a mean of 161 students. Less than half of programs (45.2%) reported a current enrollment of less than 50 students while 29.5% of programs reported more than 125 enrolled. The number of students accepted on average annually for the past five years had a mean of 119 students (range 2–10,150). Only eight programs (3.4%) reported turning down qualified applicants due to a lack of capacity. The mean number of students graduating from RN-to-BSN programs each year was 65 (range 0–1,500). Nearly a quarter of programs (23.3%) reported more than 75 graduates per year. Eighteen programs reported receiving grant funding; of these, 39% reported receiving Federal grants, 50% reported state grants, and 28% reported foundation support.

Credit hours required in RN-to-BSN programs ranged from 16–120 for nursing hours (median = 31; mean = 38.7) and 0–112 for non-nursing hours (median = 42; mean = 41.3). BSN credit hours that were required to be taken at the institution granting the RN-to-BSN degree ranged from 0.25 to 180 (median = 30; mean = 38.5). Most programs estimated time to completion among full-time students at 9–12 months (43.0%). Among part-time students, this estimate rose to 19–24 months (46.8% of programs). Just over half of programs required students to complete the RN-to-BSN program in a certain time frame (50.2%). These programs reported a median of 60 months as the maximum time allotment. Minimum GPA requirements for program entrance and maintenance of enrollment were reported by 209 (88.2%) and 200 (84.4%) programs respectively. Ninety-eight programs (41.4%) reported collaborating with community colleges to offer courses to students.

Regarding the environment of their course delivery, just over half of programs (50.6%) reported that their course offerings were online only and 45.2% reported that they were a hybrid program, with some courses offered online and some in the classroom setting. Considering only nursing courses required for RN-to-BSN completion, respondents reported 68.4% of the courses were online only with 27.0% reporting hybrid course offerings. Almost two-thirds of respondents (65.8%) reported that 100% of their students take online courses each year.

Addressing rural learners

Ninety RN-to-BSN programs (38.0%) reported that they specifically target rural RNs in their student recruitment efforts. Institutions that targeted recruitment of rural RNs to their RN-to-BSN programs were significantly more likely to offer ADN programs compared to those not targeting rural RNs (18.9% versus 13.9%; p=0.037; Table 1). Also, programs targeting rural RNs were significantly more likely to report community college collaborations than those that did not (50.0% versus 36.8%; p<0.001; Table 1).

Program responses regarding the proportion of learners from rural areas was nearly evenly split between the available response categories, with 26.6% of programs reporting less than a quarter of their students were from rural communities, 22.4% reporting between a quarter and a half, 25.7% reporting more than half, and the remaining 25.3% of responses either “unable to determine” or left blank (Table 2). Programs reporting that they target recruitment of rural RNs were significantly more likely to report having more than 50% rural students compared to programs not targeting rural RNs (51.1% versus 9.7%; p<0.001; Table 2).

Table 2:

RN-to-BSN programs’ targeting of rural learners

Characteristic All Programs (n=237) Targets Rural RNs for Recruitment (n=90) Does NOT Target Rural RNs for Recruitment (n=144) p-value
Percent of RN-to-BSN students from rural communities <25% 26.6% 14.4% 34.7% <0.001
25–50% 22.4% 25.6% 20.8%
>50% 25.7% 51.1% 9.7%
Unable to determine/
Missing/Blank 		25.3% 8.9% 34.7%
Percent of qualified applicants from rural communities not admitted due to lack of capacity Admitted all rural applicants 65.0% 86.7% 52.1% <0.001
Did not admit this percent of our rural applicants (0.25–1%) 1.7% 2.2% 1.4%
Unable to determine/
Missing/Blank 		33.3% 11.1% 46.5%
Percent of RN-to-BSN students commuting from rural <25% 22.4% 18.9% 25.0% <0.001
25–50% 5.9% 6.7% 5.6%
>50% 10.1% 20.0% 4.2%
Program is 100% online 28.7% 37.8% 22.9%
Unable to determine/
Missing/Blank 		32.9% 16.7% 42.4%
Offer content specifically prepares for rural health practice Yes 43.5% 66.7% 29.2% <0.001
No 55.7% 33.3% 70.8%
Missing/Blank 0.8% 0.0% 0.0%
If yes*, Rural health content included in other courses 68.0% 60.0% 78.6% 0.111
Clinical placements in rural 48.5% 58.3% 35.7% 0.049
Full course on rural health 12.6% 13.3% 11.9% 0.909
Other 12.6% 15.0% 9.5% 0.664
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*

