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Factors influencing the pursuit of graduate education in registered nurses : exploring the motivators… Gorczyca, Catherine 2013

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     FACTORS INFLUENCING THE PURSUIT OF GRADUATE EDUCATION IN REGISTERED NURSES: EXPLORING THE MOTIVATORS AND BARRIERS   by    CATHERINE GORCZYCA B.S.N., University of British Columbia, 2007 B.A., University of Toronto, 2005    A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF   MASTER OF SCIENCE IN NURSING     in     THE FACULTY OF GRADUATE AND POSTDOCTORALSTUDIES THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)       November, 2013 ? Catherine Gorczyca, 2013 ii Abstract Graduate-prepared nurses play an important role in fulfilling leadership, administration, education, and advanced practice positions within academic and clinical practice settings. With only a slim majority of Canadian nurses holding a graduate degree as their highest level of education, concerns exist about how vacancies in advanced roles will be filled. Many research studies have focussed on the motivators and barriers to pursing higher education in adult learners in general and on those learners who have already made the decision to seek higher education.  This research question addressed the gap between both types of learners by examining the attitudes and perceptions of registered nurses who have never enrolled in graduate studies and their perceived motivators and barriers. The problem was examined from the perspective of adult nursing education and specifically used Cross?s (1981) chain-of-response? model. Cross?s model conceptualizes the intrinsic and the extrinsic factors that motivate adult participation in learning activities. A qualitative phenomenological study design was conducted and transcribed. For increased homogeneity, a convenience sample of eight registered nurses was divided into two focus groups based on their years of nursing experience. The major themes that emerged were categorized as: motivators, barriers, perceptions and attitudes. The motivators included having a professional goal, being personally and professionally challenged, and having a role model in the form of peer support and mentorship. The barriers are divided into three categories drawn from Cross?s (1981) work, which includes situational barriers of work-life balance and financial impact with a subtheme of age and personal and family commitments, institutional barriers related to the application process, and dispositional concerns around returning to study. iii The other general themes were perceptions and attitudes in respect to pursuing graduate education, and these included alternative educational opportunities, non-graduate careers, supporting resources, theory?practice gap, value of graduate education, and misconceptions of graduate level roles. The findings highlighted that more work needs to be done to promote the different opportunities and roles available for graduate-prepared nurses and to promote the resources available within both the academic and healthcare employment settings.  iv Preface This research was approved by the Providence Health Care Research Ethics Board. The Certificate Number of the Ethics Certificate obtained was H13-00899.   v Table of Contents Abstract ............................................................................................................................... ii Preface................................................................................................................................ iv Table of Contents .................................................................................................................v List of Figures ................................................................................................................... vii Acknowledgements .......................................................................................................... viii Chapter One: Introduction of Problem and Purpose ............................................................1 Purpose of the Study ................................................................................................3 Theoretical Framework ............................................................................................4 Definition of Terms..................................................................................................6 Summary ..................................................................................................................6 Chapter Two: Literature Review .........................................................................................7 Background ..............................................................................................................8 Theories of Participation in Adult Education ........................................................10 Motivators ..............................................................................................................11 Barriers ...................................................................................................................12 The Nursing Shortage: Beyond the Baccalaureate Level ......................................14 Chapter Three: Research Design and Methods ..................................................................18 Research Approach ................................................................................................18 Ethics and Human Subject Protection....................................................................19 Sample Selection and Recruitment ........................................................................20 Data Collection ......................................................................................................21 Data Analysis .........................................................................................................23 Rigour and Trustworthiness ...................................................................................25 Chapter Four: Findings ......................................................................................................27 Participant Demographic Information ...................................................................28 Motivators ..............................................................................................................29 Professional Goal .......................................................................................29 Personal and Professional Challenge .........................................................31 Role Modelling: Peer Support and Mentorship .........................................31 Barriers ...................................................................................................................32 Situational Barriers ....................................................................................33 Work-Life Balance.........................................................................33 Financial Impact.............................................................................34 Age .................................................................................................35 Personal and Family Commitments ...............................................35 Institutional Barriers ..................................................................................36 vi Dispositional Barriers ................................................................................37 Returning to Study .........................................................................38 Perceptions and Attitudes ......................................................................................39 Alternative Educational Opportunities ......................................................39 Non-Graduate Careers ...............................................................................40 Supporting Resources ................................................................................40 The Theory-Practice Gap ...........................................................................41 The Value of Graduate Education ..............................................................42 Misconceptions of Graduate Level Roles ..................................................43 Summary of Findings .............................................................................................44 Chapter Five: Discussion ...................................................................................................45 Recommendations ..................................................................................................51 Academic Institutions ................................................................................51 Healthcare Organizations ...........................................................................52 Limitations .................................................................................................53 Conclusions ............................................................................................................53 References ..........................................................................................................................57 Appendices .........................................................................................................................65 Appendix A: Consent Form ...................................................................................65 Appendix B: Focus Group Questions ....................................................................68 Appendix C: Focus Group Statements Summary ..................................................69   vii List of Figures Figure 1. Chain-of-response model for understanding participation in adult learning activities. .. 5 Figure 2. Thematic diagram of the factors influencing the pursuit of graduate education in registered nurses............................................................................................................................ 28  viii Acknowledgements I would like to express my sincerest gratitude to my thesis advisor, Dr. Bernie Garrett, for providing continuous support, enthusiasm, and wisdom throughout this process. I would like to express as much gratitude to the other two members of my thesis committee: Dr. Maura MacPhee and Elsie Tan. I have had the privilege of their guidance both as committee members in my graduate degree and also as my professors when I first started my nursing education in the undergraduate program. I would like to thank the Registered Nurses who participated in the focus groups featured in this project. I am grateful for their generosity with their time, effort, and insightful comments. My sincerest gratitude and heartfelt thanks to my nursing colleagues, who inspire me with their ability to bring nursing theory to life in their everyday practice. In particular, I would like to thank Barb Bedell, my mentor and role model, who I feel very fortunate to have had the opportunity to work with. I am so grateful for her wise words and belief in my ability to succeed. She was always there to give me the encouraging and supportive nudge that I needed each step of the way as I moved forward to where I am now. Lastly, I would like to thank my mom, dad, and brother. Your pride in me has been my motivation to always do my best. You have supported me all the way through my education, and I would not be where I am today without your love and encouraging words.  Chapter One: Introduction of Problem and Purpose 1 Chapter One: Introduction of Problem and Purpose Nursing is a profession which is increasingly developing its own research and body of literature. Nursing is no longer viewed as simply a practical occupation but a profession that values higher education as a means to build competent practitioners at all levels (Canadian Nurses Association [CNA], 2006; Watson, 2006). Arguably, nurses at all levels of education have experience which can significantly shape nursing practice. Only those nurses who pursue graduate studies, however, gain the research and advanced critical thinking skills required to take on higher level positions in the nursing domains of advanced clinical practice research, leadership, administration, and education. (National League for Nursing, 2011a; Plunkett, Iwasiw, & Kerr, 2010). In 2009, the total registered nurse (RN) workforce in Canada was 266,341. Of these, 8,576 were graduate prepared (master?s or doctorate), which is 3% of the total nursing workforce. Thirty eight percent of RNs had an undergraduate degree, and 59.1% were diploma prepared (Donner & Waddell, 2011). The shortage of graduate-prepared nurses may be a significant reason as to why higher level nursing positions administration and leadership are difficult to fill. As a consequence, nurses may assume these roles although they do not hold the most appropriate level of educational preparation (Plunkett et al., 2010). Interestingly, due to the shortage of qualified nurses who do hold a graduate degree, considerable competition exists amongst both universities and nonacademic healthcare institutions for hiring graduate qualified nurses (Cathro, 2011). Advanced education in nursing is crucial for preparing advanced practice nurses, which include clinical nurse specialists and nurse practitioners. A clinical nurse specialist generally specializes in a focussed area of clinical practice and acts as a leader and advocate for quality  Chapter One: Introduction of Problem and Purpose 2 healthcare provision. The role of a clinical nurse specialist can entail work as a clinician, consultant, educator, and researcher (CNA, 2009a). The role of the nurse practitioner in British Columbia includes an additional registration by the College of Registered Nurses of British Columbia. Nurse practitioners diagnose and treat acute and chronic illnesses from a holistic nursing perspective, and they also prescribe medications (Schreiber et al., 2003). Nursing literature has shown direct links between nurse leadership and healthy work environments. Healthy work environments, in turn, are associated with positive outcomes for staff and patients, such as lower staff turnover and better patient satisfaction (Sherman & Pross, 2010). An aspect of a healthy work environment is supporting nurses in having autonomy in their clinical practice. This support can include creating an environment that encourages formal continuing educational opportunities. Masters-prepared nurses have been shown to report higher professional autonomy in clinical nursing situations compared to those nurses who do not hold a master?s degree (Weston, 2010). A well-known fact among the public is that a general nursing shortage currently exists (Canadian Nurses Association, 2009b). The topic that is less frequently discussed among nurses and the public, however, is the shortage of qualified graduate-prepared nurses who can fulfill more advanced roles in leadership, administration, education, and research. The shortage of graduate-prepared nurses has a direct effect on the future of nursing for all nursing domains. This is particularly evident in the statistics for replacement and retention of nursing faculty (Berent & Anderko, 2011). The number of nurses who are qualified within the replacement pool (master?s and doctoral graduates) to succeed retiring university faculty is inadequate (Canadian Nurses Association & Canadian Association of Schools of Nursing [CNA & CASN], 2012).  