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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.


The Role of the North Carolina Community College System in Nursing Education

R. Scott Ralls

N C Med J. 2011;72(4):307-309.PDF | TABLE OF CONTENTS

Two-thirds of nurses educated in North Carolina receive an associate’s degree in nursing (ADN). Community college graduates work in health care areas and geographic regions in which recruitment and retention of employees are difficult. To enhance educational preparation for its graduates, the North Carolina Community College System has redesigned the ADN curriculum and encouraged partnerships for seamless transition to more-advanced nursing degrees.

The recent Summit for Creating the Future of Nursing and Health Care in North Carolina highlighted several critical messages related to the future of nursing and the important role nurses can (and should) play in redesigning our nation’s health care system. As a key player in preparing North Carolina’s nursing workforce, the North Carolina Community College System can and will rise to the challenge of preparing nursing professionals who are able to respond to the state’s evolving health care needs, as long as our state and local partners continue to provide the funding and support necessary for these high-cost programs. Today, approximately two-thirds of the nurses educated in our state enter the profession with an associate’s degree in nursing (ADN) [1].

Health care jobs lead the way in North Carolina job growth. As the state emerges from the recent recession, the North Carolina Community College System has made health care education a top priority for workforce development. That commitment has included (1) a comprehensive study of our nursing programs, conducted by the University of North Carolina (UNC)–Chapel Hill Cecil G. Sheps Center for Health Services Research; (2) an aggressive effort that sought and secured weighted funding for students in health care programs that are costly to deliver; (3) system support for the science programs that undergird our health care programs; and (4) a curriculum-improvement process that changed not only what we included in our curriculum but also the way we teach that curriculum to our students.

We at the North Carolina Community College System are proud of the fact that our colleges provide a qualified nursing workforce for all North Carolina communities. Fifty-five of our 58 community colleges are approved by the State Board of Community Colleges and the North Carolina Board of Nursing to offer an ADN. Between 2005 and 2010, these colleges graduated more than 12,000 first-time takers of the National Certification Licensing Examination for Registered Nurses (NCLEX-RN).

The 2008 report by Fraher and colleagues [1] noted that graduates of ADN programs at North Carolina community colleges were more likely to be retained in our state’s workforce, with 90% of our recent graduates joining the North Carolina workforce or continuing their pursuit of nursing education; more likely to be employed in health care areas, such as long-term care, home care/hospice, and mental health settings, in which recruitment and employee retention are difficult; and more likely to be employed in rural and underserved counties, with half of all community college graduates practicing within 13 miles of their program of enrollment [1]. All these facts weigh heavily in meeting our communities’ and our state’s demand for health care workers.

And the need for nurses and allied health professionals will continue to grow in North Carolina, given our aging population and the associated increase in health care needs, the influx or migration of new residents into our state, the “graying” of our workforce, and reforms to the health care system. During the next 20 years, the number of North Carolinians aged 65 years and older is expected to grow from 1.2 million to 2.1 million, and, in 71 of North Carolina’s counties, it is likely that the number of people older than 60 years will be greater than the number younger than 17 years [2]. By 2019, it is anticipated that the state will need to significantly increase its health care workforce to meet the health care needs of the 1.1 million currently uninsured North Carolinians who are projected to receive insurance through the Affordable Care Act [3].

Additionally, as Fulcher and Mullin [4p4] recently noted, “(1) The majority of the nation’s new RNs [registered nurses] are educated in [ADN] programs. (2) All schools of nursing teach students the competencies necessary for RN practice, as measured by NCLEX pass rates. (3) ADN programs provide the nation the greatest numbers of minority RNs. (4) Employers are equally likely to hire ADN and BSN [bachelor of science in nursing] prepared RNs. (5) ADN programs educate the majority of RNs in rural settings.”

In the United States and North Carolina, the ADN is the most frequent route for entry into practice. A 2010 report from the Health Resources and Services Administration [5] indicated that, among registered nurses, the initial nursing degree was the ADN for 45.4%, a bachelor’s degree or higher for 34.2%, and a diploma for 20.4% [5]. In 2010, the US Bureau of Labor and Statistics projected a national increase of 581,500 new registered nurse jobs by 2018, with more than 400,000 additional jobs opening up by that time because of the retirement of registered nurses currently in the workforce [6].

In short, demographic data, study findings, and real-world experiences seem to confirm that quality ADN programs, such as those in the North Carolina Community College System, are critical in meeting our state’s and our nation’s nursing needs. But how do we, as a system, continue to move forward in meeting these needs, given the balance we must achieve between the high cost of these programs and the fiscal concerns at both the state and the local levels, as well as the growing call for more nurses who have a bachelor of science in nursing? This last point is illustrated by a key recommendation set forth by the Institute of Medicine of the National Academies (IOM) [7], and also discussed at North Carolina’s statewide summit, to increase the proportion of nurses with a baccalaureate to 80% by 2020.

The North Carolina Community College System has several initiatives in place to support this goal, including the redesigned ADN curriculum, accelerated or bridge programs, articulation agreements, university centers on community college campuses, and participation in the Regionally Increasing Baccalaureate Nurses (RIBN) project.

