Concurrent Enrollment ADN-BSN Programs: A Call to Expand Access to This Innovative Approach to the BSN

. Background . Te National Education Progression in Nursing’s current goal is for one million incumbent nurses and 90% of new ADN nurses to achieve a BSN or higher by 2025 in the United States. To meet this goal, programs nationwide are exploring options to increase BSN graduates. One method is the concurrent enrollment ADN-BSN pathway. Tis review examines how nurse educators develop and implement concurrent enrollment ADN-BSN programs in the US and calls to expand access to this important approach to academic progression in nursing. Method . A PRISMA search strategy was used to identify articles that detailed the development and implementation of dual-admission nursing programs. Ten relevant works were analyzed in this review. Results . Dual enrollment programs vary in program type and implementation methods nationwide and ofer an innovative, cost-efective, and time-efcient approach to obtaining the BSN. Conclusion . While employing dual or concurrent enrollment partnerships between community colleges and universities is a complex endeavor, these programs are a powerful and cost-efective way to increase the number of BSN nurses in the workforce and should be considered for expansion as we promote academic progression for all nurses.


Introduction
Te National Education Progression in Nursing (NEPIN) collaboration has championed academic progression for nurses [1].NEPIN was formed from the Robert Wood Johnson Foundation's original grant project, Academic Progression in Nursing (APIN).Its focus is gathering stakeholders in the United States to identify and support practices promoting nurses' academic progression.Te stated goal of the collaboration is to have one million incumbent nurses, and 90% of new associate degree nurse (ADN) graduates achieve the baccalaureate (BSN) degree or higher by 2025.In addition, the overarching goal is to promote ways for all nurses to attain advanced degrees to help ensure the best healthcare and patient outcomes in every setting throughout the United States.
Te focus on academic progression in nursing also has roots in another collaboration.In 2010, the Institute of Medicine (IOM) and a Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing published a goal of 80% of the nursing workforce achieving a BSN by 2020 [2].Te leading nursing organizations responded quickly to this goal.In 2010, the Tri-council for Nursing (the alliance between the American Association of Colleges of Nursing (AACN), the American Nurses Association (ANA), the American Organization for Nursing Leadership, the National Council of State Boards of Nursing, and the National League for Nursing) embraced and endorsed the focus on academic progression for nurses, putting forth their consensus statement supporting the IOM's goal [3].
Te literature supports the emphasis on increasing BSNprepared nurses in the workforce.As the American Association of Colleges of Nursing [4] reported in their fact sheet, Te Impact of Education on Nursing Practice, the evidence strongly supports the association of BSN-prepared nurses with improved patient outcomes.In response to these strong associations, many healthcare organizations have advocated for an increase in BSN-prepared nurses in their practice settings.Examples of these settings include magnet-designated hospitals, the United States Armed Forces, the U.S. Public Health Service, and the Veteran's Administration [4].
One method promoted by NEPIN to increase the number of BSN-prepared nurses in the workforce is a dual admission or dual enrollment model [5].Tis model, also referred to as a concurrent ADN-BSN program, allows a community college and a university to partner, providing a pathway for study that simultaneously results in ADN and BSN completion.Concurrent enrollment programs allow students to take advantage of the lower-cost community college for most of their coursework while earning the desired BSN [6,7].Other benefts of these programs include helping students avoid academic breaks, streamlining educational progression, and strengthening community partnerships between ADN and BSN programs [6,8].

Methods
MEDLINE, CINAHL, ERIC, and Google Scholar databases were searched for nursing literature describing programs ofering dual enrollment or concurrent enrollment partnerships in undergraduate nursing.Te Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were used to complete the search.Inclusion criteria included peer-reviewed English-language articles published in the last 20 years that described the use or development of a concurrent or dual enrollment model to enable ADN students to attain a BSN upon graduation from their ADN program.Search terms used were dual enrollment, concurrent enrollment, academic progression, ADN, BSN, and nursing education.Tese terms were searched individually and in various combinations as keywords, subject headings, and also within article titles.Reference lists for each resource were also mined to capture any additional relevant works.Last, websites for each of the members of the Tri-Council for Nurses were searched for relevant blogs, fact sheets, or announcements.Te author used the PRISMA methodology to review the articles, delete duplicates, and fnalize the ft for the search criteria.Ten articles were included in the fnal review.

Catalyst for the Concurrent ADN-BSN Pathway.
Various program designs and implementation strategies for dual or concurrent enrollment programs exist nationwide.All programs in the fnal review referenced the [2] call for increased BSN-prepared nurses as the primary catalyst for program development.Other reasons for ADN-BSN dual or concurrent enrollment program development included addressing the nursing shortage in the US [9], addressing the lack of BSN nurses in rural areas [10], addressing the lack of university programs in rural areas [11,12], and reducing costs for associate degree nurses seeking baccalaureate degrees [11,13].Many programs and communities cited the desire to increase diversity in their student population and workforce as a crucial reason to develop concurrent programs [11,12,14,15].Tese stakeholders noted that students from specifc backgrounds, such as economically disadvantaged, frst-to-college, or culturally diverse, were less likely to seek a BSN program.Hence, a dual enrollment ADN-BSN program allowed the expansion of the BSN option to them and expanded the diversity found in the nursing workforce.Another program implemented the dual enrollment model to obtain clinical placements for ADN students in local magnet or magnet-seeking hospitals since these hospitals were less likely to work with ADN programs otherwise [11].As a result, these hospitals were more likely to provide clinical placement for students enrolled in a dual enrollment program.Last, Graziano et al. [14] noted that in several community colleges in Minnesota, the average time for obtaining the ADN was four years (similar to the BSN), and therefore, dual enrollment in a concurrent ADN-BSN program was a win-win by ofering the cost savings of the ADN with the academic advancement of the BSN.

