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JULY/AUGUST 2011 :: 72(4)
Future of Nursing in North Carolina

The policy forum of this issue takes as its point of departure an April 2011 summit of North Carolina nurse leaders, who met to review and discuss recommendations from The Future of Nursing: Leading Change, Advancing Health, a report recently published by the Institute of Medicine of the National Academies. Commentaries from experts across the state affirm the importance of ensuring that an effective, educated nursing workforce is present; that nursing education involves a seamless process; that nurses can practice to the full extent of their education and training; that nurses are full partners in redesigning health care; and that an effective, comprehensive health care workforce planning system is in place. Also in this issue, original articles address the use Charlotte-area emergency departments for primary care services and the presence of defibrillators in North Carolina public schools.

INVITED COMMENTARY

Regionally Increasing Baccalaureate-Prepared Nurses in North Carolina: The RIBN Project

Mary P. "Polly" Johnson, Vincent P. Hall, Brenda Causey

N C Med J. 2011;72(4):304-306.PDF | TABLE OF CONTENTS



A more highly educated nursing workforce is needed to address the increasingly complex health care needs of our citizens and to expand the pool for future faculty and advanced practice nurses. North Carolina must create new partnerships between community colleges and universities to support seamless progression toward a baccalaureate degree. The RIBN model provides one option to meet this goal.

Like the nation as a whole, North Carolina is facing a nursing workforce shortage, in both numbers and level of preparation that will negatively impact the delivery of safe and effective health care in our state. Nationally, the nursing shortage is projected to grow to 260,000 registered nurses (RNs) by 2025 because of a rapidly aging workforce and sustained population growth [1]. The most significant problem fueling the nursing shortage in the United States is the lack of faculty to educate the number of qualified individuals applying to nursing programs, with over 49,948 qualified applicants being denied admission to programs in 2008 alone [2].

In an effort to proactively address short- and long-term nursing workforce needs in North Carolina, in 2004 the North Carolina Institute of Medicine issued a hallmark task force report that listed 16 priority recommendations focused on development and sustainment of nursing faculty, recruitment and retention of nurses in the workforce, nursing education programs, and transition from graduate to RN to professional practitioner. In addition to increasing the numbers of nurses, a priority recommendation also addressed the need to increase the proportion of nurses with a bachelor of science in nursing (BSN) to 60% [3]. Most recently, the 2011 Institute of Medicine of the National Academies report on the future of nursing called for 80% of all nurses to have at least a BSN by 2020 [4].

The demand for an expansion of the educational preparation of nurses is being driven by a number of other forces in addition to the need to expand the pipeline for future faculty. With increases in chronic health conditions across all ages, the complexity of acute illnesses and treatment regimens, and care being provided in complicated and often fragmented health care delivery systems, nurses are required to have higher levels of critical thinking, problem solving, and patient-management skills. The minimum of a BSN is now being required for positions such as clinical leaders, patient-care managers and administrators, public health nurses, and school nurses. With our state’s population growth and health care reform initiatives, the demand for advanced practice nurses, particularly as primary care professionals, also increases the need to expand the pool of BSN nurses who will then seek advanced degrees to help meet the health care needs of North Carolinians.

Certainly, the most critical requirement for ensuring that we have a future nursing workforce sufficient in number and preparation to care for the people of our state is an adequate supply of nursing faculty. In North Carolina, there is a current shortage of nursing faculty that prevents expanding admissions to nursing programs. In October 2009, 127 full-time and 74 part-time faculty positions were reported as unfilled in North Carolina [5]. A major component of the faculty shortage is the inadequate pipeline for nurses to earn a master’s degree or higher and enter faculty roles; at a minimum, nursing faculty must have a master’s degree in nursing, to meet accreditation standards.

Currently, there are 80 nursing education programs in North Carolina that lead to RN licensure: 59 are associate’s degree in nursing (ADN) programs, of which 55 are in community colleges; 2 are diploma programs; 18 are baccalaureate programs; and 1 is an entry-level master’s degree program. In a review of the highest earned degrees held by RNs with an ADN who were practicing in the state in 2008, 66% remained at the ADN level, with less than 15% having obtained a BSN or higher degree in the field [6]. Although North Carolina’s nurse educators have worked diligently to facilitate articulation between ADN and BSN programs with 18 RN to BSN completion programs currently offered in the state, we continue to have insufficient numbers of ADN graduates continuing their education. Moreover, ADN nurses who complete a BSN degree may do so several years after completing their ADN. In 2009, 63.4% of nurses completing the ADN were in the age range of 20-30 years, whereas 68% of ADN-prepared nurses in BSN-completion programs were between 31 and 60 years of age [5]. This age discrepancy further limits the length of service potential for future nursing faculty, nurse administrators, and advanced practice nurses who begin their careers at the ADN level. Continuing these nursing education patterns will result in proportionally fewer nurses with a BSN or higher degrees. This trajectory has serious implications for the future of health care in our state.