Multiple response option

Bolded / italicized: significant p-value at < 0.05

Almost two-thirds of all programs indicated that they admitted all qualified rural applicants (n=154; 65.0%; Table 2). Most programs responded either “unable to determine” or left their answer blank for the proportion of RN-to-BSN students that commute from rural areas (n=78; 32.9%). This finding was more frequent among programs that did not target rural RNs for recruitment compared to those that did (42.4% versus 16.7%; p<0.001). Sixty-eight programs (28.7%) reported that their program is 100% online; 37.8% of these programs targeted rural RNs, while 22.9% of these programs did not (p<0.001).

Slightly less than half of programs reported offering content intended to specifically prepare students for rural health practice (n=103, 43.5%; Table 2). Programs targeting recruitment of rural RNs were significantly more likely to respond that they offered this content compared to those that did not target rural RNs (66.7% versus 29.2%, p<0.001). This content was primarily offered as part of other courses (68.0%) but 13 programs offered a full course on rural health (12.6%). Programs that targeted rural RNs were significantly more likely to offer clinical placements in rural communities compared to those that did not (58.3% versus 35.7%; p=0.049; Table 2). Twelve programs (5.1%) responded that at least three-quarters of their students take a rural health course each year.

Programs’ student recruitment and retention strategies and barriers

The top three recruitment strategies utilized by RN-to-BSN programs included recruiting at health care agencies (94.5% of programs), recruiting at schools with other nursing programs (85.2%), and social media (72.6%) (Table 3). Recruitment strategies were not different based on the programs’ self-reported intention of targeting rural RNs. Most respondents did not differentiate recruitment or retention outcomes based on residence of their students (e.g. rural versus urban), as survey questions asking for rural-urban comparisons resulted in high non-response rates. Further, almost a third of programs (30.8%) stated that they do not track student recruits by their home location.

Table 3:

RN-to-BSN programs’ student recruitment methods

Recruitment Method* All Programs (n = 237) Targets Rural RNs for Recruitment (n=90) Does NOT Target Rural RNs for Recruitment (n=144) p-value
Recruiting at health care agencies (e.g. hospitals, long term care facilities) 94.5% 94.4% 95.1% 0.100
Recruiting at schools with other nursing programs (e.g. ADN, LPN) 85.2% 84.4% 85.4% 0.753
Social media 72.6% 74.4% 71.5% 0.865
Open houses [at own institution] 70.0% 72.2% 69.4% 0.340
Recruiting at conferences 59.1% 65.6% 55.6% 0.210
Formal partnerships with health care agencies (e.g. tuition reimbursement, reduced tuition for employees) 57.0% 60.0% 55.6% 0.566
Formal partnerships with other agencies/employers 29.5% 34.4% 26.4% 0.417
Formal partnerships with the Veterans Administration 7.2% 10.0% 5.6% 0.391
Other 17.7% 15.6% 18.8% 0.639
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*

Multiple response option

Bolded / italicized: significant p-value at < 0.05

Barriers to recruitment and retention most often identified by RN-to-BSN program directors were student difficulties in balancing family and work obligations (73% and 72.2% respectively). Cost of tuition was also reported as a barrier to student recruitment by a majority of programs (56.5%) (Table 4). An issue for retention was the ability for students to identify clinical placements, with 24.5% of programs overall reporting difficulty with this. The most common reason for students having issues with finding placements was limited capacity at training sites (16.9%). Student barriers associated with online courses, as reported by program directors, were primarily balancing school, work, and family obligations (80.2% of programs) (Table 5). Rural-relevant issues associated with online courses that were reported as challenging for students included poor internet connectivity (26.2% of programs), lack of internet where student resides (15.2%), and lack of affordable internet (10.6%).