Chapter One: Introduction of Problem and Purpose 3 A low percentage of graduate-prepared nurses needs consideration because the question remains: Who will fulfill advanced nursing roles within the domains of nursing, such as conducting research, taking on faculty positions, or providing professional leadership? All of these roles are necessary to continue to advance the science of nursing. With nursing being a key provider of care, which is increasingly evidence-based, the exploration of this issue is important. Undergraduate nursing education may not be enough to prepare the nurses, who find themselves in these roles, to be qualified at providing care and at finding resources that are well researched and based on the most current literature (Girot & Albarran, 2012). Purpose of the Study Without giving attention and support to the advanced preparation and higher education of nurses within all the domains of nursing, frontline nurses by providing undergraduate education, and moving the science of nursing forward through research in advanced clinical nursing, administration and leadership. The intention of this study was to illustrate that a significant need exists for nurses to be supported in filling advanced clinical, educational, and administrative roles, which will in turn support the frontline staff (Villeneuve & MacDonald, 2006). This study aimed to investigate the reasons that more RNs do not pursue higher education, specifically by exploring the motivators that RNs believe will support their pursuit of this academic endeavor and the barriers that they perceive to be deterring them from pursuing higher education. The overall research question for this study was: What are the perceptions and attitudes of registered nurses on the value of graduate nursing education? As a part of this, the study also addressed the following subquestions: 1. What are the perceived motivators to undertake graduate nursing education?  Chapter One: Introduction of Problem and Purpose 4 2. What are the perceived barriers towards pursing graduate nursing education? Theoretical Framework Many models and theories have been developed to explain and to understand the motivators and barriers for pursuing education (Boshier, 1973; Miller, 1967; Rubenson, 1977). Most of these frameworks stem from the discipline of adult education rather than healthcare. Studies in nurses? participation in education have paralleled studies of participation in adult education by examining the demographic characteristics of participants, motivators and the barriers. The nurses? studies, however, looked through the theoretical lens of general adult education (Thompson, 1992). In this study, I examined the problem from the perspective of adult nursing education and, to do this, I specifically used the Cross?s chain-of-response model (Cross, 1981). This model is an appropriate framework to investigate nurses? motivators and barriers in pursuing advanced education as the framework focuses on motivational theory in learning and, particularly, the individual?s perceptions of barriers and opportunities. Cross?s (1981) chain-of-response model is a conceptualization of the intrinsic and the extrinsic factors that motivate adult participation in learning activities. According to Cross, these factors are interrelated. The motivation to participate in adult learning activities is influenced by the strength of factors that support participation versus the strength of factors that deter from participation. Cross?s model represents a cycle, and the seven steps all have their own impact on the decision-making process about whether to participate and continue in adult education (see Figure 1). Interactions with different aspects of life within the model are reflected by connecting arrows. Cross believed that participation in a learning activity, whether in organized classes or self-directed, is  Chapter One: Introduction of Problem and Purpose 5 not a single act but the result of a chain of responses, each based on an evaluation of the position of the individual in his or her environment. Figure 1. Chain-of-response model for understanding participation in adult learning activities. Note. Reprinted from Adults as Learners (p. 124), by K. P. Cross, 1981, San Francisco, CA: Jossey-Bass. Copyright [1981] by Jossey-Bass. Reprinted with permission. Although participation in education can provide many opportunities, such as a new or promoted position at work or an increase in income, certain barriers can block a learner from have a chance at these opportunities. The barriers to participation are a central concept in the work of Cross (1981), which is why the model was valuable in examining the barriers to advanced education as perceived by nurses. The barriers are divided into three main categories: situational barriers, institutional barriers, and dispositional barriers. Situational barriers are personal life barriers such as a lack of money, time, or pressure from family, which deters the nurse from returning to graduate school. Institutional barriers stem from difficulties related to the institution that provides the education, such as the school being geographically far, classes being held at inconvenient times, admission requirements being stringent, or the school lacking student services. The institutional barrier relates to how much the potential learner knows about the educational program (Cross, 1981). In  Chapter One: Introduction of Problem and Purpose 6 the case of graduate nursing education, an institutional barrier could relate to a misunderstanding of the purpose of a master?s in nursing and the opportunities that this qualification can provide for a nurse?s career. Lastly, dispositional barriers are those that relate to the learner?s self-esteem and attitude towards learning and being a student. They include confidence to succeed, feeling too old, or being discouraged by a previous negative experience as a student. Definition of Terms For the purposes of this study, a nurse or study participant refers to an RN who is registered with the College of Registered Nurses of British Columbia. Advanced education, graduate education, and higher education will be terms used interchangeably to mean a master?s degree in nursing. A clinical nurse specialist (CNS) is an advanced practice nursing role recognized in Canada. A CNS is graduate prepared, generally specializes in a focussed area of clinical practice, and acts as a leader and advocate for quality healthcare provision. A CNS? job can include a role as clinician, consultant, educator, and researcher. A nurse practitioner (NP) is a graduate-prepared nurse who is registered with the College of Nursing under this designated title; an NP diagnoses and treats acute and chronic illnesses from a holistic nursing perspective and also prescribes medications (Schreiber et al., 2003). Summary This chapter described the importance of graduate nursing education for the profession. It also outlined the problem of the lack of graduate-prepared nurses and the effects this lack currently has on the nursing profession and will have in the future. The next chapter will review the current literature on the topic of motivators, barriers, and perceptions of graduate nursing education. Chapter Two: Literature Review 7 Chapter Two: Literature Review A literature search of peer-reviewed research articles and journals was conducted using the databases Google Scholar, CINAHL, and ERIC. I used different combinations and individual searches of keywords that included: nursing education, higher education, masters in nursing, graduate education, pursuing graduate education, continuing education, and motivators and barriers for nursing education. Inclusion criteria consisted of articles published from 2003 to 2013, although older articles with high significance to the theoretical aspects of the paper were reviewed as well. Articles searched for were restricted to those available in the English language and obtainable in full-text format. In many studies that examined motivators and barriers of pursuing graduate education, the researchers studied the perspectives of those who had already enrolled in or graduated from either an undergraduate or graduate degree and so their perspectives were that of someone who had already made the decision to pursue higher education. Another major area of study has been that of bridging education for diploma-trained RNs, who are college trained, to post-RN university baccalaureate. Canadian research that specifically explored the motivational factors and barriers for why nurses choose or do not chose to pursue a master?s in nursing. A small number of Canadian studies focus on bachelor-prepared nurses who have not enrolled in a master?s program demonstrates a gap in the literature and further research in this area of study. In one Canadian study, Cragg and Andrusyszyn (2005) examined the processes of personal and professional change experienced by graduate student nurses. The study looked at 22 Canadian recent masters of nursing graduates and examined how their experience of undergoing  Chapter Two: Literature Review 8 graduate education had changed their attitudes and values about themselves from a personal and professional viewpoint (Cragg & Andrusyszyn, 2005). The authors found that the participants experienced what they perceived as a valuable developmental process in their master?s program (Cragg & Andrusyszyn, 2005). Currently, an inadequate amount of literature exists in terms of research that explores the attitudes from the perspective of nurses who hold a Bachelor of Science in Nursing (BSN) and who have not pursued graduate nursing education. Another Canadian study examined BSN students? self-efficacy and value regarding their intention to pursue graduate education (Plunkett et al., 2010). The authors concluded that BSN students are more likely to intend to pursue graduate studies if they have high self-efficacy and if they value a graduate education (Plunkett et al., 2010). Most of the studies found in this literature review were from the United States, Australia, and Britain. These studies examined the destination of masters-prepared nurses and the manner in which the career of a nurse improves or is benefitted by a master?s degree (Watkins, 2011; Whyte, Lugton, & Fawcett, 2000). Background Starting in the late 1990s with the Atlantic provinces, all Canadian provinces and territories (except Qu?bec) have transitioned to requiring a bachelor?s degree for nursing entry-to-practice, which in turn has resulted in a slow but steady increase in masters- and doctoral-prepared nurses. In 2011, for example, 644 graduates were in a master?s program, which had increased from 607 graduates in 2010, and 77 graduates in a doctoral program in 2010, which increased to 89 doctoral graduates in 2011 (CNA & CASN, 2012). The master?s degree is no longer viewed as a stepping stone towards pursuing a PhD but is an educational destination that  Chapter Two: Literature Review 9 is sought out as a valuable qualification and is ?perceived as an important degree in its own right? (Drennan, 2012, p. 103). As of 2012, 32 universities in Canada offer a Master of Nursing (MN) or Master of Science in Nursing (MSN) programs. MN and MSN programs are offered in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, Nova Scotia, New Brunswick, and Newfoundland (Canadian Association of Schools of Nursing [CASN], 2012). Statistics from 2010?2011 showed that 68% of the universities mentioned above offered wholly electronic or a blended model of online and face-to-face delivery of their graduate nursing program (CNA & CASN, 2012). Universities have created various flexible options for program study including distance education, which is one strategy that has been put into place to attract and increase accessibility for graduate nursing students. Many graduate nursing education programs in Canada include a variety of courses that focus on leadership and administration in addition to the focus on education. The Canadian Association of Schools of Nursing (CASN) conducted a survey on current practices and program delivery modalities among the 32 masters of nursing programs across the country. The survey was very comprehensive as out of the 32 nursing programs, 31 programs had responded to the survey. This represented a response rate of 96.9% (CASN, 2012). Nursing research and leadership were considered to be the most important components of master?s of nursing programs by the participants. Three-quarters of the 32 schools currently prepare students for research at some level, and 93% of the schools identify a research course as a core element of MN and MSN programs (CASN, 2012). Notably, nonthesis options for graduation from a master?s program, such as a major paper option or a coursework option, are common among many universities across Canada, such as Memorial University (2013) in  Chapter Two: Literature Review 10 Newfoundland, McGill University (2012) in Quebec, and Athabasca University (2012) in Alberta. Theories of Participation in Adult Education Most studies that examined participation in adult education focus on a variety of factors that are categorized into reasons for participation (or motivators) and deterrents to participation (or barriers). The examination of why some adults participate and some do not can help to explain how motivators and barriers influence this decision (Henry & Basile, 1994). Over the past few decades, various conceptual frameworks or models have been created in an attempt to explain or predict participation in adult education. For example, Cross?s (1981) chain-of-response model for understanding participation in adult learning activities provides the theoretical framework for this study, as described in the previous chapter. Another example is Eccles et al.?s (1983) expectancy-value model of achievement motivations, which suggests the impact of task value on educational choices. Eccles et al. (1983) divided task value into four aspects: utility value (long-term usefulness), intrinsic value (enjoyment or immediate rewards), attainment value (personal value), and cost value (what an individual will sacrifice to complete the task, i.e., time and money). This model has been applied decades later in nursing research, with Plunkett et al.?s work in 2010, in which the authors studied self-efficacy and value influences in BSN students. Most frameworks on motivators and barriers of pursuing graduate education stem from the discipline of adult education rather than healthcare. Also, many of these theories focus on factors for adults pursuing any type of education, not strictly formal graduate education; however, these frameworks are useful and can be applied to other disciplines. Many of the factors that motivate and deter adults from participating in any kind of organized adult learning  Chapter Two: Literature Review 11 overlap with those found in the nursing literature. For example, career advancement and personal satisfaction are common motivating factors whereas cost and time are commonly stated barriers in nursing and adult education literature (Cathro, 2011; Henry & Basile, 1994). Studies exploring nurses? participation in education have paralleled studies of other people?s participation in adult education. These studies were done by examining the demographic characteristics of participants and the motivators and barriers as well as by looking from the perspective of adult education theory (Thompson, 1992). Motivators In his article in press, Zahran (2012) performed semi-structured interviews with 37 master?s level nurses for the sole purpose of studying their motivation to study at the graduate level and their perception of the way they think it will affect their practice. His findings uncovered that the motivators for his sample were in line with D?rnyei?s (2001) notion of instrumental motivation that is ?the desire to do something in order to achieve practical goals? (Zahran, 2012, p. 3). Zahran?s findings included: self-development, broadening career opportunities, and developing practice. Cathro (2011) adopted psychologist Kurt Lewin?s (1975) theoretical framework of force field analysis, which suggested that with any change both driving forces (motivators) and restraining forces (barriers) are involved and have an impact on the change process. The driving forces must outweigh the restraining forces that, in the case of Cathro?s research, would lead nurses to pursue graduate education. The driving forces that she identified included: interest, financial assistance and employer incentives, flexible program delivery options, family support, mentoring, and collaboration between employers and academic institutions (Cathro, 2011). The  