Advanced Nursing Education

Critical Factors That Influence Diploma and Associate Degree Nurses to Advance

Rose Lavine McGhie-Anderson

Nursing Education Perspectives


Abstract

Aim: The purpose of this study was to gain an understanding of the social processes associated with the decision of diploma and associate degree nurses to advance academically.

Background: Advanced nursing education needs to be pursued along the continuum of the nursing career path. This education process is indispensable to the role of nurses as educator, manager, nurse leader, and researcher who will effect policy changes, assume leadership roles as revolutionary thinkers, and implement paradigmatic shifts.

Methods: Data were collected from two groups of participants using face-to-face, semistructured interviews. Group 1 consisted of diploma and associate degree nurses; Group 2 consisted of baccalaureate, masters, and doctoral degree nurses who have progressed academically.

Results: Emerging from the thick, rich data were core categories of rewarding, motivating, and supporting as critical factors that influence professional advancement.

Conclusion: This qualitative study elucidated that professional advancement was the social process that grounds. The emergent theory was the theory of professional advancement.


Advanced nursing education is used synonymously with the terms academic progression and professional progression. Academic progression refers to articulation models that promote lifelong learning through the addition of academic credentials (National League for Nursing [NLN], 2011). It is therefore a movement of advancement by degrees (Birks, Chapman, & Francis, 2010 Institute of Medicine [IOM], 2011). Having qualified faculty and advanced practice nurses to manage new and emerging environments of care in various settings will be unattainable if approximately 60 percent of nurses entering the workforce are associate degree (AD) graduates. Worldwide, nurses are called to work in environments where there are increasing health care reforms, complicated patient care needs, technological advancements, and improved evidence-based practices. These ongoing changes call for nurses who are competent in leadership, health policy, system improvement, research, evidence-based practice, and collaboration. This is essential in facilitating the delivery of high-quality care (NLN, 2011).

Seventy-eight percent of the 3 million nurses in the United States are registered nurses (Health Resources and Services Administration [HRSA], 2016). The nursing profession is considered the largest segment of the health care industry, with nurses accounting for 84.4 percent of the workforce (American Association of Colleges of Nursing [AACN], 2012). Of this workforce, only 40 percent hold a baccalaureate degree (HRSA, 2013).

The IOM (2011) recommends that, by 2020, 80 percent or more of the nursing population should be educated at the baccalaureate level. The implication is that 465,000 diploma and AD nurses are to return to school by that time (HRSA, 2013). Studies such as that of Aiken et al. (2011) have shown that the presence of nurses who are academically advanced improves patient outcomes in the hospital environment. Surgical mortality rates exceeded 60 percent in hospitals with lower educational level nurses, whereas hospitals with more highly educated nurses had better patient outcomes.

Literature Review

A review of relevant literature across disciplines was conducted to explore the phenomenon of advanced nursing education, that is, critical factors that influence diploma and AD nurses to advance. The review was divided by topics into the major theoretical and research literature, including: a) the historical context of advance nursing education, highlighting trends and developments in nursing over the centuries and the direction nursing needs to take for the future; b) motivations to advance; c) perceptions of advanced nursing education; and d) benefits of advanced nursing education. A synthesis of the literature was undertaken to explicate what is known and unknown about the factors that influence nurses to advance academically. The literature review revealed that further research is needed to address empowerment in the workplace and the decisions for academic advancement (Sarver, Cichra, & Kline, 2015).

Historically, many hospital-based nursing programs collaborated with colleges and universities to meet the educational needs of diploma nurses to transition to AD and BSN (Clinton, Murrels, & Robinson, 2005). ADN programs began in the early years following World War II; the Ginzberg report, released in 1949, recommended a two-year nursing program to meet the existing nursing shortage (Ginzberg, 1949). In 1965, the American Nurses Association published a position paper that indicated that the BSN level should be the minimum preparation for entry into the nursing profession. This position paper is supported by current research that shows that the presence of BSN-educated nurses helps improve patient outcomes (Aiken et al., 2011). Magnet hospitals are increasingly employing a higher percentage of baccalaureate nurses as a preference for entry into practice (AACN, 2012).

Literature on the motivation to advance professionally has shown that Canada, Sweden, Portugal, Brazil, Greece, Iceland, and the Philippines all require a four-year undergraduate degree to practice as an RN (AACN, 2012). A quantitative study conducted by Spetz and Bates (2013) examined the relationship between education, experience, and wages of RNs. The study included a multivariate regression to examine the effects of education on wages and a multinomial regression to examine the relationship between education and job title. The findings revealed that lifetime earnings for the nurse whose initial education was a BSN were comparatively higher than wages for ADN nurses. In addition, the BSN was associated with being an advanced nurse with an academic and/or management title. The study also indicated that nurses are motivated to complete a BSN degree because of potential financial and professional benefits.