Table 4:

Barriers to student recruitment for RN-to-BSN programs, any student

Potential Barrier* All Programs (n = 237)
Family obligations of prospective students 73.0%
Work obligations of prospective students 72.2%
Cost of tuition 56.5%
Required non-nursing courses 46.0%
Lack of tuition reimbursement by employers 42.2%
Lack of student loan forgiveness programs 36.3%
Length of time to degree completion 22.4%
Lack of preferential hiring of BSN-prepared nurses 21.1%
Distance prospective students must travel 12.2%
Lack of capacity (e.g. shortage of nurse faculty or clinical sites for training) 6.3%
Other 11.0%
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*

Multiple response option

Table 5:

Faculty and student challenges with distance learning perceived by directors of RN-to-BSN programs, any student

Potential Challenge* Faculty Students
All Programs (n = 237) All Programs (n = 237)
Campus IT assistance unavailable after hours 29.1% 27.4%
Limited IT skills 26.2% 46.8%
Poor internet connectivity 16.9% 26.2%
Faculty disinterest in teaching in an online environment 12.7% ---
Cost of online course delivery platforms 10.1% ---
Difficulty balancing school/work/family --- 80.2%
Poor academic preparation --- 31.2%
Lack of internet where students reside --- 15.2%
Lack of computer ownership by students --- 11.0%
Student disinterest in taking courses offered online --- 10.6%
Lack of affordable internet access --- 10.6%
Other 17.3% 3.4%
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*

Multiple response option

A majority of programs were able to offer special projects outside of the classroom setting to address rural health needs (55.7%). These included projects that were policy/advocacy oriented (n=63), community service oriented (n=107), or other (n=37). Other responses included but were not limited to community assessments or practicums (n=6), study abroad/mission work (n=6), community health fairs/clinics (n=4), and community-based research (n=3).

Discussion

Our study examined the current status of U.S. RN-to-BSN programs, specifically focusing on the degree to which programs target and serve rural students. Consistent with previous research, just over half of RN-to-BSN programs responding to our survey were in public universities and approximately 40% of programs were in private universities (McEwen et al., 2012). This study also confirmed previous findings of small program sizes and common program lengths (McEwen et al., 2012). From the previous study to this one, enrollment of more than 125 students increased from 21% to 29.5% and more than 75 graduates per year increased from 13% to 23.3% (McEwen et al., 2012). This suggests efforts to increase the number of BSN prepared nurses are escalating, despite nursing faculty shortages (AACN, 2019b).

The increasing number of BSN prepared nurses may be due, in part, to employer preferences and/or requirements to hire nurses who have obtained the BSN degree. As of August 2018, nearly 90% of hospitals and other health care providers reported a strong preference for new nursing hires to have a BSN, while 46% reported having the BSN degree as a requirement for employment (AACN, 2019c). Employers may also have to comply with new state laws that require the BSN for new nurses. For example, New York recently enacted a law requiring future nurses to obtain their BSN within 10 years of their initial licensure (State of New York, 2017).

Advancing education specifically among rural nurses is critical to reducing health disparities between rural and urban populations, yet only 38% of RN-to-BSN programs specifically recruited rural RNs (IOM, 2011). By comparison, 54% of U.S. nurse practitioner (NP) programs reported actively recruiting students from rural areas, despite 92% of their program locations being in urban areas (Skillman et al., 2014). Encouragingly, programs that targeted rural RNs for recruitment more frequently offered ADN programs as well, suggesting the possible recognition of the need for a “pipeline” to BSN studies for rural nursing students.