Chapter Two: Literature Review 12 restraining forces that Cathro identified were financial costs, work and family responsibilities, and lack of nursing mentorship. Organizational incentives and rewards may motivate nurses to pursue a master?s degree. The Nurse Educator Pathway is an excellent example of a program in British Columbia that supports nurses in their pursuit of professional development in nursing education. Nurses in the program require support by nursing employers for educational time off to attend the sessions. The program integrates the health service sector and the education sector by preparing nurses in nursing education across both areas (Semeniuk, Mildon, Purkis, Thorne, & Wejr, 2010). Another project, the Health Services Researcher Pathway funded by the Michael Smith Foundation, is developing an evidence-based pathway to support the transition of practice-based nurses? into researcher roles. The implementation of practice changes is often difficult because nurses lack experience and knowledge in using evidence-based practice and research methods as a common approach to work towards positive patient outcomes (Fineout-Overholt, Melnyk, & Schultz, 2005). Progressing from basic BSN knowledge of research to eventual master?s- and doctoral-level preparation, this pathway clearly describes the knowledge, skills, and attitudes that nurses have at various stages of their career. The purpose of the pathway is to promote a culture of research in nursing, which has positive effects on quality of care, and on the potential to direct nurses along a career trajectory toward various roles within nursing research (Nursing Leadership, 2012). Barriers In Plunkett et al.?s (2010) study, which examines BSN students? self-efficacy and value influences in regards to graduate education, the authors found that the average participant  Chapter Two: Literature Review 13 answered ?unsure? (p. 8) in terms of how much he or she values graduate studies. The authors proposed that this may be indicative of students? poor understanding of the value of graduate education, which was seen as a barrier to pursing graduate education; however, Plunkett et al. (2010) also provided a statistically significant finding (with a mean score of 2.97 out of a maximum score of 5), which suggested that nurses valued the utility aspect of graduate education. This suggested that when nurses consider the long-term benefits of graduate education, such as enhanced career options and salary, they are more inclined to pursue graduate studies (Plunkett et al., 2010). In reference to Cathro?s (2011) work and her application of Lewin?s force field analysis, the author identified that when the restraining forces cannot be overcome, they result in barriers that obstruct nurses from being able to pursue graduate education. For example, Cathro found that although financial assistance and employer incentives were a driving force to pursue graduate education, financial costs of tuition, time, and lost salary were restraining forces. In examining the demographics of nurses as a whole, age may also be a contributing factor to why many nurses are not pursuing higher education. In 2011, the average age of RNs in Canada was 45.3 years old (Canadian Institute for Health Information, 2012, p. 2). Returning to school may be difficult and stressful due to the fact that most nurses have been away from the formal education setting for potentially decades and have competing factors of family and work to balance (Battle & Wigfield, 2003). In 2011, the percentage of RNs approaching retirement (age 60 or older) in Canada was 11.9%, and the percentage of RNs over 70 years old was 0.8% (CIHI, 2012). A closer look at this group of nurses also shows that a large proportion of the RNs over age 60 (58.1%) were working on a part-time or casual basis (CIHI, 2012, p. 3).  Chapter Two: Literature Review 14 The Nursing Shortage: Beyond the Baccalaureate Level The role of nurses holding graduate degrees in the nursing profession is important. The CASN identified that a master?s education builds upon the competencies acquired at the baccalaureate level by developing the ability to ?analyze, critique, and use research and theory to further nursing practice? (2011, p. 1). In 2009, the Canadian Nurses Association (CNA) released a report entitled Tested Solutions for Eliminating Canada?s Registered Nurse Shortage. The report stated that, by the year 2022, the projected nursing shortage could reach 60,000 full-time equivalent RNs if policies were not put in place to improve the situation. The CNA suggested improving the retention of practicing RNs and increasing the enrolment in RN entry-to-practice programs was essential. One of the strategies they recommended was for nurses to be provided opportunities for continuing education and professional development, which could include support for pursuing graduate education. Recruitment and retention of nurses is a challenge for nurse administrators. Studies have demonstrated a relationship between management style and anticipated staff turnover (Kleinman, 2004; Volk & Lucas, 1991). Evidence suggested that although no clear cut way to best prepare effective managerial leaders is available, the literature suggested that graduate education may be an important factor (Drennan, 2012; Kleinman, 2004; Volk & Lucas, 1991). According to the literature, transformational leadership characteristics of nurse administrators have shown to have a positive influence on rates of staff turnover and overall job satisfaction. Transformational leadership characteristics include identifying and communicating a vision for the work group and demonstrating the values of respect and trust of the staff. Dunham-Taylor (2000) conducted a study that examined 396 nurse executives and 1115 staff  Chapter Two: Literature Review 15 who reported to them and who rated the nurse executives? leadership style, staff extra effort, staff satisfaction, and work group effectiveness. The results suggested that nurse leaders who held graduate degrees were found to have effective leadership characteristics and, in particular, nursing leaders with master?s degrees in nursing, rather than other disciplines, were found to have better transformational leadership preparation. The author?s study found a positive significant correlation between higher degrees (63% had a master?s or doctorate) and higher transformational scores, which suggested that advanced education may enhance transformational characteristics (Dunham-Taylor, 2000). Kleinman (2004) and Dunham-Taylor (2000) suggested that investment in attracting and supporting the attainment of advanced education for nursing leaders is an important strategy for organizations as it is found to be a valuable investment in contrast to the costs associated with staff nurse turnover. Of the several domains of nursing in which graduate nurses most commonly work, administration, education, advanced clinical practice, and leadership, nursing education, and in particular nursing faculty shortage, is most widely researched as it relates to graduate-prepared nurses. The majority of articles found on the topic of preparing nurses for positions that require higher education were focussed on how to attract and retain qualified nurses both in the clinical setting and the academic setting. The shortage of graduate-prepared nurses has a direct effect on the future of nursing for all nursing domains. This is particularly evident in the statistics for nursing faculty for replacement and retention (Berent & Anderko, 2011). The number of nurses who are qualified within the replacement pool (master?s and doctoral graduates) to succeed retiring university faculty is inadequate (CNA & CASN, 2012). This is an issue when you consider the retirement  Chapter Two: Literature Review 16 rates of current nursing educators. For instance, among nursing faculty in Canada, 31% are over the age of 55, and 12% are over the age of 60 (CASN, 2010). In some instances, this shortage can impact refusal of qualified applicants to nursing school, which could translate to fewer new graduate nurses entering the workforce and contributing to the global nursing shortage (Plunkett et al., 2010). The problem of faculty shortages is complex. Ramifications for future generations of nurses exist that could possibly affect the provision of quality patient care directly. This problem not only directly affects nursing students but also nursing research. Increases in student enrolments require an increase in qualified nurse educators. In 2012, the American Association of Colleges of Nursing (AACN) released data that showed nursing schools in the United States rejected 75,587 qualified applications of baccalaureate and graduate nursing programs; more than 14,354 of the applications were to a graduate program. The study indicated that two-thirds of the schools stated that the primary reason for the rejections was insufficient number of faculty (American Association of Colleges of Nursing, 2012). With a shortage in the pool of nurses with a master?s degree, this means an even smaller pool for those who pursue doctoral education. McDermid, Peters, Jackson, and Daly (2012) suggested that many doctoral-prepared nurses focus their careers on research and prefer not to teach undergraduate students. Another interesting feature of the nursing faculty shortage is that nurses who are masters prepared have the option to work in either, or both, the academic and clinical world. Many factors, such as research interests or clinical specialization, may influence a nurse to choose one setting over the other. The literature, however, pointed to the fact that academic salaries may not be as competitive as administrative or clinical salaries in the healthcare setting (Rother &  Chapter Two: Literature Review 17 Lavizzo-Mourey, 2009). Potentially, this lack of a competitive salary may influence a graduate-prepared nurse?s decision to decline work as faculty. A low percentage of graduate-prepared nurses needs consideration as to who will fulfill advanced nursing roles within the domains of nursing, such as conducting research, taking on faculty positions, or providing professional leadership, all of which are necessary to continue to advance the science of nursing. Although an effort has been made to have strategies in place for attracting RNs to pursue baccalaureate degrees, a continuing shortage of RNs with nursing education at the master?s and doctoral education level exists. With nursing being a key provider of care that is increasingly evidence-based, undergraduate nursing education may not be enough to prepare nurses for these roles or to provide the leadership to support care that is well researched (Girot & Albarran, 2012). Chapter Three: Research Design and Method 18 Chapter Three: Research Design and Methods This section presents the chosen approach and research design, the sampling population, sample selection criteria, and the recruitment methods. In addition, data collection methods and the analytic plan, ethical considerations, and limitations are discussed in detail. Research Approach This study aimed to uncover the attitudes and beliefs of RNs in respect to motivators and barriers for pursuing advanced education in nursing. A descriptive phenomenological approach was chosen as most appropriate for this type of study because the research was exploratory in nature and was not seeking to prove a hypothesis; rather, it was an inductive study designed to elicit rich and thick descriptions of the participants? beliefs and attitudes. A qualitative design using a phenomenological approach explores questions of human experience in depth and can reveal many assumptions and beliefs through the themes identified, which may not emerge using a quantitative research design. In phenomenology, the researcher makes time and space for repeated iterations of experience from different perspectives and engages in deep levels of immersion (Kearney, 2001). The phenomenological methodology investigates the subjective human experience and is an approach that explores, and seeks to come to an understanding of, people?s everyday life experiences (Polit & Beck, 2012). The descriptive phenomenological approach to inquiry is a philosophical approach used in qualitative study and was developed by philosopher Edmund Husserl and Martin Heidegger; this approach was based on the earlier ideas of Georg Hegel and Immanuel Kant (Earle, 2010). The assumption specific to Husserl?s philosophy ?was that experience, as perceived by human consciousness, has value and should be an object of scientific study? (Lopez & Willis, 2004, p. 727). Husserl believed that subjective information should be important to scientists seeking to  Chapter Three: Research Design and Method 19 understand human motivation because human actions are influenced by what people perceive to be real (Lopez & Willis, 2004). Ethics and Human Subject Protection Ethical approval for this work was needed as this research involved human subjects. This was achieved through review of the proposed research by the University of British Columbia Behavioural Research Ethics Board and the Providence Health Care Research Ethics Board. The study adopted procedures to assure confidentiality. My supervisors and I were the only people to have access to the research and data. Participants? identities were protected by using pseudonyms and descriptions of the members rather than their names. All participants completed an informed consent process (see Appendix A), and participants were explicitly told that they were free to withdraw from the study at any time and could contact the researcher to withhold any information already submitted in the study if they wished. Study participants were informed of the study?s potential risks and benefits. A potential risk was potential breach of confidentiality. Another potential risk was that the participants could hear and disseminate the other participants? personal views on graduate education in nursing and, as participants worked in the same hospital, they may have known one another. At the start of the focus group, I reiterated the purpose of the study, the process for protecting participants? confidentiality, data collection methods, and audio recording methods. Also prior to the focus group, I emphasized that the information from the focus group conversations should be kept confidential. All participants were asked to agree to this principle, and they signed consent forms (see Appendix A). To promote confidentiality, pseudonyms were used during the data analysis process and are included in the findings. Study participants had time to ask questions before the beginning of each focus group, and study participants were  Chapter Three: Research Design and Method 20 informed of their right to withdraw from the study with no adverse consequences related to their employment. Sample Selection and Recruitment A nonprobability convenience sample of eight participants was recruited consisting of RNs who work in a large urban hospital. Inclusion criteria for participants in this study were nurses who currently hold a Bachelor of Science of Nursing and were fluent English speakers. Exclusion criteria included RNs who have a master?s degree or who have applied for a master?s of nursing program previously. Also, those who hold a nursing diploma as their highest level of education were excluded. Recruitment of participants occurred within a large urban hospital. As professional email was not a primary means of communication for many nurses within this hospital, other means of recruitment took place. A poster was designed to promote my contact information in order to enrol; it also included the purpose of the study, the information about the focus group, the specific participant inclusion and exclusion criteria, the time commitment, and the incentive prize of a $25 Starbucks gift card. The incentive prize was offered for each of the two focus groups and was self-funded. The poster used to recruit subjects was approved by the ethics committee within the hospital prior to posting in designated areas throughout the hospital, such as bulletin boards. Once participants contacted me by email or phone, I answered further questions about how the focus group would run and organized dates and times for the focus groups. Over the next few weeks, eight prospective participants approached me and contacted me via email. Reminders for the interviews were sent to the participants by email, text messages, and verbally in person.  