Aiken et al. (2014) conducted a retrospective observational study that reviewed 26,516 professionals at the bedside for the period 2009–2010. The aim was to assess if there were differences in patient-to-nurse ratios and nurses’ educational qualifications in 9 of 12 registered nurse forecast (RN4CAST) countries that had similar patient discharge data and if there were variations in mortality rates after common surgical procedures. The implications are that reduction of nursing staff in hospitals may adversely affect patient outcomes and BSN-degree-educated nurses significantly reduce preventable hospital deaths.

Sarver et al. (2015) explored RNs’ perceptions about returning to school for a BSN and their perceived motivators and barriers to the pursuit of professional advancement, as well as their perceptions of ensuing benefits. A quantitative, descriptive approach was used to understand the meanings and the interpretations of nurses who pursued a BSN degree. The findings revealed that RNs valued advanced nursing education; however, support was needed from nurse leaders along with improved access to information. The authors recommended conducting qualitative research to explore the relationship between being empowered in the workplace and the decision-making process to advance academically.

Benefits of academic progression were elucidated in studies such as qualitative, case study research conducted in Australia to investigate how existing registered midwives were challenged by current statutory requirements related to continued professional development (Gray, Rowe, & Barnes, 2014). The study indicated that health professionals have legal, regulatory, and ethical obligations to remain up-to-date and informed by advancing professionally. The commitment to advance was attributed to motivation as the core theme. The researchers believed that when individuals are supported and valued, they will be motivated to continue to develop professionally.

Eley, Francis, and Hegney (2013) also conducted a study on career progression. A quantitative cross-sectional cohort design with a mailed survey was used to measure the extent of the relationship between opportunity for career progression in nursing and turnover and retention. The study revealed that lack of career progression among nurses remains a major concern for patients and families, nurses, and the nursing profession.

Method

Grounded theory is a qualitative research process used to describe data that are systematically collected and analyzed. The researcher begins with no preconceived conclusions of a theory; the theory emerges from data to provide insight, to enhance understanding, and to provide the interpretations and meanings that may guide action. In a grounded theory methodological approach, there is an existing relationship between data collection, analysis, and the theory that will emerge from the data. A theory derived from data is the reality of participants’ social interactions and experiences. According to Strauss and Corbin (1998), “theorizing is the act of constructing” (p. 25). The researcher asks questions that will stimulate the thoughts of the participants and extracts a creative, cohesive, and organized schema from the raw data to which categories are assigned.

Following institutional review board approval, the researcher purposefully selected participants from hospitals and colleges of nursing who would provide insight into the phenomenon of interest. The initial sample consisted of 22 individual participants for Group 1 and 7 focus group members for Group 2. The final individual members for Group 1 were 15 diploma and ADN nurses who were not advancing academically. Although 22 individual participants met the criteria for interview, saturation was reached after the 13th participant was interviewed; an additional two participants were interviewed to confirm saturation. Atlas.ti qualitative data analysis software was used to manage and organize the data.

Group 2 was composed of seven focus group members, nurses who advanced to BSN, master’s of science, and doctoral education in nursing. The data collected were from interviews and observations for the primary purpose of discovering concepts and their relationships.

Participants who indicated willingness to participate in the study were assessed to determine if they met the criteria for participation. Prior to each interview, participants were informed of the purpose of the study and their rights to participate or withdraw at any time without fear of repercussion. They were allowed time to sign their consent forms and complete the demographic questionnaire and were given a $10 American Express gift card as a token of appreciation for their participation.

Participants used pseudonyms instead of their real names. Individual interviews were conducted in a quiet environment in community libraries or via Skype in individual study rooms to allow for neutrality and privacy. Interviews lasted for 45 to 60 minutes and were recorded. Twelve interviews were conducted face-to-face, and three were conducted via Skype. The principal challenge encountered with Skype was the loss of connectivity due to a thunderstorm; however, reconnection went smoothly. The main challenge of the face-to-face interviews was scheduling.

The process of open, axial, and selective coding was completed in a cyclical manner to derive data saturation. This was done to confirm saturation, increase trustworthiness, and ensure that the selection of the representation of diploma and AD nurses represented the whole.

The phenomenon of interest was the core problem that shaped the data derived from the participants in this study. This allowed the researcher to consider the interactions and the relationships formulated by participants, their descriptions of shared experiences, interpretations, attitudes, and the decisions for diploma and AD nurses to advance academically. The analytical processes that stood out in categorizing and formulating concepts involved the process of asking questions to uncover the deep meanings of what, who, where, when, how, and with what consequences and making constant comparison of data to excavate the real meaning behind each story. The process of deduction was repetitive and continuous to complete, refine, and review all emerging categories and concepts until all possible domains were exhausted.

Findings

The purpose of this study was to gain an understanding of the social process associated with the decisions of diploma and AD nurses to advance their nursing education. The thick, rich, data emerged into concepts as directed by three research questions: 1) What are the critical factors that influence diploma and AD nurses to advance their nursing education? 2) How do diploma and AD nurses perceive motivations to advance their nursing education? 3) What factors would motivate nurses to advance academically in their nursing career?