To increase the overall number of BSN prepared nurses, the AACN has called for collaborations with community colleges (Conner & Thielemann, 2013). In our study, only 41% of RN-to-BSN programs reported ongoing collaborations with these institutions. Community college partnerships may help decrease the rural-urban BSN disparity, as they are broadly available, cost-effective sources of nursing education in rural areas that have multiple recruiting advantages (AACN, n.d.; Conner & Thielemann, 2013; Farmer et al., 2017; Hawkins et al., 2018; Swearingen et al., 2013).

Concurrent enrollment models between community colleges and universities may be an effective strategy for producing additional rural BSN graduates. These models may include flexibility that, for example, allows students to obtain a non-nursing associate degree while transitioning into a BSN program. One example from Colorado includes introductory nursing courses co-taught by community college and university faculty in both locations during the first year with a transition to the university campus for years two and three (Goode et al., 2016). These types of collaborations will also be necessary to reach the overall goal of increasing the number of BSN prepared nurses, as the current level of capacity in baccalaureate nursing education is insufficient to meet the demand (Orsolini-Hain, 2012). In order to accelerate these efforts, leadership investment from both ADN and BSN programs is needed to provide resources and release-time for faculty to co-create seamless academic progression programs. Mutual respect, trust, and facilitative communication strategies are needed to nurture innovation among program leaders.

Academic-practice partnerships may also be effective for increasing the number of BSN prepared nurses in rural areas, and they may be necessary where employers and/or states require the BSN. Some universities are responding to the greater demand for BSN prepared nurses by offering even more flexibility in helping RNs who desire to pursue a BSN. These universities not only offer online course options, but also programs that can be completed face-to-face “at work” in local health care or technical college facilities and even competency-based programs that do not have strict time constraints, instead awarding the BSN after demonstration of mastery (Litwack & Brower, 2018). Competency-based programs especially allow universities the opportunity to engage their local health care partners to ensure program success, as well as to develop new competencies (e.g., interdisciplinary education) that become necessary as a result of health care reform (Orsolini-Hain, 2012). Collaboration between ADN and BSN programs and practice partners on a competency-based program model can result in a seamless academic progression that focuses on standardizing learning outcomes for nurses seeking the BSN (Carissimi & Burger, 2017).

Another flexible approach utilized by nurse educators in Alabama allows ADN prepared nurses to participate in a rural regional medical center’s BSN nurse residence program (Cheshire et al., 2017). A goal of this partnership is to incentivize nurses to pursue the BSN degree by allowing them to complete activities and assignments that align with shared objectives of the residency and RN-to-BSN programs. As reported by Cheshire and colleagues, the program has been highly successful with nearly 30 nurses completing both programs and an additional 25 nurses recruited for the RN-to-BSN program. This type of program demonstrates the potential benefit of academic-practice partnerships for a rural facility, which can use these models to “grow their own” thereby saving on recruitment and staff turnover costs in the future. For rural and underserved areas, academic-practice partnerships are a powerful amalgam that are properly aligned and incentivized to improve health care, with the greatest potential impact on vulnerable populations.

These partnerships may also address barriers for rural learners that occur as a result of a limited availability of placements at rural clinical sites. Approximately a quarter of RN-to-BSN programs reported that clinical placements were difficult in rural communities. Substituting clinical time with simulated patient care experiences may be another viable strategy to bolster clinical placement sites in rural areas, given evidence that replacing up to 50% of traditional nursing clinical hours with simulation does not adversely affect education outcomes (Hayden et al., 2014). However, guidelines for implementing simulation-based educational experiences may be difficult for programs targeting rural nurses to achieve due to costs or lack of appropriate facilities (Alexander et al., 2015). State boards of nursing should carefully consider the resource needs of rural nursing education when adopting policies or advocating for legislation that supports simulated patient care experiences.