Given the important role community colleges have in educating the majority of the North Carolina nursing workforce, it is imperative that we identify new ways for qualified nursing students entering community colleges to seamlessly progress to the completion of a baccalaureate degree at the beginning of their careers if we hope to increase the proportion of BSN-prepared nurses and build the necessary faculty pipeline to avert a severe workforce crisis. Implementation of a successful program that dually enrolls students in a seamless ADN and baccalaureate educational track provides one option to meet the goal of an adequate future nursing workforce.

The Western North Carolina (WNC) Regionally Increasing Baccalaureate Nurses (RIBN) Project
The WNC RIBN Project is a component of a multiregional project funded in part by the Robert Wood Johnson Foundation, Northwest Health Foundation, the Jonas Center for Nursing Excellence, the University of North Carolina (UNC) general administration, and The Duke Endowment. In late 2008, Asheville-Buncombe Technical Community College (AB Tech), Western Carolina University and the Foundation for Nursing Excellence began the RIBN journey. With advice from a national team of experts, the WNC RIBN team shared strategies for curriculum and faculty development, including evaluation tools, with partners in metropolitan New York City. The WNC RIBN team adapted the Oregon Consortium for Nursing Education model for dual admission of qualified students into a community college and a 4-year university, yielding a seamless, 4-year educational tract [7]. The North Carolina model provides a framework for community colleges to regionally partner with private or public universities to offer an accessible BSN educational track to qualified applicants, particularly individuals who do not intend to leave their local communities to attend a traditional 4-year BSN program.

The WNC RIBN model is a dual-admission, rigorous, 4-year educational track approved by community college and university partners. The dual-admission requirements are more stringent than those for the community college ADN program and for general admission to most 4-year academic institutions. The RIBN student is home based at the community college for the first 3 years of the program and maintains admission status at the university by completing a university course each semester that meets the general requirements for completion of a baccalaureate. University courses are Internet based, which helps keep down the cost for the student. At the end of the third year of study, the student completes the ADN program and is eligible to take the National Council Licensure Examination for Registered Nurses. To matriculate into the upper division courses at the university in the fourth year of the RIBN track, the student must be licensed as a RN. Courses in the final year of study focus on professional nursing practice, leadership, gerontology, community/public health, and evidenced-based practice. The RIBN curriculum is concept based and uses teaching techniques such as unfolding case studies to support learning. Emphasis is placed on clinical reasoning and integration of didactic content with clinical experiences [8].

A critical retention point for students in the RIBN track occurs after the third year, when the student has achieved licensure as a RN and begins transitioning into practice. Only personal professional goals of achieving a BSN or higher degree and strong support for such achievement from both academic and employing institutions will keep the RIBN student from opting out of the final year of coursework for the BSN. Through planning with a local advisory board of regional health care leaders who advise and support the RIBN project and its students, the WNC RIBN team is currently exploring strategies to help retain students in the program during this transitional period.

Another key element of the RIBN project is the role of a student success advocate or advisor, who markets the RIBN program to area high schools and career counselors; advises students before, during, and after admission; and assists students in obtaining financial aid and accessing other academic services that support one’s academic success. Of equal importance in attracting qualified applicants, the North Carolina Nurse Scholars Commission has approved the RIBN track as an official baccalaureate program, which opens the door for eligible students to receive up to 4 years of funding, in the form of a loan, through this state merit-based loan program. One year of the 4-year loan is forgiven for every year of employment as a nurse in North Carolina.

The first cohort of 16 students entered the WNC RIBN track in 2010, with a BSN completion date of 2014. Twenty applicants have been approved for the 2011 cohort. Twenty of the 100 slots for yearly admission to the AB Tech ADN program have been dedicated to eligible RIBN applicants. This number is expected to expand over time on the basis of demand and available resources.

The RIBN team has implemented ongoing data collection and evaluation to identify indicators of success for students and continued program development. Identified value-added components of this regional model to increase the proportion of BSN-prepared nurses include the following: (1) the program draws on the strengths of the partnering academic institutions, (2) it promotes resource sharing among partner institutions, (3) it increases student access to BSN programs, especially in more rural areas, (4) it increases proportion of younger graduates entering workforce, (5) it includes 3 years of didactic and clinical nursing courses, (6) it provides an economically feasible option for earning a BSN, and (7) its graduates are more likely to practice in their home areas of the state.