Three main categories that emerged from the data were Rewarding, Motivating, and Supporting. Subcategories that emerged were role differentiation, passion, and positive work environment. Role differentiation and passion were pulled into motivating as a core category; positive work environment was pulled into supporting.

These categories emerged as the critical factors that influence and ground diploma and AD nurses in their decision-making toward academic advancement. The definitions assigned to these descriptors were expressed by the participants and supported by the Hertzberg motivation-hygiene theory (Hertzberg, Mausner, & Snyderman, 1959).

Rewarding

 

Rewarding is the sum of all benefits provided to employees from their employer. It is seen as all monetary and nonmonetary and psychological payments provided by an organization in return for employee contribution (Bratton & Gold, 2003). Rewarding encapsulates every aspect of work that is considered valuable to the employee and includes healthy work environment, employer support, learning opportunities, career development, and benefit packages associated with salary (Armstrong & Stephen, 2005).

Rewarding was found frequently in the data collected from the research participants and reemphasized as one factor that would influence diploma and AD nurses to advance academically. It emerged from the data repeatedly, more than the other main categories. Rewarding is categorized as tangible and intangible and is described by the participants as consistent, creative ways of recognition in order to motivate nurses toward academic progression.

Tangible rewards are concrete, measurable, and observable. Examples that nurses highlighted were job promotion, salary increase/bonuses, plaques, gift cards, dinners, increased leadership roles, and active participation in the decision-making process for patient care. According to a participant, Viaflar, rewarding would help promote advancement within the nursing profession, increase the scope of practice, and increase the opportunity to pursue higher degrees; in addition, Viaflar commented that rewarding would help reduce the nursing shortage. According to Conover and Richards (2015), numerous states are looking for less costly ways to alleviate the nursing shortage. They state that nurse practitioners in North Carolina, who practice at their full scope, will bring significant benefit to the state.

Zully, another individual participant, commented that intangible rewarding should be attractive and motivating. Examples of intangible rewarding highlighted by the nurse participants included the following: greater ability to stay current with nursing education and advancement in technology; a sense of fulfillment with their academic achievement; increased knowledge that will enhance safe, competent patient care; an increase in leadership opportunities; and experience in the decision-making process in patient care delivery.

Motivating

 

Motivating is the drive for action that results in rewarding (Kouneiher, Charron, & Koechlin, 2009). It therefore targets the cognitions and behaviors that are directed for action. This action is enhanced when rewards are attributed to performance (Miller, Shankar, Knutson, & McClure, 2014). Motivating was identified as the second most dominant category that would be the driving force to influence diploma and AD nurses to advance academically; the study participants described motivating as impactful, both intrinsically and extrinsically.

As one of the main categories, motivating pulls with it the subcategories of role differentiation and passion. Interviewee Virm highlighted that if the organization motivated her, she would become passionate about her academic advancement. Yagle stated, “I am not passionate about nursing; it is my second career. I just needed the money to take care of my family. At the end of each work day, I just want to get home.”

Supporting

 

A supporting work environment involves all aspects that act and react on the body and mind of an employee. From an organizational psychological perspective, it is the physical, mental, and social environments where employees are working together and their work is analyzed for increased productivity (Jain & Kaur, 2014). A supporting environment was interpreted as the culture of an organization that hinges strongly on professional standards and the subsequent impact on the employees. As a main category, it pulls with it the subcategory positive work environment.

Interviewee Llaney felt that a positive work environment is one that promotes civility and equal opportunity, and one that operates an engaging education department would be beneficial in encouraging nursing advancement. Environmental culture as a major category was seen by the study participants Zully and Yerrkar as necessary in the role of helping to influence advanced nursing education. Supporting group members confirmed that the perceptions of the diploma and AD participants regarding the factors that hinder advanced nursing education mirror some of the views they discussed to which they added further comments.

A diagram, available as Supplemental Digital Content at http://links.lww.com/NEP/A38, is a visual representation of the conceptual relationship that developed among the main categories of rewarding, motivating, and supporting, as well as the subcategories of role differentiation, passion, and positive work environment. The reason for the model is to make visible the categories that emerged from the data and to make known the social processes, limitations, and relevance to the study.

Depicted in the diagram are the thought processes of the diploma and ADN nurses as interpreted by the researcher to help visualize the interconnections among categories. Rewarding, represented as a blue arrow, may be tangible and intangible. The sides of the arrow used to illustrate this main category represent the interrelationship, interaction, reflexivity, and intercreativity of the participants in their social environment. A rewarding system is regarded as important in an organization to channel the employees’ rewards. It has a positive impact on motivating and is to be fair, equitable, and consistent among employees. A rewarding work environment is one that is motivating for individuals and supporting toward desired outcomes and may influence behaviors toward a desired direction (Hafiza, Shah, Jamsheed, & Zaman, 2011).