Chapter Three: Research Design and Method 21 Data Collection In keeping with a qualitative phenomenological approach, focus groups were used to explore the perceptions of participants on the value of graduate education. Focus groups interviews were selected for data collection, a means to elicit rich conversation, and for the advantage of active group interactions rather than individual interviews. Focus groups were chosen for this study because they are sometimes viewed as less intimidating and time intensive than individual interviews, can provide more in-depth information than questionnaires, and allow further exploration of themes arising (Shaha, Wenzel, & Hill, 2011). Jayasekara (2012) wrote that focus groups may ?reduce the influence of interviewer on the participants by tilting the balance of power toward the group? (p. 412). In addition, Jayasekara recommended that focus groups be comprised of homogenous participants to avoid the generation of power issues and to promote comfort among the participants. The participants in this study had many commonalities, such as their occupation and their choice to not pursue graduate education; however, some variation in the ages and cultural backgrounds existed, which brought different views to the discussion in a beneficial way. Initially, I planned to have three focus groups consisting of six to eight participants per group; however, recruitment of the groups was the greatest challenge. This range was originally chosen because of the importance for groups to not be much larger than eight, as that would prevent some members from feeling comfortable to share their thoughts, nor smaller than five, as that may limit discussion (Jayasekara, 2012). In the case of this study, the participants were very engaged and offered a more than adequate amount of data; therefore, two groups of four participants were deemed sufficient.  Chapter Three: Research Design and Method 22 The duration of each focus group was about an hour. The locations of the focus groups were two different conference rooms within the hospital where the participants worked. The rationale for this location was that it would provide a private and convenient place with which the participants were familiar and with limited distractions. I obtained permission from the group to audio record the conversations and simultaneously took brief notes, although I primarily relied on the recording so that I could be present with and attentive to the group. I also acknowledged the importance of paying attention and of recording nonverbal cues of the group, which may communicate emotional responses that are not spoken. Within the 24 hours after each focus group, I wrote field notes, methodological memos, and reflective memos to facilitate an accurate recall of what was observed and understood during each focus group. Bracketing is a technique used to ensure the researcher?s awareness of their own preconceived notions, assumptions, and biases. Lopez and Willis (2004) stated that bracketing is an important component throughout the process when listening to and reflecting upon the data contributed by the participants; in my case, I moderated, transcribed, and analyzed the data. Bracketing was an important process to engage in, considering I may have introduced my own biases as I am also a RN and am pursuing my graduate education; therefore, in an effort for me to suspend my own judgments and values and to be neutral as much as possible, bracketing was a useful tool. I had to continually reflect on the initial notes I had taken and to review the data I had collected in order to re-evaluate and reflect on my ability to remain unbiased. The focus group questions (see Appendix B) presented to the group were semi-structured and open ended to elicit discussion and allow the participants to steer the conversation while I kept the overarching topic as the main focus. The questions allowed me to steer the conversation  Chapter Three: Research Design and Method 23 from very broad questions to more specific questions, from narrow ideas down to concrete examples. The content of the questions was based on common themes around barriers and motivators that are most prevalent in the current literature on this topic and, in particular, were guided by the work of Cross (1981) and her chain-of-response model. Cross?s (1981) chain-of-response model looked at the factors that motivate adults? participation in learning activities, and these factors are interrelated. In the focus groups, my research interest was the motivation to participate in graduate education and the factors that influence nurses, or what they perceived would influence them, to participate. This was in contrast to the strength of factors that deter them from participation (i.e., barriers). Barriers were focussed on the three categories as defined by Cross (1981), which are situational, institutional, and dispositional. The questions used in the focus groups asked about the factors that the participants felt would be their motivators, barriers, and their general perceptions and attitudes. Due to the nature of nurses? schedules, I was challenged to find common dates and times. I had made several changes to the original focus group dates to accommodate nurses who had picked up extra shifts or who had made plans on their days off. Although I did have further interest from potential participants, I had difficulties finding a time that suited them all at once and that would allow them to remain for at least an hour. This proved to be a barrier. Data Analysis Data analysis began shortly after each session with the group so that my own reflections were accurately captured in a timely fashion. I began recorded transcription promptly afterwards. By transcribing the voice recordings myself, I had the opportunity to become very familiar with  Chapter Three: Research Design and Method 24 the data, which facilitated the data analysis process. Transcription, listening and reviewing the recordings, was a time-consuming process. Qualitative content analysis was used to find themes and elicit meaning from the focus group transcriptions and was based on a descriptive phenomenological approach. Significant statements were identified and extracted. I used the collected data to find reoccurring themes and concepts. Although qualitative research does not draw statistical results from the data, the data must still be analyzed in a systematic way. For the purposes of this study, constant comparative analysis was the method implemented to analyze the qualitative data. The method involves coding the data into emergent themes or codes. The process consists of reading through all of the transcribed materials and notes taken throughout the process and of attributing a code to sentences, paragraphs, or sections. These codes are then associated with a theme that emerges. The codes were drawn from the data rather than from predetermined themes drawn from the literature or elsewhere (Hewitt-Taylor, 2001). The purpose of drawing codes from the data is to understand the perception of the participants and to be open to the possibility of new ideas emerging rather than limiting the findings to preconceived themes or categories. The process of constant comparative analysis requires repeated, systematic review of the data to ensure that no new themes have emerged or are missed in the process. Coded sections with similar, or the same, themes are compared to one another to check for consistency. Constant comparative analysis is an ongoing process where the data is repeatedly reviewed until no new themes emerge (Hewitt-Taylor, 2001).  Chapter Three: Research Design and Method 25 Rigour and Trustworthiness Rigour in qualitative research is a crucial element in the development of the trustworthiness, or rigour, of the research findings. In order to ensure rigour and trustworthiness in this study, Lincoln and Guba?s (1985) framework was implemented. According to Lincoln and Guba, trustworthiness can be described in terms of credibility, transferability, dependability, and confirmability. Credibility refers to research that is subject oriented, not researcher defined (Sandelowski, 1986). In this study, credibility was obtained by documenting my thoughts and feelings after each transcript was transcribed in order to attempt to prevent my personal opinions from being introduced and from influencing the research process. The last step of the data collection was seeking validation from the participants regarding the initial findings and the themes that emerged. This analysis included returning to the participants for validation of the results, also known as ?member checking? (Polit & Beck, 2012, p. 545). Although member checking does not fully validate the findings, it does provide the participants with the opportunity to give feedback on my interpretations of their discussions and does contribute to the trustworthiness of the research (Hewitt-Taylor, 2001). The initial findings were presented to all participants via an email requesting their optional participation in this part of the process. At the beginning of each focus group, I was clear that this invitation would be sent out, that decision to participate was strictly voluntary, and that no participant was under any obligation to take part. Participants were welcome to provide as much or as little feedback as they wished. Transferability is utilized to discover how well the findings can fit contexts outside the study situation. This includes providing a detailed account of the research context and the participants (Craig & Smyth, 2007). In my study, thick descriptions were provided in order to be  Chapter Three: Research Design and Method 26 explicit about every step of the research process including the site sample and sampling strategy as well as how participants were accessed, how data was collected and recorded, and how the analysis was conducted. Thick descriptions are developed by writing detailed accounts of an audit trail in the form of field notes. Dependability involves examining the way in which the data changes over time and the alterations that are made in the researcher?s decisions during the analysis process (Graneheim & Lundman, 2004). Dependability of qualitative research is closely related to the quality of the data and, in this study, a voice recorder was used to ensure quality and accuracy of the data, thereby increasing its dependability, as did the transcriptions, which were transcribed verbatim (Craig & Smyth, 2007). Permission was given by the participants, which is necessary for ethically sound research. Lastly, confirmability assesses how the researcher may have affected the research findings and looks at how the procedures and results are free from bias. Lincoln and Guba (1985) suggested the researcher identify personal biases by memo writing and reflection with other researchers to increase confirmability in their research study. Confirmability in this study was maintained by keeping an audit trail, which included an in-depth recording of the research process by way of personal journaling and maintaining notes regarding my methodological choices (Craig & Smyth, 2007). This practice allowed me to reflect more critically on the research process and allowed the research findings to present themselves out of the data and not from out of my own personal bias. Chapter Four: Findings 27 Chapter Four: Findings In this study, I examined the perceptions and attitudes of registered nurses with regards to pursuing graduate education and, in particular, the motivators and barriers that would promote or hinder their participation in higher education. This chapter begins with a brief description of the participants? demographic information. The remainder of the chapter describes the findings of the focus groups conducted, including direct quotations that help to convey the participants? perceptions and attitudes. The main themes of this study are categorized into motivators, barriers, and perceptions and attitudes. The barriers are divided into three categories drawn from Cross?s (1981) work, which includes situational, institutional, and dispositional barriers. The other six major themes that emerged from the research were categorized under a general theme of perceptions and attitudes in respect to pursuing graduate education, as the perceptions and attitudes were not directly viewed as a motivator or barrier but were still significant in explaining the participants? viewpoints. Figure 2 provides a summary of the findings discussed in this chapter. Appendix C provides the frequency for statements made by all eight participants according to theme and subtheme.    Chapter Four: Findings 28  Figure 2. Thematic diagram of the factors influencing the pursuit of graduate education in registered nurses. Participant Demographic Information Although specific demographic information, such as age, BSN graduation year, title of current role, and employment status (part time or full time), was not collected during the data collection phase, some general characteristics about the participants were observed and were part of the selection criteria and these can be reported. The study included eight participants. All Factors Influencing the Pursuit of Graduate Education in Registered NursesMotivators- Professional Goal- Personal and Professional Challenge- Role Modelling: Peer Support and MentorshipBarriersSituational- Work-Life Balance- Financial Impact:- Age- Personal and Family CommitmentsInstitutionalDispositional- Returning to StudyPerceptions and Attitudes- Alternative Educational Opportunites- Non-Graduate Careers- Supporting Resources- Theory -Practice Gap- Value of Graduate Education- Misconceptions of Graduate Level Roles Chapter Four: Findings 29 participants held a bachelor?s degree in nursing (or an approved equivalent). None of the participants had ever applied to a graduate nursing degree program. Seven of the participants were female and one was male. Four of the participants were considered ?experienced? with approximately five or more years of experience, and the other four participants were considered ?less experienced? with less than five years of experience. In the following section, I will describe the themes in regards to nursing motivation to pursue graduate education. Motivators The participants in this study had never applied to a nursing master?s program; therefore, their responses regarding motivating factors for applying were based on what would motivate them hypothetically if they had an ideal situation for which they were supported in all the necessary ways. The themes described below highlight the three most prominent potential motivators for the participants, and they include: having a professional goal, being personally and professionally challenged, and having a role model in the form of peer support and mentorship. Professional Goal The participants expressed that higher education was important when striving for a particular nursing role that required it, such as a formal leadership role in clinical practice or education. They felt inspired both by other nurses who held these positions and by the prospect of graduate education but only when they had a particular job in mind. Some participants expressed that until they had a concrete plan for a specific professional destination, they would not consider pursuing graduate education. They suggested that nurses were inspired by roles held by graduate education nurses. One participant stated, ?There are people with some really neat jobs and I think, wow, I want to do what you are doing. That would be my motivation.? Another participant added:  Chapter Four: Findings 30 I think I would want to have a particular job in sight that I wanted and then I would direct my education towards that. I don?t think I would go necessarily just because I want to do my master?s. I want to have something to go to at the end of it. The participants expressed that they wanted to ensure the process of pursuing graduate studies would lead to a role that required this extra education. As the participants in the study were not themselves motivated to pursue graduate education at the time, these perceptions were based on their personal assumptions rather than personal experience. The participants spoke about potential motivation that other nurses may have but that they themselves did not relate to. The participants were concerned that the roles for which graduate education is required (such as clinical nurse specialist) were limited in the healthcare setting and that a lot of competition exists between those nurses already qualified. Although the participants expressed that a desire to take on a specific role was a motivating factor to pursue graduate education, they were also concerned that the demand would be high for these positions and that this demand acted as a negative motivational barrier. One participant commented: For example, to be a clinical nurse specialist, why would I get my master?s in that and then have no idea where I would work after that? Those jobs are limited, so why would I invest my own money to go get a master?s when there isn?t anything assured afterwards? The participants also spoke about an interest in research as being a key motivator for those nurses who already knew that research was the professional path they wanted to take. Although research does not lead to a specific job necessarily, it is an area of nursing that the participants saw as a professional goal. One participant explained: I don?t really like doing research, that?s just not something that I?m interested in, but some people really like that. I went to school with people who knew that research was exactly what they wanted to do; it was a goal for them. Knowing the little that I know about getting a master?s, I know that research is a part of getting your master?s. A lot of it is research and so if that is what your goal is or what you are interested in, then for sure.  