Program Development.
Although the programs studied had varied curricula, the development and design processes for each had many similarities.For example, several programs addressed the need to develop solid partnerships with all stakeholders during the planning phase and to include members of community colleges, articulating universities, and clinical or community partners in planning so that accreditation, residency, fnance, and other issues could be addressed early in the process [12,15,16].In addition, both Bopp and Einhellig [6] and Wiseman et al. [16] emphasized that responsibilities, obligations, and policies should be detailed early in the partnership process with a memorandum of understanding.Finally, several stakeholders wrote grants to help assist with the costs associated with developing and implementing dual enrollment programs [10,14].
Educators emphasized crafting program plans to integrate the curriculum and a seamless transition for students from ADN to BSN [9,12,15].Eliminating curricular redundancies was of primary concern [17].Sharpnack et al. [15] reported using gap analysis to assist faculty in identifying strengths, weaknesses, and overlaps of each partner curriculum before devising program pathways.Bopp and Einhellig [6] reported the importance of detailing student prerequisite and admission requirements, program policies, and progression pathways.Several institutions ran small pilot studies before instituting full program enrollment [10,11], and others sought the advice of experts or consultants to help with the development and implementation of programs [17].
Some partnership teams negotiated shared resources between institutions, including advisers and faculty, to help ensure student success and consistency [9,14,15,18].Other partnerships encouraged the community college advisors to be responsible for program recruitment so that each eligible ADN student could be ready to apply for dual enrollment admission when appropriate [11].Programs also emphasized the need for advisors to ensure that students had instruction about obtaining fnancial aid correctly (usually with the university as primary).Tis action helped provide 2 Nursing Forum the necessary funds for dual enrollment program costs [10,16].

Challenges.
Colleges and universities reported many challenges in developing dual or concurrent ADN-BSN curricula.For example, program developers cited the detailed advanced planning necessary for successful, streamlined partnerships.Many components are needed for such programs, including letters of agreement for curriculum and fnances and navigation for the reporting required by colleges and universities [10].Bopp and Einhellig [6] identifed another signifcant hurdle: the difculty of integrating two nursing curricula without redundancy.Wiseman et al. [16] emphasized the challenges that schools faced in adding workforce and workload, citing the need to take on extra advisors and costs to coordinate programs.Finally, Jones and Close [9] reported that a dedicated program director was crucial to support the success of a dual enrollment program, but this position added the challenge of additional costs.Students also described difculties as they navigated the concurrent programs.Masters [10] reported a range of student challenges.Tese included concerns such as needing more connection to the university and university peers, additional time to travel outside of communities for classes, and adapting to classwork in an electronic format for online or hybrid courses.Wiseman et al. [16] discussed student concerns about fnancial aid and the burden of paying tuition.Sharpnack et al. [15] reported students' challenges in managing heavy coursework and extra clinical assignments associated with dual enrollment.While some programs had students fnishing ADN programs simultaneously with their BSN counterparts [11], others required the student to complete the ADN program and obtain licensure before fnishing the BSN component [15].Te latter students had the added challenge of simultaneously transitioning to nursing practice while fnishing the curriculum, potentially adding stress and contributing to attrition [15].

Limitations
Two limitations of this review were the relatively small number of articles in the literature describing dual/concurrent enrollment programs as well as the age of some of the relevant program descriptions.In addition, the descriptions or labels for the various programs across the nation were not aligned among the programs, particularly across state lines, so relevant works may not have been identifed in the literature search.Last, comparison among programs was difcult because each type varied widely.

Discussion
Dual or concurrent enrollment programs for ADN and BSN partnerships are becoming more widespread to help meet healthcare and nurse workforce goals in the United States.Te most successful models for dual enrollment programs are developed with careful planning between the partnering institutions to promote program communication, balance the workload for faculty and support staf, and meet clinical expectations for stakeholders and students.Other critical components for successful partnerships include consistency among partners regarding goals, policies, and progression.Moreover, the BSN curriculum should build on and reinforce the ADN curriculum to help avoid redundancies, ensure content is presented at the appropriate time in the program, and emphasize the expanded BSN role.

Conclusion
Te literature shows that promoting academic progression for nurses improves patient outcomes.Te NEPIN goal of 90% BSN nurses by 2025 was conceived in response to these data and should be the catalyst for achieving academic progression for the associate degree nurse.Employing dual or concurrent enrollment partnerships between community colleges and universities is a powerful and cost-efective way to help meet that goal.While creating partnerships and implementing programs can be complex, many schools have used these programs to successfully enhance the education of the ADN student.Other schools can answer the call to promote academic progression in nursing by modeling these eforts and developing their own concurrent enrollment programs.