Central within the model is the arrow representing the interconnection of the segments of the diagram. Occurring within this dynamic central point is meaning generation and transformational experience. This occurrence and experience lead to action, interaction, and consequences as a direct result of the decisions made by the study participants toward academic progression.

In the supplemental diagram, the green arrow illustrates motivating, and the sides of this arrow represent communication, sharing of knowledge, mutual benefit, and interconnectivity for all participants within that environment. Motivating is described as a psychological process that will give purpose and direction for desired behaviors, intrinsic as well as extrinsic (Rahim & Wan Daud, 2012). According to Baron (1983), individuals may be influenced by motivating in their decision-making to carry out a task, and their performance may be energized with passion when it is followed by rewarding.

The red arrow represents supporting, a positive work environment, and culture of the organization where the participants are employed. As a factor that influences advanced education, the interconnection shown by the arrow contributes to the intercultural connection between nurses and each employer’s cultural experience and what they bring into the environment. An organization’s mission, values, philosophy, and norms also shape, support, and create a dynamic intercultural experience and generate meanings that influence academic progression. The diagram expressing the relationship between the categories depicts the integration of the factors that are postulated as the critical components that will influence nurses to progress academically and the theory that may emerge to support academic advancement.

Formulated Theory

A conceptual framework is described by Miles and Huberman (1994) as a written or visual product that explains graphically or narratively the core things to be studied, including key factors, concepts, or variables, and the relationship(s) among them. The theory of professional advancement emerged from the data as the basic social process that expounds the critical factors that influence diploma and AD nurses to advance academically. It emerged from the categories interpreted and constructed by the researcher as rewarding, motivating, and supporting among diploma and AD nurses to advance academically. This is interpreted by the researcher as the theory of what is out there in the communities of these nurses and is a problematic factor that involves consequences that impact academic advancement.

Studies have shown that the history of an organization in which there is an environment that is rewarding and motivating toward nurses’ academic pursuits will promote decision-making toward professional advancement. It is believed that supporting in organizational structure and system, clear values, and strong interpersonal relationship will impact the patterns of interaction, behavior, and the commitment of employees (Cunningham, Bernabeo, Wolfson, & Lesser, 2011). Organizational cultural environment consists of the collective thinking, habits, attitudes, feelings, practices, and behavior patterns of the employees (Mohelska & Sokolova, 2015). Research indicates that the culture that exists in a health care environment is impactful on nurses’ attitudes, knowledge, practices, and motivations to advance academically (Fedorowsky et al., 2015). These interactions and relationships are interpreted by the participants who attribute meaning to their reality (Charmaz, 2006).

The degree of a supporting, positive work environment reveals the impact this has on employees and is substantiated by the level of effect on health care organizations and the circular influence on diploma and AD nurses. The study participants’ interpretation was evidenced by the number of nurses who are still unprepared to advance professionally. The categories that emerged from the dense data that produce salience and a pattern were interpreted by the researcher through a process of repeatedly examining the dimensions and properties of the emerging thoughts and feelings of the participants, reviewing the context of the storyline and the conditions that existed during the interactive relationships of the diploma and AD nurses, their actions, and their resulting consequences (Strauss & Corbin, 1990).

There is no existing specificity for creativity in the art and science of grounded theory research (Strauss & Corbin, 1998). However, throughout the interplay between the data, the researcher noted the persistent reoccurrence of the factors that would influence participants to advance academically.

Limitations

The researcher was open-minded to certain limitations that were presented in this study regarding the study participants. As a result of regional and cultural differences, participants may have varied in their responses in a way that impacted the results of the study. BSN, master’s, and doctorally educated nurses were not included in the sample for individual participants. Only diploma and AD nurses who were not advancing academically were included, and they may have provided information they thought the researcher wanted to hear, primarily because they did not deem the phenomenon of interest as important or relevant to them. The geographical location of participants was a factor in setting up times for face-to-face interviews.

Recommendations

 

The theory of professional advancement that emerged from this study depicts a model that was interpreted by the researcher from the thick, rich data provided by the study participants. This model elucidates the critical factors that would influence diploma and AD nurses to advance academically. The findings shed light on a social relationship between the study participants and their social environment that may have impacted their decision-making toward academic advancement. The results of this social interaction and the meanings attributed to it by the nurse participants may have gone unnoticed or misunderstood.

The emergent theory is not an end in and of itself. Rather, it provides an avenue for further research to address advanced nursing education among diploma and AD nurses. It may also be useful for strategy development to promote advancement by degrees. This study’s findings may be a recommendation for policy change and policy formation or serve as a mobilizer for strategic planning and interventions that would enhance and encourage academic progression.