Chapter Four: Findings 31 Participants perceived that research is a key component to graduate nursing education. This was viewed as a motivating factor to pursue graduate education for those nurses who were interested in research as a career goal. Personal and Professional Challenge Participants expressed that a drive to pursue graduate education could come from a desire to be challenged academically and professionally, and they added that they would be motivated to take on a challenge that fulfills their personal need for learning and provide them with new professional opportunities. Although the participants themselves did not want to pursue the challenge at this time, they were aware that other nurses, who have pursued graduate education, were motivated by the personal and professional challenge. One participant stated: I think there is still an element of personal drive as well. You know, I?m happy where I?m at, I?m happy in my role, I want to take on something else; it?s almost a challenge, a personal challenge as well. The participants explained that nurses who are feeling comfortable in their current role will be ready to build on that role and on their skills by taking on the challenge of graduate education. One participant said, ?I think the level of engagement in their current work pushes them. If they are really engaged in it and can see benefits of getting a further education it, then they will.? I sensed from the more experienced participants that a point exists in a nurse?s career at which he or she will hit a plateau in satisfaction with his or her role. This is a point at which nurses may feel compelled to take on a new challenge and push themselves further academically and professionally by pursuing a graduate degree. Role Modelling: Peer Support and Mentorship Most of the nurses in this study agreed that having a coworker or peer, who was enrolled simultaneously in the master?s program with them, would be perceived as valuable; these nurses  Chapter Four: Findings 32 said that having a peer would increase their likelihood of wanting to apply themselves and would improve the graduate experience. A total of 11 statements were made by the participants specifically giving prominence to this point. The nurses reported that they anticipated enrolling in the master?s program was already a hard process to endure and, therefore, a support person throughout the experience would be very beneficial. Nurses viewed peer support as valuable for many reasons, such as answering questions about the application process or receiving suggestions about course selection. Just knowing that someone was ?in the same boat? was an important motivator. One participant explained, ?People tend to like someone to come along with them on their journey. If you could find a peer who wants to do it too then you might be more inclined to do it. That would be a motivator.? Another participant added: I think it?s important having a resource person who has already done it [graduate education] or who is going through the process so you can ask what that looked like for them or if they have tips they can offer. Participants were inspired by nurses who were already enrolled in a graduate program, or who had completed it, and this inspiration was seen as a motivator as well. They perceived that a desire to pursue graduate education could stem from the environment in which a nurse works and, particularly, by the example set by nursing leaders who have pursued graduate education. One participant commented: It?s inspiring for nurses to see their peers pursue graduate education. It also has to do with who you hang around with because those are the people who are going to be influencing you. As a leader, it?s a good thing for the staff to see you doing this. The next theme described the perceived barriers. Barriers The participants in this study identified many significant barriers that they expressed had deterred them personally or that they identified as deterring other nurses they knew from  Chapter Four: Findings 33 applying to a graduate program. Their discussions regarding the barriers were more in depth than of the motivators, perhaps because they perceived many challenges that hindered their own ability to pursue a master?s degree and could speak from experience. The participants offered many positive suggestions as to ways they believed these barriers could be overcome, and many of these suggestions are explored in the discussion section of this paper. The themes described below are divided into situational, institutional, and dispositional barriers. Subthemes are incorporated to describe the findings in a more in-depth manner. Situational Barriers The term situational barrier was described to the participants before proceeding to the focus group questions that addressed this type of barrier. To review, situational barriers are personal life barriers, such as a lack of money, time, or a pressure from family, which deter the nurse from returning to graduate school (Cross, 1981). Work-Life Balance The participants emphasized the anticipated challenge of maintaining a work-life-school balance, which falls under the category of a situational barrier. Five of the eight participants expressed concern that the balance between family, personal needs, and study would add an anticipated stress, and this was a major deterrent. A key barrier for nurses in the focus groups was the competing demands of work and life and the recognition that adding school to their already full schedules would require a sacrifice that does not appeal to them. When asked how this barrier could be overcome, one participant explained, ?I?m not ready to have my interests split; full-time work week and going home and studying. I don?t know what supports I would need to make that live-able, for how many years, two or three at least??  Chapter Four: Findings 34 Financial Impact A common theme that emerged from discussions was cost as a general concept of sacrificing time: in other words, the cost of potentially being away from work and not being paid and the finances required to fund the education. This is a concept known as ?opportunity cost,? and it stems from the field of economics. Opportunity cost examines costs not only restricted to monetary or financial costs but also extended to time lost or effort made (Bone, 2002). Opportunity cost is a significant barrier for the participants in this study as they expressed a total of 22 statements specifically about financial impact as a barrier. In reoccurring statements through the discussions, all but one participant mentioned the stress of financial impact as a significant barrier. One participant described her perspective: I just think the financial thing would be the big thing for me. Also, just where people are in their lives, like for me, like if I was going to have a kid or something. . . I?m at the point now where it might not be a good time to take on some other huge project. Like if you were trying to work and take on a master?s and have a kid; where does that fit in? For me it would be just about what is going on in my personal life. Another participant described his perspective: It?s the cost and time. I think if you could focus it all at once. Like, when you do your undergrad you have those four years to do it all and you?re done. When you are doing your master?s you are either doing it for 2 years nonstop, working fulltime which actually depends on if the job that you are in would be able to support you doing that or you need to take two years of your life off or spread it over five years or whatever. Other people who I have spoken with have spread it out over longer periods of time and they say. . . they just want it done. So you lose interest, right? You?re taking a course every semester for the next 5 years; it kind of loses its. . . [appeal].? The participants focussed on the concerns that they had overheard other graduate prepared nurses express and assumed that these problems would occur for them as well. Participants stressed the financial struggles that they anticipated if they started graduate studies. A participant noted:  Chapter Four: Findings 35 I think also, it could just be about being satisfied with what you have now, I?m happy with my pay; I?m happy what I have now. I don?t know if I really want to put so much effort into going back to school. Another commonly expressed concern was competing financial needs, such as previous student loan. One participant elaborated: What does it cost for tuition, you know the two year or the five years you are doing your master?s and then, the time you?d be taken off of work, the money you?d be paying a university to do it, I haven?t finished paying off my other student loan yet. Age For many, the concern over their age was related to financial issues. Participants pointed out that age, the time of life, and experience level at which a nurse decides to pursue graduate education makes a difference to the decision-making process. The idea of ?worth? and ?pay off? for pursing graduate studies is a reoccurring theme. A participant stated: When I was younger, I thought nothing of getting 40,000 dollars of student loans. It didn?t bother me. But now that I?m in my mid-30s, I?d rather put that towards a house or a beautiful new car or even my retirement savings. I don?t want to work forever so why would I go into debt again considering the pay off. What?s the pay off for me? Am I going to get that much of a better career or pay check? I mean, that may sound really selfish and greedy, but what is the payoff? I could invest that money more wisely, like nice vacations with people I care about. Personal and Family Commitments I sensed that the nurses believed taking on graduate education would mean sacrificing not only their own money and time but also that of a spouse or partner. When asked how the participants felt they needed to be supported to overcome this barrier, one participant said: A saving plan. Talking to my husband to say I?m going to go back to school so how is this going to affect our life together now? When you have to pick up more shifts, or go part time, does he have to take on a second job to support me? And looking into options, will I be able to do this part time, full time, that kind of thing. Some participants described their perspectives on study costs in the context of other life commitments. One participant stated:  Chapter Four: Findings 36 As well, you know, the longer that you are out, the more happens to you, you have a mortgage and you have a dog and you have all these other commitments that don?t stop just because you are doing your master?s. They highlighted that the financial stress was a barrier for them and that finances are a sacrifice that affects their family as well. One nurse noted, ?You have to take into consideration that you are taking a lot of money out of a savings pot that could be coming from a family?s savings.? One participant described her experience of contemplating whether to pursue graduate education: I sat down with my husband and we looked at all the finances and he said, so what will be the remuneration for you? What will you get extra at the end of it? We looked at how long is it going to take to recoup the money we will spend? And it doesn?t equate. It doesn?t. Institutional Barriers The term institutional barrier was described to the participants as barriers that stem from difficulties due to the institution that provides the education, such as a geographically far school, inconvenient times for classes, stringent admission requirements, or the lack of student services (Cross, 1981). As the participants had not applied for graduate education, most of them had not thoroughly examined the process of applying for graduate education; therefore, they were not even aware or had not considered the potential institutional barriers that may exist. The number of statements made in regards to this barrier was the lowest, at 9 statements. This could potentially not be regarded as a significant barrier because the participants had not had much experience in exploring the different factors related to the institutional barriers as they had not engaged in the process of applying to the institutions. One aspect of institutional barriers that they did comment on was the rigidity of the application process, particularly the timing of  Chapter Four: Findings 37 application deadlines, which was not convenient and did not support those who may have decided after the deadline. A participant commented as follows: I think one thing that?s interesting about [some universities is] that they have an actual deadline that you need to apply by, say, April 1. So, if I decided that I really want to get my master?s, sometimes those deadlines are something that would discourage someone. They might think I?m not going to wait until next year, I really want to do it now, I want to get started as soon as I can. If I have to wait until next April, I won?t apply because I won?t have the time. Another participant added: I was thinking of deadlines, too, since I think they only have one or two intakes, and I think [some schools] only have one a year. I actually did fill out an application, but I never applied since I missed the deadline, and the next one isn?t for another half a year. So, you could just kind of forget about it. So, if they had more intakes per year I think that would be better. The participants believed that a barrier for them was nursing schools that did not provide enough promotion of their graduate programs and of the value of a graduate nursing education in general. Due to this lack of awareness about different nursing programs, the participants suggested that interested nurses would have an easier time applying to a graduate program if they were more familiar with the universities that offered programs and the manner in which the programs differed in their curriculum. Dispositional Barriers Lastly, the third barrier that was described to the participants was dispositional. Dispositional barriers are those that relate to the learner?s self-esteem and attitude towards learning and being a student. They include lacking confidence to succeed, feeling too old, or being discouraged from a previous negative experience as a student. These opportunities and barriers influence the adult in their potential pursuit of education (Cross, 1981). The questions regarding dispositional barriers ignited much discussion, and participants offered 23 statements specifically to this topic.  