Online RN-to-BSN programs could increase educational access for rural nurses by reducing barriers such as long driving distances to campus. In the previous survey of programs, those that were “exclusively online” accounted for 24% of responses; in the present study, this number increased to 29% (McEwen et al., 2012). Growth in online content was also indicated by an increase from two-thirds of courses offered in a hybrid format in the previous study to nearly all programs (n=227; 95.8%) reporting these offerings in our study. This is an expected finding given that, at the time of the previous survey, programs had reported plans to expand their efforts in this area (McEwen et al., 2012).

Online coursework is not without its challenges, however. Commonly cited barriers for students and educators in this study were limited information technology (IT) skills and the lack of IT assistance after hours. Limited student computer literacy has been previously reported by other RN-to-BSN programs (McEwen et al., 2013; Spencer, 2008). Lack of IT assistance may be especially problematic for rural nursing students, as broadband capacity is less available in rural areas (Hawkins et al., 2018; Prieger, 2013). Poor internet connectivity was cited as a barrier for students by just over a quarter of programs in our study. Quality of online-only programs may also be a concern, although similar educational outcomes have been found in studies comparing on-campus and online RN-to-BSN programs (Mancini et al., 2015; McEwen et al., 2013). Mitigating barriers to online education is another strategy that RN-to-BSN programs may consider in order to recruit and retain rural learners.

Over half of directors reported program cost as a barrier to student recruitment (Table 4). BSN programs are often very expensive, and financial burden is a commonly cited reason among nurses for not finishing their BSN (Duffy et al., 2014; Spetz & Bates, 2013). Low salaries among rural nurses may also be a contributing factor (Lindeke et al., 2005). Further, RN-to-BSN programs specifically have high attrition rates due to the time commitment needed for program completion (Jones-Schenk, 2017). The tradeoffs in time and cost can be demotivating for nurses, especially when employers reportedly do not guarantee more pay for the higher degree level (McEwen et al., 2013; Swearingen et al., 2013). Policies that assist rural nurses in furthering their education may include loan repayment programs for rural practice (HRSA Bureau of Health Workforce, n.d.). Nurses may also benefit from employer policies that allow them to transition to part-time work with full-time benefits while pursuing further education (Warshawsky et al., 2015). Accessible financial support in the form of scholarships and loan repayments has been shown to promote enrollment and retention (Conner & Thielemann, 2013; Hawkins et al., 2018; Skillman et al., 2014; Swearingen et al., 2013).

Strengths and Limitations

This study was limited in targeting only program directors that were identified by a list obtained from the AACN. However, as the major body representing nursing schools, this was the most likely source of survey respondents available. Physical location of programs in rural or urban areas was not available for analysis. Further, survey participants were not provided a definition of rural to consider when reporting on their targeting of those students. However, when definitions of online/hybrid course offerings were provided, unclear responses were received. Strengths included the national scope of the survey and the examination of RN-to-BSN programs’ targeting of rural learners, the latter of which has not been examined in prior literature.

Conclusions

With relatively few existing RN-to-BSN programs targeting and serving rural learners, the recommendation of the BSN as entry to professional nursing practice may be problematic for many rural nurses. Policy makers, educators, and stakeholders must collaborate to support these programs and other policies that assist and incentivize rural nurses to continue their education. Further, all nursing programs should be encouraged to target, recruit, and retain rural students as well as provide specific rural training opportunities for all students. Our findings give stakeholders a starting point on strategies to use to increase recruitment and retention of potential rural RN-to-BSN students. Ultimately, more rural RN-to-BSN graduates will lead to higher education levels among rural nurses and may improve patient outcomes among rural populations.

Acknowledgments

This study was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under cooperative agreement # U1CRH30539. The information, conclusions, and opinions expressed in this article are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred. Dr. Demetrius Abshire was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number K23MD013899.

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