The emergent categories of rewarding, motivating, and supporting undergird the theory of professional advancement as a middle range theory derived from the data provided by the study participants. It may be used as a formal, substantive theory that can be provisionally verified. As a result, each of the emergent factors may be encouraged, promoted, and implemented in the work environment and evaluated for increasing the number of nurses who are motivated toward academic advancement. The researcher recommends further studies to address the impact on advanced education among nurses, as well as other professionals. In addition, this study may be replicated nationally or internationally and among different cultural groups of individuals and in different settings.

Conclusion

 

It became apparent throughout the data analysis process that diploma and AD nurses who are not advancing academically experience various factors that impact their decision-making in influential dimensions. This impact subsequently leads to inevitable choices, decision-making toward progressing academically, resulting outcomes, and related consequences. Strategies to promote a positive impact would be directly linked to the factors the nurses interpreted in their environment.

Analysis of the data revealed many interrelated factors that impact the decision-making process toward academic advancement. They include having a passion for nursing; having various supporting factors such as family, community, and work-related support; and being able to distinguish a clearly defined role for diploma-, AD-, and BSN-educated nurses. These, along with other subcategories, are interwoven in the main categories: rewarding, which may influence positive behaviors and may be tangible or intangible; motivating, a driving force that stimulates action may be derived intrinsically or extrinsically; and supporting, a positive demonstration in organizational culture of encouragement from the employer to strengthen and help mobilize employees in a desired direction.


References

Aiken, L. H., Cimiotti, J. P., Sloane, D. M., Smith, H. L., Flynn, L., & Neff, D. F. (2011). Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care, 49(12), 1047-1053. doi:10. 1097/MLR.0b013e3182330b6e Aiken, L. H., Sloane, D. M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., … RN4CAST Consortium. (2014). Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study. The Lancet, 383(9931), 1824-1830. doi:10.1016/S0140-6736 60188.4 American Association of Colleges of Nursing. (2012). Fact sheet: The impact of education on nursing practice. Retrieved from www.aacnnche.edu/mediarelations/fact-sheets/impact-of-education American Nurses Association. (1965). American Nurses Association first position on education for nurses. American Journal of Nursing, 65(12), 106-111. Armstrong, M., & Stephen, P. (2005). A handbook of employee reward management and practice. London, UK: Kogan Page. Baron, R. A. (1983). Behavior in organizations. New York, NY: Allyn & Bacon. Birks, M., Chapman, Y., & Francis, K. (2010). Becoming professional by degrees: A grounded theory study of nurses in Malaysian Borneo. Singapore Nursing Journal, 37(3), 31-42.

Bratton, J., & Gold, J. (2003). Human resource management: Theory and practice (3rd ed.). New York, NY: Palgrave Macmillan. Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. Thousand Oaks, CA: Sage. Clinton, M., Murrells, T., & Robinson, S. (2005). Assessing competency in nursing: A comparison of nurses prepared through degree and diploma programs. Journal of Clinical Nursing, 14(1), 82-94. Conover, C., & Richards, R. (2015). Economic benefits of less restrictive regulation of advanced practice nurses in North Carolina. Nursing Outlook, 63(5), 585-592. doi:10.1016/j.outlook.2015.05.009.Epub2015 Cunningham, A. T., Bernabeo, E. C., Wolfson, D. B., & Lesser, C. S. (2011). Organizational strategies to cultivate professional values and behaviors. BMJ Quality & Safety, 20(4), 351-358. doi:10 1136/bmjqs.2010.048942 Eley, R., Frances, K., & Hegney, D. (2013). Career progression—The views of Queensland’s nurses. Australian Journal of Advanced Nursing, 30(4), 23-31. Retrieved from http://www.anmfvic.asn.au/ Fedorowsky, R., Peles-Bortz, A., Masarwa, S., Liberman, D., Rubinovitch, B., & Lipkin, V. (2015). Carbapenem-resistant enterobacteriaceae carriers in acute care hospitals and post-acute-care facilities: The effect of organizational cultures on staff attitudes, knowledge, practices and infection acquisition rates. American Journal of Infection, 43(9), 935-939. doi:10.1016/j.ajic.2015,05.014 Ginzberg, F. (1949). A pattern for hospital care: Final report of the New York State hospital study. New York, NY: Columbia University Press. Gray, M., Rowe, J., & Barnes, M. (2014). Continuing professional development and changed re-requirements: Midwives’ reflections. Nurse Education Today, 34(5), 860-865. Hafiza, N. S., Shah, S. S., Jamsheed, H., & Zaman, K. (2011). Relationship between rewards and employee’s motivation in the non-profit organizations of Pakistan. Business Intelligence Journal, 4(2), 327-334. Health Resources and Services Administration. (2013). The U.S. nursing workforce: Trends in supply and education. Retrieved from bhpr.hrsa.gov/healthworkforce/ supplydemand/nursing/nursingworkforce/ Health Resources and Services Administration. (2016). Stats for stories: National nurses day/national nurses week. Retrieved from http://www.census.gov/ newsroom/stories/2016/may/nurses.html Hertzberg, F., Mausner, B., & Snyderman, B. (1959). The motivation to work. New York, NY: John Wiley & Sons. Institute of Medicine. (2011). The future of nursing: Focus on education. Retrieved from iom.nationalacademics.org/Reports/2010/The-Future-of-Nursing-LeadingChange-Advancing-Health/Report-Brief-Education.aspx Jain, R., & Kaur, S. (2014). Impact of work environment on job satisfaction. International Journal of Scientific and Research Publications, 4(1). Retrieved from www. ijsrp.org/research-paper-0114/ijsrp-p2599.pdf Kouneiher, F., Charron, S., & Koechlin, E. (2009). Motivation and cognitive in the human prefrontal cortex. Nature Publishing Group, 12(7), 939-945. Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An expanded sourcebook (2nd ed.). Thousand Oaks, CA: Sage. Miller, E. M., Shankar, M. U., Knutson, B., & McClure, S. M. (2014). Dissociating motivation from reward in human striatal activity. Journal of Cognitive Neuroscience, 26(5), 1075-1084. doi:10.1162/jocn_a_00535 Mohelska, H., & Sokolova, M. (2015). Organizational culture and leadership—Joint vessels. Science Direct, 171, 1011-1016. National League for Nursing. (2011). Transforming nursing education [NLN Vision Series]. Retrieved from www.nln.org/newsroom/nln-position-documents/nlnliving-documents Rahim, M. A., & Wan Daud, W. N. (2012). A proposed conceptual framework for rewards and motivation among administrators of higher educational provider in Malaysia. International Journal of Business and Commerce, 1(9), 67-78. Retrieved from www.ijbcnet.com/1-9/IJBC-12-1806.pdf. Sarver, W., Cichra, N., & Kline, M. (2015). Perceived benefits, motivators, and barriers to advancing nurse education: Removing barriers to improve success. Nursing Education Perspectives, 36(3), 153-156. doi:10.5480/14-1407 Spetz, J., & Bates, T. (2013). Is a baccalaureate in nursing worth it? The return to education, 2000–2008. Health Services Research, 48(6 Pt. 1), 1859. doi:1111/ 14756773.12104 Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage. Strauss, A. L., & Corbin, J. M. (1998). Basics of qualitative research: Grounded theory: Techniques and procedures for developing grounded theory (2nd ed.). Thousand Oaks, CA: Sage.