Chapter Four: Findings 38 Returning to Study Several nurses described anxiety around returning to the academic setting and stated that this anxiety would be a barrier to pursuing a master?s degree in nursing. Their memories of feeling stressed about their academic performance remained vivid, and a few participants perceived the stress as a barrier to wanting to have this experience again. The participants commented that their previous experiences in school, whether that be nursing school or other types of formal education, deterred them from wanting to return to the academic setting for various reasons. An experienced participant described his anxiety, which stemmed from the length of time away from the academic setting: I think from the time that you finish your degree, the longer that you are out, I?d say the probability of going back probably decreases because you start, well you know, I?ve been out for 7 years and it makes me wonder, would I want to go back? Do I remember APA [American Psychological Association]? Another experienced participant explained her differing perceptions of her non-nursing degree and the contrast with her previous nursing degree: I have a BA [Bachelor of Arts] from [a university] and I loved going there. I loved that time. Then when I went to [nursing school]. . . that was probably the worst experience of my life. Nursing school, the way we were treated by our teachers, I don?t want to do that again. I love the academic world, but nursing school was completely different. A commonality for most of the participants was an anxiety around academic expectations of the amount of reading and writing of academic papers. The participants expressed both a low level of confidence of their academic skills and a disinterest in returning to engage in academic endeavours that are viewed as ?non-clinical.? One participant explained: I really enjoyed nursing school and I thought it was really fun and I enjoyed clinical and I felt like I had a lot of support from my instructors and my classmates, it?s just that I didn?t like writing papers. I feel like if I go back to get my master?s it won?t be clinical, which I enjoy doing, but more academic like writing papers and a lot of reading.  Chapter Four: Findings 39 Perceptions and Attitudes Besides motivators and barriers, six major themes emerged from the research, which I categorized under perceptions and attitudes in respect to pursuing graduate education. Although the perceptions and attitudes were not directly viewed as a motivator or a barrier they were still significant in explaining the participants? perspectives on graduate education in nursing. The six themes identified include: alternative educational opportunity, non-graduate careers, support resources, theory-practice gap, the value of graduate education and misconceptions of the graduate level roles. Alternative Educational Opportunities Consensus occurred amongst most participants that a choice has to be made between studying a nursing specialty, such as critical care, or starting a graduate nursing program. Few participants considered that they could do both but rather had to make a decision of one or the other: I think for most people they kind of have to have a goal of what direction they want to do because right now I?m thinking about getting my master?s, but I don?t really know what I want to do. I?ve only been working for 5 years now but do I want to go into leadership or do I want education or do I want to do my high acuity training or intensive care? That is still experience that I want to learn for myself, too. So, getting my master?s might kind of deter me from other things that I might want to do in the meantime. The participants expressed that continuing education as a whole is important for all nurses and is an expectation for nurses to engage in as a means to maintain their professional practice. The participants stated that they wanted to engage in more continuing education; however, they also stated that with other avenues for educational endeavors, such as the CNA certification and specialty courses, the clinical aspect of these options was more desirable and could be more easily applied to practice. A participant stated: Also I think some nurses don?t consider the option of going for a master?s because they are [thinking], I just graduated, I?m focussed now on bedside nursing or I want to pursue critical care, for example, so there are specialized education that they can take, so a master?s is just something that just stays in the back of their mind.  Chapter Four: Findings 40 Non-Graduate Careers Participants explained that they had witnessed many nurses in their workplace be successful and progress into leadership roles without a master?s degree. This raised the question if a graduate degree was worth the effort it takes when career advancement was possible either way. They commented that potential nurse leaders were often selected by management and ?groomed? for positions that were often difficult to fill. If a nurse shows potential and interest in a leadership role, the employer provides supports to attempt to prepare the nurse for the role, but enrolment in a graduate nursing education is not a seen as a part of this process. One participant explained: I think there is a leadership path and a management path and there?s an educator pathway, so luckily there are different routes that you can take, so likely a master?s in nursing may not be exactly what a nurse needs to get to whatever arm they want to go. So, if you are focussing on management, leadership or education, probably or likely none of those things need a master?s in nursing. Many participants expressed that once a nurse graduates and starts to gain experience working at the bedside, they start to think about other nursing career options. The participants stated that pursuing graduate education would often be one of the last options because of the other opportunities available that do not require such a major commitment. They also stressed that holding a specialty education or a certification was perceived as more advantageous because these are short-term commitments. From their experience, they knew of many nurses whose highest level of education was a BSN and who were in leadership positions within their workplace and in clinical teaching positions. Supporting Resources Participants were clear about the lack of promotion of resources available to support nurses financially to pursue higher education. The participants made a total of 20 statements on  Chapter Four: Findings 41 the topic of the need for increased clarity on the availability of resources. They all agreed with the comment that one participant made: There is a lot of research that needs to be done to figure out where you can get funding from. It?s not like, here?s a list of where you can apply to; there?s so much looking . . . you have to do some sleuthing, quite a bit of sleuthing. Although the participants knew funding existed, they felt the process of applying and obtaining funding was not well promoted. They also felt that not knowing the types of positions available to MSN-qualified nurses was another reason some nurses did not choose to pursue graduate education. A participant explained the difficulty of finding important information about the possibilities for graduate-prepared nursing roles when she said: I just think if it?s advertised a little bit more, because you don?t hear about the benefits of a master?s and what it can get you for your future so I think a lot of nurses don?t really think about it that way. The participants expressed that a lot of support exists for taking educational opportunities that apply to their role within their clinical work, such as workshops or in-services. They also perceived, however, that they were less aware of the opportunities available to support a path towards higher education, such as opportunities to participate in research or the time and supports to participate in special projects that could expose them to the academic side of nursing but was still applicable to clinical practice. The Theory-Practice Gap The majority of the participants questioned whether a master?s in nursing education was the most appropriate type of education to apply to clinical practice. I sensed that participants were skeptical about the relevance of theory to clinical practice. Most participants did not see a master?s degree as the advancement in education that was necessary for improving patient care. One participant who was an experienced nurse stated:  Chapter Four: Findings 42 I think the profession of nursing requires nurses to have more education in order to keep the professional status of the profession. Although, I would question some of the education that is available as to how that would help that person. I think that the universities focus far too much on research even though research is a good thing, and we need to have research, but we can?t have every master?s nurse a research nurse. We have to have a master?s nurse that is totally clinically sound and who can be a clinical expert and to mentor other people along, and I think there needs to be that kind of a path. I think the concentration needs to happen more around the clinical scene. The clinical ?master-ship? is what is required out there. I don?t think universities even have that kind of a focus. If you take your front line nurse, but you are a master?s prepared nurse who really can help guide these nurses raise the bar. To make these nurses the best that they can be because you?ve got some extra skills now. I?m not thinking this would be a [manager] or a clinical nurse specialist, but something else. Another experienced nurse added to the comment made above: It?s important to remember that nursing is still very practical based, and something I?ve noticed is the new graduate nurses are exceptionally academically driven. It depends on what school they come from on the focus of where they wind up. That causes me a concern sometimes. If a nurse wants to come into nursing to be a nurse, allow her to be a nurse and, if she only comes out with a bachelor?s, so be it. That?s her choice. If she has a goal right from the start; ya, I?m going to be a nurse, but I?m going to do just for a year to get my hands dirty, but I actually want to be a [manager]. We need to work on that type of mentality because the care at the very basis is going to suffer. You can be very academic, but if the focus is not where it should be at the beginning then that?s when the problems start. I always said I don?t want a master?s; it?s a piece of paper, and it will not make me a better nurse clinically. The less experienced participants expressed that they felt they were not ready to embark on an educational path that is not based in clinical practice. They felt that there is a certain level of expertise and experience that a nurse should obtain before ?leaving the bedside.? These nurses also believed that graduate education may be something they would like to pursue but not until a certain point in their career. As one less experienced participant stated, ?When I?m older and tired of working at bedside.? The Value of Graduate Education The participants did see the value in a master?s degree in terms of an important element of moving the profession as a whole forward and of forming experts in different fields within nursing. The participants made 13 statements specifically on this topic and were all in agreement  Chapter Four: Findings 43 that graduate education is important to support professional development and to continue growing the body of nursing knowledge through nursing research. Most participants commented on the importance of having well-prepared educators to teach and to help develop the next generation of nurses: If we are talking about from an education or teaching perspective, somebody needs to teach the nurses what they are going to do, we have to develop the next generation. Then there?s the research part which is so important to the development of practice. Things change every day and it?s important to have that research to back up what we are doing and why we are doing it. That?s at the basis of nursing and best practice. The participants emphasized that the value of nursing education comes from applying the theory learned in the classroom to the practice that occurs at the bedside. Misconceptions of Graduate Level Roles The participants indicated that the roles of MSN-educated nurses are not generally understood beyond positions in teaching and in research. The participants believed that opportunities available to graduate-prepared nurses are not promoted enough to inspire nurses to pursue them themselves. One participant explained: I think a lot of these things [value of graduate nursing education] could be introduced in nursing school because your goal in nursing school is you want to graduate and start working but bedside nursing is all you really know. I never knew what an educator was or any nurse leader really was. Nurses don?t really know about these roles or that they even exist. So, I think if in nursing school they could start introducing it and students can start learning about these roles. They can set different goals for themselves. They may think to themselves, after I do nursing school maybe I do want to do my master?s because they see where it can take them. The participants perceived that undergraduate education prepares nurses to focus on nursing at the bedside, which leaves the other roles in nursing leadership, education, and administration less understood. One participant commented: We need to know, what does a master?s in nursing mean? So far, we said research and teaching and that?s it. If you haven?t looked into it, you don?t know what they do. I couldn?t even name one job that a PhD nurse would have, well, other than teaching and research. There is no list of jobs that shows you where these [graduate prepared] kinds of nurses would be going.?  Chapter Four: Findings 44 The participants explained that they really only understood the role of MSN-educated nurses from a practical point of view, such as when they work with someone in the role on a regular basis (e.g., their clinical nurse specialist). They felt that their undergraduate education would have been the best time to introduce the various roles so that undergraduate students could be inspired to set goals to pursue positions in which a graduate education would be beneficial or necessary. Summary of Findings The purpose of this study was to explore the perceptions and attitudes of nurses with regards to graduate education and, in particular, the motivators and barriers that would promote or hinder their participation in higher education. Although the viewpoints and experiences of the participants were very individual, many commonalities emerged from the discussions. The motivators were divided into three subthemes: having a professional goal, challenging oneself personally and professionally, and having the support of a role model, peer support, and mentor. As the participants were all bachelors-educated nurses, their perceptions of motivators were based on assumptions of their observations and not on personal experience. The barriers found were divided into three categories drawn from Cross?s (1981) work, which included situational, institutional, and dispositional barriers. The barriers identified offered a thorough explanation of factors that deterred nurses from pursuing graduate education. The other six major themes that emerged from the research described prominent perceptions and attitudes of the participants in respect to pursuing graduate education; these perceptions and attitudes were not directly viewed as a motivator or barrier but were still significant in explaining the participants? viewpoints on this topic.  