Expanding the RIBN Model Across North Carolina
Because the RIBN model builds on the current nursing programs in both the community college and university systems rather than depleting resources from either system, several nursing programs have expressed interested in implementing this model in various regions of the state. Employers have also expressed great interest in seeding this new educational track to meet their demands for a more BSN-prepared nursing workforce. Five additional regional partnerships between both public and private ADN and baccalaureate nursing programs are currently setting up the necessary academic agreements and processes to implement the RIBN educational track beginning in 2012. These regional partnerships include Centralina, composed of UNC-Charlotte, Gaston College, Central Piedmont Community College, and Carolinas College of Health Sciences; Hickory, composed of Lenoir-Rhyne University, Caldwell Community College and Technical Institute, Catawba Valley Community College, Western Piedmont Community College, Wilkes Community College, and Mitchell Community College; Eastern North Carolina, composed of East Carolina University, Lenoir Community College, Beaufort County Community College, Roanoke-Chowan Community College, and Pitt County Community College; Wilmington, composed of UNC-Wilmington and Cape Fear Community College; and Rural Piedmont, composed of Pfeiffer University and Stanly Community College.

Three of these partnerships involve more than 1 ADN program partnering with a university in their respective regions. Given this level of interest and exponential expansion, the goal of the Foundation for Nursing Excellence is to make the RIBN educational track available to student applicants across the entire state by 2016. Replication guidelines, along with dual admission criteria, curriculum, and sample agreements between partnering institutions, are accessible on the Foundation for Nursing Excellence Web site (available at: http://www.ffne.org/ribn-project) [9].

To meet the challenge of significantly increasing the proportion of BSN-prepared nurses in North Carolina, all available opportunities for completing a baccalaureate education must be used to the fullest extent possible. The dual-entry RIBN track offers an additional and cost-effective educational option for North Carolina to meet this challenge and positively impact the delivery of safe, effective health care.

Acknowledgments
Potential conflicts of interest. All authors have no relevant conflicts of interest.

References
1. Buerhaus PI, Auerbach DI, Staiger DO. The recent surge in nurse employment: causes and implications. Health Aff (Milwood). 2009;28:w657-w668.

2. Despite surge of interest in nursing careers, new AACN data confirm that too few nurses are entering the healthcare workforce [press release]. American Association of Colleges of Nursing Web site. http://www.aacn.nche.edu/Media/NewsReleases/2009/workforcedata.html. Published 2009. Accessed May 5, 2011.

3. North Carolina Insititute of Medicine. Task Force on the North Carolina Nursing Workforce Report. North Carolina Insititute of Medicine Web site. http://www.nciom.org/task-forces-and-projects/?nursingworkforce. Published 2004. Accessed May 5, 2011.

4. Institute of Medicine of the National Academies. The Future of Nursing: Leading Change, Advancing Health. Institute of Medicine of the National Academies Web site. http://books.nap.edu/openbook.php?record_id=12956. Published 2011. Accessed May 5, 2011.

5. North Carolina trends in nursing education: 2004-2009. North Carolina Board of Nursing Web site. http://www.ncbon.com/content.aspx?id=1090. Published 2010. Accessed May 5, 2011.

6. Cecil G. Sheps Center for Health Services Research, University of North Carolina–Chapel Hill. North Carolina Health Professions 2009 Data Book. http://www.shepscenter.unc.edu/hp/publications/2009_HPDS_DataBook.pdf. Published 2010. Accessed May 5, 2011.

7. Tanner C, Gubrud-Howe P, Shores L. The Oregon Consortium for Nursing Education: a response to the nursing shortage. Policy Polit Nurs Pract. 2008;9(3):203-209.

8. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Reform. San Francisco, CA: Jossey-Bass; 2010.

9. Regionally Increasing Baccalaureate Nurses (RIBN) project. Foundation for Nursing Excellence Web site. http://www.ffne.org/ribn-project. Accessed May 5, 2011.


Mary P. “Polly” Johnson, MSN, RN president and chief executive officer, Foundation for Nursing Excellence, Raleigh, North Carolina.
Vincent P. Hall, PhD, RN, CNE director, School of Nursing, Western Carolina University, Cullowhee, North Carolina.
Brenda Causey, MSN, RN chair, Nursing Programs, Asheville-Buncombe Technical Community College, Asheville, North Carolina.

Address correspondence to Ms. Polly Johnson, NC Foundation for Nursing Excellence, PO Box 31824, Raleigh, NC 27622 (polly.johnson@ffne.org).