 

A total of 18 of 19 participants answered questions on the postintervention survey to assess if the messages helped them to eat healthier, become more active, and remember to check their blood glucose levels and take their medications if needed (Table 2). Over half (66.7%) felt that the messages helped them to remember to check their blood glucose levels. Half of these participants felt that the messages helped them to eat healthier and 38.9% could not agree or disagree with this statement. Seven of the 18 participants felt that the messages helped them to be active. Approximately, one third (33.3%) of these women did not require medication, but of those who did, 66.7% agreed or strongly agreed that the messages helped them to remember 

The majority of all participants (63.2%) agreed or strongly agreed that they would use the messages in future pregnancies if diagnosed with GDM, and 78.9% agreed or strongly agreed that they would recommend the text messaging program to a friend with diabetes in pregnancy. Fifteen (79.0%) women felt that the number of daily messages were “just right.” Over half (52.6%) of participants liked the educational messages, whereas 42.1% liked direct reminders regarding medications and blood glucose checks. Nine participants marked that there was nothing that they disliked regarding the messages; however; five marked that they disliked the lack of personal interaction. A total of 18 (94.7%) participants marked that they read all the messages and 1 (5.3%) marked that they read most of them. In total, 68.4% of participants marked that the messages “fit ok” with their personal treatment plan.

In an attempt to understand ways in which we can improve upon the messages for future studies and clinical usage, the participants were asked to give suggestions to improve messages. First, a couple of participants expressed a desire for more specific information regarding diet and asked in the future “be more specific with diet and activity advice and provide more info on healthy snacks.” Another issue raised was the timing of the messages and included suggestions such as “messages were sent too early in the morning” and “messages would be better timed if they came about 30–45 minutes before a meal.

Discussion

Diabetes is a patient-managed disease, which means that the patient must understand their diagnosis and have buy-in that the benefits of adhering to their treatment plan outweigh opposing factors. The empowerment of patients to make this decision is a widely recognized approach to diabetes management (Funnell et al., 1991 Tang et al., 2010). Gestational diabetes mellitusis an opportune time to encourage women to improve glucose control to improve both maternal and fetal outcomes. Text messaging has been shown to promote improvement in preventive health beliefs and behaviors in pregnancy (Moniz, Meyn, & Beigi, 2015).

This study was unique in that we attempted to understand the acceptability and feasibility of a text messaging intervention in the treatment plan of those diagnosed with GDM. Participants enrolled in the program reported overall satisfaction with the messages, and an overwhelming percentage of participants (63.2%) were willing to use the messages again in future pregnancies complicated by GDM. It was also encouraging that a majority of the women would recommend the program to a friend. Readership of the messages was high, with 94.7% stating they read all the messages.