Chapter Five: Discussion 45 Chapter Five: Discussion In this chapter, I discuss the overall findings and connect them with the existing literature. The themes of motivators, barriers and attitudes, and perceptions are based on the findings. This chapter also highlights the differences between the responses of the less experienced and more experienced groups. When analyzing the findings of the focus groups using Cross?s (1981) chain-of-response model, clear linkages to all of the criteria of the model could be seen. The model demonstrated that the external and internal influences of both motivators and barriers to pursuing education are interrelated and cyclical, and this was observed in the findings of this study. In this study, Cross?s (1981) chain-of-response model was used to help guide an initial assessment of the general elements of motivators and barriers from principles of adult education. After the initial assessment, I could refine more specifically which of these factors applied to BSN-educated nurses. As a way of summarizing the findings, a valuable process is to briefly move through Cross?s (1981) model and to provide examples of how the some of the focus group findings can be applied to each phase of the cycle. The first phase of Cross?s model (see Figure 1 found in Chapter 1) is the relationship between self-evaluation (A) and attitudes about education (B). Nurses? attitudes and perceptions of graduate education influences the ways in which they move through Cross?s theoretical cycle and whether they even move past the initial phase depending on their beliefs around pursuing education as a goal. For example, if a nurse?s goal is to become a clinical nurse specialist, the importance of the goal (C) and the expectation that education will meet that goal (C) is an important factor. The nurse?s life transitions (D), such as starting a family, may impact whether the nurse will continue toward the educational goal, which leads to  Chapter Five: Discussion 46 opportunities (called motivators in this study) and barriers (E). These opportunities and barriers may help or hinder the progress through the cycle. At this point in the model, a barrier may occur, which depends on what information (F) the nurse receives: for example, in the form of positive peer support or lack thereof. If the barrier arises, it may result in having to return to the beginning of the cycle for re-evaluation of the goal; however, if the barrier can be overcome or if strong enough motivating factors exist, this leads to participation in education (G), the final stage in Cross?s model. Cross?s (1981) model is intended to examine the adult learner from the perspective of engaging in formal education, which is not necessarily employment related. One key factor that emerged from the focus groups but that did not exactly fit into the model was the strong influence of employer support or lack thereof and the impact of employer support or lack of support on motivation to reach professional goals (Fitzgerald, Kantrowitz-Gordon, Katz, & Hirsch, 2012). The participants expressed that having a specific professional goal was an important motivator. Their responses made it clear, however, that the nurses in the focus group generally had a very limited understanding of what roles are available for graduate-prepared nurses, which is problematic because setting goals, as an important motivating factor, cannot happen without that knowledge. One participant commented: We need to know, what does a master?s in nursing mean? So far, we said research and teaching and that?s it. If you haven?t looked into it, you don?t know what they do. I couldn?t even name one job that a PhD nurse would have, well, other than teaching and research. There is no list of jobs that shows you where these [graduate-prepared] kinds of nurses would be going. Therefore, for a specific professional goal to be the motivation for pursuing graduate education, a nurse would first need to understand what the role is and be confident enough that it is a role he or she is willing to invest in.  Chapter Five: Discussion 47 Cost, as a general concept, is a significant factor and a perceived financial barrier that was discussed by almost all participants in the study. Eccles et al. (1983) defined cost as ?what individuals have to give up to gain something else? (p. 59). The nurses were in consensus that cost in all forms is a barrier, which in combination with other barriers, is the deciding factor to not pursue graduate studies. This perception, of cost being a barrier, can be linked to comments made by participants around their age, which presumably does introduce more family and personal obligations and responsibilities and thereby introduces further barriers to making the commitment to pursue graduate education (Morgenthaler, 2009). One participant explained: I just think the financial thing would be the big thing for me. Also, just where people are in their lives, like for me, like if I was going to have a kid or something . . . I?m at the point now where it might not be a good time to take on some other huge project. Like if you were trying to work and take on a master?s and have a kid; where does that fit in? For me it would be just about what is going on in my personal life. Plunkett et al. (2010) proposed that, because these costs and obligations increase over a nurse?s experience and career, recruitment for graduate nursing would best be done upon BSN completion when nurses have less perceived costs in their lives. Arguably, although new graduate nurses may have less family and personal commitments, the financial cost may still be great due to student loans accrued during their BSN education. In Plunkett et al.?s (2010) study that examines BSN students? self-efficacy and value influences in regards to graduate education, the authors found that the average participant was unsure in terms of valuation of graduate studies. This finding is congruent with my study?s findings. The authors proposed that this may be indicative of students? poor understanding of the value of graduate education (2010). When nurses view long-term benefits of graduate education, they are more inclined to pursue graduate studies. This view is in line with other research on motivation to pursue graduate education in which the perception of utility of nurses? education is a strong predictor of returning  Chapter Five: Discussion 48 to school (Battle & Wigfield, 2003; Delaney & Piscopo, 2004). This view is also in line with the participants? discussion in which they highlighted the importance of utility and usefulness of the master?s degree, particularly in respect to applying the theory of a master?s degree to the practice of nursing. Participants in my study observed that the longer one waits to return to school after graduating, the less likely that nurse is to go back to pursue graduate education. This is found to be true in the current literature as well, which suggested that nurses who are in the earlier stages of their career would have greater intention to pursue graduate studies because they have more time to determine if their professional goals could be met with or without pursuing graduate education, and they would plan accordingly (Battle & Wigfield, 2003; Delaney & Piscopo, 2004). Conversely, nurses who start to consider graduate education in the later stages of their careers have less time to plan their professional goals and may be nearing retirement and making other nonprofessional life goals (Morgenthaler, 2009). More experienced nurses in the focus group directly commented on their age and questioned whether taking on such a major commitment made sense for them considering the number of years they had remaining in their career. The opinion among most of the participants was that pursuing a master?s degree is for those nurses who have aspirations for research or who want to be an educator, such as a nursing professor or clinical instructor. The nurses expressed a disinterest for pursuing nursing research and linked their lack of interest in research to their lack of interest in pursuing graduate education. One participant expressed: I don?t really like doing research, that?s just not something that I?m interested in, but some people really like that. I went to school with people who knew that research was exactly what they wanted to do; it was a goal for them. Knowing the little that I know about getting a master?s, I know that research is a part of getting your master?s. A lot of it is research and so if that is what your goal is or what you are interested in, then for sure.  Chapter Five: Discussion 49 Their perceived disinterest in pursuing research could be a direct consequence of underexposure to research in a practical and tangible way and as applicable to ?the real world.? The participants expressed that BSN-level nurses have a perception that one chooses research or one chooses clinical practice. They perceive that a choice in research as a BSN-prepared nurse will ultimately lead to pursuing graduate education and, therefore, stepping away from relevant clinical practice. The participants in the focus group strongly expressed that this gap exists and that it is a deterrent to pursuing graduate education. An examination of what influences perceptions and attitudes about graduate education is important. As one of the participants in the focus group mentioned, awareness of graduate nursing education should start at the undergraduate level. The stigma and discernment around pursuing nursing research can be demystified with exposure at the early stages of education and throughout the undergraduate program. The key to the success of this exposure would be to present nursing research as relevant, accessible, and clinically practical. By seeing the application of nursing research, nurses will be able to connect theory and practice, and this may translate into their clinical practice and may eventually be a motivator for graduate education. The study?s findings suggested that a master?s education was not being seen as clinically relevant. Participants perceived that by pursuing a master?s degree, a nurse is choosing to step away from the bedside and away from clinical practice. This was an overarching theme in the discussion and the nurses? views clearly expressed that a strong dichotomy exists between the two paths. The pursuit of a graduate degree to build on a clinically focussed nursing education was not seen as an overlapping complementary concept. This is problematic because those who have strong clinical expertise may discount a master?s as a worthwhile option because graduate studies are not seen as clinical.  Chapter Five: Discussion 50 Many opportunities exist, however, for masters-prepared nurses to remain in clinical practice. The clinical nurse specialist role is an example of a masters-prepared, advanced nursing practice role that is designed to bridge the theory-practice gap by applying strong clinical skills and judgment to roles as a clinician, researcher, consultant, and educator (CNA, 2009a). My study examined the nurses who have not engaged in graduate education and, therefore, their perspective is coming from a place of not having lived the experience of being a graduate student. I found the examination of the literature, from the viewpoint of those nurses who have already undertaken the process, interesting. Many positive outcomes of graduate education were identified by Cragg and Andrusyszyn (2004) who examined the change in knowledge and attitudes of 22 Canadian recent MN graduates. The authors found that students perceived many positive outcomes, which the BSN nurses in my study had not commented on, such as greater breadth and depth of understanding of the healthcare system and nursing?s place in it, greater self-confidence, and increased pride in the nursing profession. As mentioned earlier, although the two focus groups were comprised of participants who were fairly homogenous, the levels of experience differed between the two groups. Some of the key differences in perceptions have been incorporated into the discussion above. In the introduction to the focus group questions, the participants of both groups were asked what percentage of nurses in Canada they believed held a graduate degree. Generally, the more experienced group believed that the percentage of nurses with a graduate degree was high  (25?40% of nurses holding a master?s in Canada), but the less experienced group thought it was much lower (10?20% of nurses holding a master?s in Canada). This could be because the more experienced nurses are increasingly exposed to the roles of graduate-educated nurses, such as nurses in leadership positions. The less experienced nurses may be less aware of these existing  Chapter Five: Discussion 51 roles and so do not think many nurses in general are graduate prepared. Interestingly, both groups estimated a percentage that was far from the actual rate of about 5% (CIHI, 2012). An overwhelming theme that emerged from this study was that making the decision to pursue graduate education is part of a process. This process involves a shift also many facets of personal and professional life. Graduate education is viewed by the participants not as an isolated academic endeavour but as a life altering one. Therefore, the decision to pursue graduate education must be planned to ensure that all of the financial, personal, and professional elements of change are considered. Contemplation and planning for graduate education involves careful and deliberate consideration of how a nurse?s current lifestyle will be affected, which is then weighed against the benefits. In the case of most of the nurses in this study, the pursuit of graduate studies is not seen as an investment that they are prepared and willing to embark on at the time of the study. Recommendations The majority of studies on this topic are conducted with nurses who have already made the decision to pursue graduate education and have researched the outcomes of pursuing graduate education (Cotterill-Walker, 2011; Drennan, 2008; Drennan, 2010). More research needs to be done to see what motivates and deters nurses from pursuing graduate education. Academic Institutions This research demonstrates a lack of understanding around the role of masters-prepared nurses. An increased understanding could be incorporated into nursing education, beginning at the undergraduate level. Educational institutions that have graduate nursing programs could do more to encourage nurses to apply to an MSN program by reaching potential applicants through their workplace and perhaps by holding information sessions that give nurses the opportunity to speak to an MSN student.  