As previously mentioned, diabetes is a patient-managed disease in which they make the final decision regarding their daily self-management. Participants who used an internet-based telemedicine system in the management of GDM had a significantly higher perception of their ability to bring about changes in their own behavior, as well as the behavior of others to improve their diabetes self-management and psychosocial adaptation to the disease when compared with control subjects (Homko et al., 2007). Previous studies have also shown that the utilization of technology as a means of communication between patients and health care providers reduce medical cost and saves time for both the patient and the clinician (Perez-Ferre et al., 2010).

There is conflicting data regarding the efficacy of technological communication's impact on glucose control. Dalfra, Nicolucci, & Lapolla, 2009 were able to show a benefit in the use of telemedicine and remote submission of glucose values to health care providers (Dalfra et al., 2009). The intervention group in this randomized control trial had better glucose control, lower rates of cesarean delivery and macrosomia, and lower frustration regarding the diagnosis of GDM (Dalfra et al., 2009). However, there have been other studies that show no significant difference in maternal blood glucose values between participants who use such technology and those who do not (Homko et al., 2007 Homko et al., 2012). Therefore, next steps will be to fine-tune and tailor the intervention to better fit the needs of the women and conduct a randomized controlled pilot study in women with GDM. It is imperative that our future study regarding this technology incorporate changes that take into account the suggestions given by the patients in this feasibility study. A program that allows the patient to determine a time frame in which the messages are received is vital for participant satisfaction. It is also vital to determine if this technology not only improves maternal satisfaction but also if it improves maternal and fetal outcomes (Chilelli, Dalfra, & Lapolla, 2014). In the future, if this strategy is efficacious and effective, we may be able to create a system that saves time for patients with GDM by communicating their blood glucose levels to their provider for assistance in medication, dietary, and physical activity titration to improve their glycemic control.

Nurse practitioners and other providers are in a unique position to improve population health management within their practice using technology to provide their patients with helpful information to manage their GDM. Nurse practitioners can provide cost-effective care, help women manage transitions in their lives, provide high-quality care, and improve clinical outcomes to reduce health care costs overall.

This study has revealed a real opportunity for a low-cost intervention in the management plan of a significant and complex disease process. We have shown participants' engagement, satisfaction, and interest in text messages being incorporated in their personal treatment plans for GDM. Next steps include a randomized controlled repeated-measures pilot study to assess if the intervention improves blood glucose levels and obstetrical outcomes, such as birth weight, mode of delivery, cesarean section, macrosomia, and stillbirth statistics. The intervention group will receive tailored text messaging focused on diabetes self-management, and the control group will receive text messages on general pregnancy care. We will include more women from ethnically diverse backgrounds and low-income socioeconomic status. We will measure blood glucose levels and diabetes self-management. At the completion of the pilot study, we will conduct exit interviews with the women in the intervention group to assess what the women liked or disliked about the intervention and text messages and ask for their suggestions on improving the intervention. After completion of the randomized controlled pilot study, we will calculate effect sizes to power a multisite randomized controlled study most likely partnering with the Maternal-Fetal Medicine Units Network with whom the authors currently collaborate with.

Limitations

There are some limitations to consider in interpreting our results. This study was designed as a feasibility study with a small sample size. Therefore, our results are not generalizable and require further investigation. Another limitation of this study is that although we were able to establish that the messages were acceptable to participants, clinical improvements such as improved capillary blood glucose values were not assessed.

Conclusion

In conclusion, the results of this pilot study showed that the text messages were acceptable and feasible in women with GDM. In addition, there was a high level of satisfaction with participants being agreeable to receive the messages in future pregnancies complicated by GDM and their willingness to recommend the messages to friends with GDM. Nurse practitioners and other health care providers caring for patients diagnosed with GDM are in a unique position to help women improve their blood glucose levels through the use of technology, which may be more acceptable to these women. The ultimate impact of improved glucose levels will improve fetal and infant outcomes in women with GDM.


References

Association, A. D. (2015). (2) Classification and diagnosis of diabetes. Diabetes Care, (38 Suppl), S8–S16. doi:10.2337/dc15-S005.

Bulletins–Obstetrics, C. o. P. (2013). Practice Bulletin No. 137: Gestational diabetes mellitus. Obstetrics and Gynecology, 122(2 Pt 1), 406–416.

Chilelli N. C., Dalfra M. G., Lapolla A. (2014). The emerging role of telemedicine in managing glycemic control and psychobehavioral aspects of pregnancy complicated by diabetes. International Journal of Telemedicine and Applications, 2014, 621384.

Coustan D. R., & American Diabetes Association. (2013). Medical management of pregnancycomplicated by diabetes. Online resource pp. 1–307. Retrieved from http://libproxy.lib.unc.edu/login?url=http://www.UNC.eblib.com/EBLWeb/patron/?target=patron&extendedid=P_1222227_0.

Crowther C. A., Hiller J. E., Moss J. R., McPhee A. J., Jeffries W. S., Robinson J. S., & Group, A. C. I. S. i. P. W. A. T. (2005). Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. The New England Journal of Medicine, 352, 2477–2486.

Dalfra M. G., Nicolucci A., Lapolla A. (2009). The effect of telemedicine on outcome and quality of life in pregnant women with diabetes. Journal of Telemedicine and Telecare, 15, 238–242.

England L. J., Dietz P. M., Njoroge T., Callaghan W. M., Bruce C., Buus R. M., Williamson DF. (2009). Preventing type 2 diabetes: Public health implications for women with a history of gestational diabetes mellitus. American Journal of Obstetrics and Gynecology, 200, 365.e361–368.e361.

Fioravanti A., Fico G., Salvi D., García-Betances R. I., Arredondo M. T. (2015). Automatic messaging for improving patients engagement in diabetes management: An exploratory study. Medical & Biological Engineering & Computing, 53, 1285–1294.

Funnell M. M., Anderson R. M., Arnold M. S., Barr P. A., Donnelly M., Johnson P. D., White N. H. (1991). Empowerment: An idea whose time has come in diabetes education. The Diabetes Educator, 17, 37–41.

Homko C. J., Deeb L. C., Rohrbacher K., Mulla W., Mastrogiannis D., Gaughan J., Bove A. A. (2012). Impact of a telemedicine system with automated reminders on outcomes in women with gestational diabetes mellitus. Diabetes Technology & Therapeutics, 14, 624–629.​​​​​​​

Homko C. J., Santamore W. P., Whiteman V., Bower M., Berger P., Geifman-Holtzman O., Bove AA. (2007). Use of an internet-based telemedicine system to manage underserved women with gestational diabetes mellitus. Diabetes Technology & Therapeutics, 9, 297–306.​​​​​​​

Landon M. B., Spong C. Y., Thom E., Carpenter M. W., Ramin S. M., Casey B.,… Network, E. K. S. N. I. o. C. H. a. H. D. M.-F. M. U. (2009). A multicenter, randomized trial of treatment for mild gestational diabetes. The New England Journal of Medicine, 361, 1339–1348.​​​​​​​

Lee A. J., Hiscock R. J., Wein P., Walker S. P., Permezel M. (2007). Gestational diabetes mellitus: Clinical predictors and long-term risk of developing type 2 diabetes: A retrospective cohort study using survival analysis. Diabetes Care, 30, 878–883.​​​​​​​

Mackillop L., Loerup L., Bartlett K., Farmer A., Gibson O. J., Hirst J. E., Tarassenko L. (2014). Development of a real-time smartphone solution for the management of women with or at high risk of gestational diabetes. Journal of Diabetes Science and Technology, 8, 1105–1114.

Metzger B. E., Lowe L. P., Dyer A. R., Trimble E. R., Chaovarindr U., Coustan D. R.,… Group, H. S. C. R. (2008). Hyperglycemia and adverse pregnancy outcomes. The New England Journal of Medicine, 358, 1991–2002.

​​​​​​​Moniz M. H., Meyn L. A., Beigi R. H. (2015). Text messaging to improve preventive health attitudes and behaviors during pregnancy: A prospective cohort analysis. The Journal of Reproductive Medicine, 60, 378–382.​​​​

Perez-Ferre N., Galindo M., Fernandez M. D., Velasco V., de la Cruz M. J., Martin P., Calle-Pascual A. L. (2010). A Telemedicine system based on Internet and short message service as a new approach in the follow-up of patients with gestational diabetes. Diabetes Research and Clinical Practice, 87, e15–e17.​​​​​​​

Prevention, C. f. D. C. a. (2015). Adult Obesity Facts. Available from Centers for Disease Control and Prevention Division of Nutrition, Physical Activity, and Obesity Retrieved May 24, 2016, from Centers for Disease Control and Prevention. Division of Nutrition, Physical Activity, and Obesity. http://www.cdc.gov/obesity/data/adult.html.

Saffari M., Ghanizadeh G., Koenig H. G. (2014). Health education via mobile text messaging for glycemic control in adults with type 2 diabetes: A systematic review and meta-analysis. Primary Care Diabetes, 8, 275–285.​​​​​​​

Tang T. S., Funnell M. M., Brown M. B., Kurlander J. E. (2010). Self-management support in “real-world” settings: An empowerment-based intervention. Patient Education and Counseling, 79, 178–184.​​​​​​​

Yogev Y., Xenakis E. M., Langer O. (2004). The association between preeclampsia and the severity of gestational diabetes: The impact of glycemic control. American Journal of Obstetrics and Gynecology, 191, 1655–1660.​​​​​​​

Zickuhr K. (2011). Generations and their gadgets. Retrieved from Pew Research Center Internet Science Tech RSS website: http://www.pewinternet.org/2011/02/03/generations-and-their-gadgets/

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