Chapter Five: Discussion 52 This study uncovered many questions for further research on the best ways to encourage and to support nurses in pursuing graduate education and on whether an ideal time exists in a nurse?s career for promotion of graduate studies. It is unclear if the best strategy for promotion and recruitment of potential applicants should be initiated by academic institutions actively recruiting master?s students from clinical settings or earlier by focussing on the undergraduate students and high school students (Miller & Cummings, 2012). Healthcare Organizations Healthcare organizations play an important role in promoting the resources available to support graduate education (Kleinman, 2004). The nurses in this study generally viewed their organization as very supportive but recognized that due to the nature of nursing employment, taking time off or having flexibility in their job would be helpful but not always possible. Financial supports available through the employer were not well known even though many exist. The question also arose as to whether more promotion of the nursing PhD should occur, thereby encouraging nurses to not view the master?s degree as the final academic destination but rather a stepping stone toward a doctorate degree. Another topic worth exploring would be the ways in which healthcare institutions could play a role in promoting graduate nursing education. Healthcare institutions have direct access to their nursing staff and could take a more active stance on succession planning, part of which may be steering nurses for graduate education in preparation for particular roles within the organization (Laframboise, 2011). Participants expressed their perceived barriers, which involved a lack of flexibility from their employer. Anticipated challenges were stated, such as inflexible work schedules and the potential of being denied time off. Although the participants did not state they had actually inquired about ways their employer could provide support, they assumed this aspect would be a challenge and this was a perceived barrier.  Chapter Five: Discussion 53 The implications for the future also need to be considered. With promotion strategies in place and with a shift from a majority of diploma-level nurses to a majority of BSN-level nurses, the number of masters-prepared nurses may increase significantly. As a result, the possibility of unemployment, over qualification, and heavy competition for leadership nursing roles could also grow. Another problem that may occur is the transition from a novice to expert nurse starting in a graduate-prepared role may introduce challenges of engagement, integration, and support within healthcare organizations (Donner & Waddell, 2011). If the number of graduate-prepared nurses continued to grow, how would that trend impact the overall nursing shortage, and would it be intensified as nurses move out of frontline positions and into leadership roles? These are the questions that will need to be examined as the profession of nursing evolves over time and as new trends in nursing education and nursing professional roles emerge. Limitations Only eight participants total took part in the two focus groups. More focus groups could be conducted to acquire more data and include a greater variety of responses. The participants all worked at the same hospital and, therefore, their opinions were biased to this one particular workplace, which again limited the variety of responses. All of the participants knew me, which could have introduced a bias in their answers and in their comfort level to answer honestly, even though they appeared very comfortable. Despite continuous efforts to minimize my own bias, it is important to acknowledge that I am an MSN student and an RN as well. My role as the moderator may have had implications for how I moderated the conversation, interacted with the participants, and analyzed the data. Conclusions Compared to many other healthcare professionals with whom nurses work (such as social workers and physiotherapist), nursing has been slow to move towards pursuing graduate  Chapter Five: Discussion 54 education. The face of nursing is changing as the majority of nurses who still hold a diploma as their highest level of education will retire. Yet, even still, that leaves a small minority of nurses holding an MSN. This study aimed to uncover the perceptions and attitudes of registered nurses on the value of graduate nursing education and, as a part of this, the study also addressed the perceived motivators to undertake graduate nursing education and the perceived barriers towards pursing graduate nursing education. By examining the perceived motivators and barriers to pursuing higher education, according to nurses of various experience levels, this study uncovered insights that may help nursing students and current working nurses look positively at this educational opportunity. The three most prominent potential motivators for the participants were having a professional goal, being personally and professionally challenged, and having a role model in the form of peer support and mentorship. The participants expressed that higher education was important when striving for a particular nursing role that required it or when they had a specific professional destination in mind, such as a formal leadership role in clinical practice or education. Participants expressed that a motivation to pursue graduate education could stem from a desire to be challenged academically and professionally, fulfilling their personal need for learning and providing them with new professional opportunities. Lastly, the participants expressed that having a role model in the form of peer support and mentorship was a potential motivating factor as a support person was seen as beneficial to provide emotional support and guidance. The identification of barriers, which may hinder nurses from pursuing graduate education, is important. The situational barriers found were the work-life-school balance and financial impact; more specifically, the financial impacts were identified as being related to a  Chapter Five: Discussion 55 nurse?s age and being related to personal and family commitment, as finances are a sacrifice that affects a nurse?s family as well. The main institutional barrier identified was the rigidity of the application process; nurses expressed that admission dates were too infrequent and did not support those who may have decided to apply after the deadline. Lastly, dispositional barriers identified by the participants highlighted that the participant?s previous experiences in school, whether that be nursing school or other types of formal education, deterred them from wanting to return to the academic setting for various reasons. By determining the factors that potentially motivate a nurse to pursue graduate education or deter a nurse from pursuing graduate education, healthcare workplaces and the academic sphere may be able to make changes that support their nurses in advancing their formal nursing education. In addition to the recommendations described above, the findings in this study only introduce a starting point from which future directions for research can be taken in this area. Further qualitative research needs to be conducted specifically on nurses with an undergraduate degree who are potential applicants to a graduate program in order to explore other potential motivators and perceived barriers that did not emerge from this research. It would be beneficial to explore how graduate nursing programs can most adequately prepare nurses for advanced nursing roles and to explore the perceptions that nurses have about the various graduate educational areas offered. This study demonstrated that nurses are supportive of and motivated to pursue continuing education and that they do value higher education in nursing; however, they may not necessarily value higher education in the form of a master?s degree in nursing. Although the literature highlighted the value of graduate education for nurses in the clinical setting, the participants in the focus groups debated the application of a master?s degree in clinical practice. The RNs in this  Chapter Five: Discussion 56 study expressed that nurses can take other paths in order to continue their education and to remain relevant in clinical practice. A continuation of support for nurses who want to pursue continuing education needs to occur, and more promotion of the doors that a graduate degree can open for nurses needs to be presented. References 57 References American Association of Colleges of Nursing. (2012). 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Master?s level education in Jordan: A qualitative study of key motivational factors and perceived impact on practice. Nurse Education Today, In Press, Corrected Proof, Available online 12 May 2012. doi:10.1016/j.nedt.2012.04.007 Appendices 65 Appendices Appendix A: Consent Form  Consent Form Factors Influencing the Pursuit of Graduate Education in Registered Nurses: Exploring the Motivators and Barriers  Principle Investigator and Graduate Research Supervisory Committee Chair: Dr. Bernie Garrett, School of Nursing, University of British Columbia Phone: [telephone number] [email address]  Co-Investigator: Catherine Gorczyca, School of Nursing Masters Student, University of British Columbia Phone: [telephone number] [email address]  Co-Investigators and Supervisory Committee Members: Maura MacPhee, School of Nursing, University of British Columbia Phone: [telephone number] [email address]  Elsie Tan, School of Nursing, University of British Columbia Phone: [telephone number] [email address]  Introduction: I am a graduate student at University of British Columbia School of Nursing pursing a Master?s degree with a focus on nursing education. I would like to invite you to  The University of British Columbia School of Nursing T201-2211, Wesbrook Mall Vancouver, B.C. V6T 2B5 Phone: (604) 822-7417 Fax: (604) 822-7466  Appendices 66 participate in a study aimed at exploring the perceptions and attitudes of registered nurses on graduate nursing education. This study is part of a nursing graduate student research project.  Purpose: The purpose of the study is to explore the perceptions and attitudes of registered nurses on the topic of the value of graduate nursing education. More specifically, the study will look at the following sub-questions:  ? What are the perceived motivators to undertake graduate nursing education? ? What are the perceived barriers towards pursing graduate nursing education?  In order to explore this topic, I intend to hold two focus groups. One for registered nurses who have worked for less than or equal to 5 years and one for registered nurses who have worked for more than 5 years. The purpose of dividing the nurses into number of years of experience is twofold: one, to minimize any potential intimidation a novice participant may feel speaking in a group of experienced nurses and vice versa, and two: to group together nurses who may be able to relate to one another as much as possible based on their years as a professional and length of time they have been out of formal education.  The study will also address the following sub-questions;  Study Procedures: You are being asked to participate in a focus group discussion that will take place for approximately 1.5 hours. Your participation in this study will require you to do the following:  ? Participate in a focus group discussion with other registered nurses. ? Engage with particular questions and discussion pertaining to issues in graduate nursing education.  Potential Risks: This research involves minimal risk to you. There is a potential risk of other registered nurses hearing and disseminating your personal views on nursing education. Your identity will only be known to the other participants in the focus group and a potential risk is that the other participants will hear your personal views on education. We encourage participants prior to commencing with the focus group not to discuss the content of the focus group to people outside the group; however, we cannot control what participants do with the information discussed.  Potential Benefits: There is a potential benefit for you of hearing new ideas on the value of higher education for registered nurses.  Your participation is completely voluntary. You may withdraw from this study at any time without penalty.  Research use and Confidentiality: By agreeing to participate in this project, you will be allowing the research team to use and analyze focus-group responses in order to be written up for publication as a graduate student thesis. Please note that the focus group will be audio-recorded. While other group members and the research team will know your identity, your personal  Appendices 67 identity will be kept strictly confidential. Furthermore, no biographical information will be required for the survey or focus group. All physical documents and files pertaining to this study, including audio recording will be identified only by code number and kept in a locked filing cabinet in a locked office at St. Paul?s Hospital. Any data kept on electronic media (computers) at UBC?s School of Nursing or St. Paul?s Hospital will not include the name or personal details of the individual subject and will be password protected, kept solely on the computers of the principal researcher and student participant. Any physical documents or audio recording will be destroyed after 5 years. As a research participant, you will not be identified by name in any reports of the completed study. Participants will only be identified by a unique code number.  Reimbursement: Unfortunately, we are unable to offer any financial compensation but you will be given the opportunity to be entered into a draw for a $25 Starbucks gift card.  Contact for information about the study: If you have any questions related to this project or wish to have further information with respect to the study, you may contact the Principle Investigator or the Co-Investigator.  Contact for concerns about the rights of research subjects: If you have any concerns about your rights as a research subject and/or your experiences while participating in this study, you may contact the Research Subject Information Line in the UBC Office of Research Services at 604-822-8598 or if long distance e-mail or call toll free 1-877-822-8598.    Appendices 68 Appendix B: Focus Group Questions 1. What would you guess the percentage of nurses who hold an MSN is? 2. In Canada, about 5% of RNs have a Masters in Nursing and less than 1% hold a PhD . . . what do you think about these numbers? 3. Why do you think some nurses choose to go back to school to get an MSN? 4. Have you considered pursuing a Masters in Nursing? Why or why not? 5. What types of continuing education experience do you feel are most useful for baccalaureate qualified RNs? 6. Why do you think some nurses choose not to undertake an MSN or further graduate education? 7. Institutional barriers are those practices and procedures that exclude or discourage adults from participating in organized learning activities. What kind of barriers do you think exist around the schools and the programs themselves? 8. Situational barriers arise from one?s situation or environment at a given point. What personal or professional barriers (situational barriers) do you think prevent nurses from applying for graduate education? 9. Dispositional barriers are those related to the attitudes and self-perceptions about one-self as a learner. Do you have any doubts or fears about your own abilities in regard to pursing graduate nursing education? 10. What value do you believe a graduate degree in Nursing has? 11. Do you think it?s important for the profession of nursing to have graduate level nurses? Why or why not? 12. What supports would have to be in place for you to take on this education? 13. What resources do you know about that are available to support you in your Masters in Nursing? 14. Optional Question: Something you all have in common is you pursued a Bachelor of Science in Nursing at some point. Think back to when you made the decision to start your BSN. 15. Optional Question: What factors motivated you to take on this educational commitment? 16. Optional Question: What factors supported you to complete your BSN successfully?    Appendices 69 Appendix C: Focus Group Statements Summary  Question Topics Themes Subthemes Number of Statements Motivators Professional Goal  10 Personal and Professional Challenge  10 Role Modelling: Peer Support and Mentorship  11 Situational Barriers Work-life Balance  15 Financial Impact Total 22 Age 6 Personal and Family Commitments 8 Institutional Barrier Application Process  9 Dispositional Barrier Returning to Study  23 Perceptions and Attitudes Alternative Educational Opportunities  13 Non-Graduate Careers  6 Supporting Resources   20 Theory-Practice Gap  7 Value of Graduate Education  13 Misconceptions of MSN Level Role  8 


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