One of these initiatives also addresses another recommendation in the IOM report, which states that educational programs should “prepare and enable nurses to lead change to advance health” [7p282]. Our colleges began driving our programs in this direction during our 2-year curriculum-improvement project, which included nursing faculty from 55 community colleges. This project, which started in 2006, evaluated and redesigned the ADN curriculum, resulting in a new concept-based curriculum standard and new nursing courses for our community colleges. The nursing faculty identified 49 concepts that have been intertwined into the 2-year ADN program. They also identified best practices, through literature reviews and interviews with nursing faculty in other states, and incorporated these best practices into the program. During the redesign of the curriculum, standards and recommendations from the National League of Nursing, the IOM, the North Carolina Board of Nursing, Healthy People 2010, local workforce advisory boards, and many other entities were incorporated into the curriculum.

In this redesigned curriculum, graduates of ADN programs in the North Carolina Community College System receive an education that is steeped in concepts from areas that include medical and surgical nursing; maternal and child health; psychosocial care; health, wellness, and illness; patient safety; health care systems; evidence-based practices; quality improvement; management of care; interdisciplinary team process; informatics; and decision making. Client care is individualized and presented in a practical and theoretical approach, with the ethnic and racial diversity of clients as a focal point of the education of students in the ADN program. The new curriculum was implemented by the 55 ADN programs as of fall 2010, with nearly 4,000 students well on their way to becoming the nurses and nursing leaders our state needs.

To maximize access to nursing programs, our colleges have created pathways for allied health students who desire to enter the ADN program. For example, some colleges have developed and implemented accelerated or bridge programs for the licensed practical nurse or the medic or paramedic who wishes to pursue an ADN. The accelerated or bridge program may provide the student advanced placement in some courses on the basis of work experience, licensure, and competency testing. And pathways to the nursing profession work both ways, with a significant number of new community college nursing students entering their programs as college graduates. In the fall of 2010, 14% of students in the North Carolina community college nursing program already possessed bachelor’s degrees or higher levels of academic credentials.

The North Carolina Community College System provides 2 pathways for students who desire to complete a baccalaureate in nursing. One pathway is through the comprehensive articulation agreement between our system and the UNC system, which includes 2 years of undergraduate study at the community college, followed by 2 years of professional preparation in a school of nursing at one of the UNC campuses. The other pathway is an articulation agreement involving the progression from the ADN program to a bachelor of science in nursing program, which allows graduates of the ADN program to transfer to a university to complete 2 years of general college course work and capstone nursing courses.

A goal of the North Carolina Community College System is to collaborate with the UNC System to foster degree acceleration and student retention thorough the development of university centers on community college campuses. Many community colleges have developed partnerships with universities to provide baccalaureate-completion courses on the community college campus. For example, the Winston-Salem State University School of Nursing has off-site programs on 7 community college campuses (ie, Rowan-Cabarrus Community College, Surry Community College, Davidson County Community College, Rockingham Community College, Wilkes Community College, Cleveland County Community College, and South Piedmont Community College).

Asheville-Buncombe Technical Community College, Western Carolina University, and the Foundation for Nursing Excellence adapted the Oregon Consortium for Nursing Education model for admission of nursing students into a seamless, dual-campus 4-year educational program. In the fall of 2010, they admitted their first cohort of nursing students into the Western North Carolina RIBN project. The students will complete their first 3 years of education on the community college campus (completing general studies and nursing courses), while also taking 1 course per semester with the university. After successful completion of their first 3 years of study, they receive an ADN and will be eligible to take the NCLEX-RN examination. The fourth year of study will be located on the university campus and will emphasize community health nursing, nursing leadership, and gerontology. In 2014, at the completion of their fourth year of study, they will obtain their baccalaureate in nursing [8].

Five additional RIBN collaborative partnerships between community colleges and universities have been identified in the state. These RIBN partnerships are expected to admit their first cohorts of students in fall 2012.

These innovations occurred in the throes of the recent recession, at the same time our community college “family”—including presidents, trustees, faculty, staff, and administrators—supported our collaborative efforts to make health care education a top priority and to secure weighted funding for our colleges, from College of the Albemarle to Tri-County Community College, which are working to meet the call of our citizens, our health care professionals, and our state. North Carolina is fortunate that our state’s leaders heard that call and responded with funding to support a weighted approach to providing these in-demand health care programs to our students.

Our nearly 50-year-old system of colleges was built to respond to the industrial education and training demands of our state’s business community. Our founding fathers and mothers might be surprised to learn that, in 2011, we are fulfilling that same mission, but during the next 50 years, we will continue to meet our state’s escalating demand for high-quality health care professionals. North Carolina needs our colleges’ health care programs and our graduates, and our system is committed to working collaboratively to seek out efficient, innovative educational approaches and to continue to stretch our funding dollars, as much as possible, to meet that need.

Potential conflicts of interest. R.S.R. has no relevant conflicts of interest.

1. Fraher E, Belsky D, Carpenter J, Gaul K. A Study of Associate Degree Nursing Program Success: Evidence From the 2002 Cohort. Chapel Hill, NC: Cecil G. Sheps Center for Health Services Research; 2008.

2. North Carolina Division of Aging and Adult Services. North Carolina Is Aging! Published January 2011. Accessed May 22, 2011.

3. North Carolina Institute of Medicine (NCIOM). Implementation of the Patient Protection and Affordable Care Act in North Carolina: Interim Report. Morrisville, NC: NCIOM; 2011. Accessed July 25, 2011.

4. Fulcher R, Mullin CM. A Data-Driven Examination of the Impact of Associate and Bachelor’s Degree Programs on the Nation’s Nursing Workforce. Policy brief 2011-02PBL. Washington, DC: American Association of Community Colleges; 2011.

5. Health Resources and Services Administration. The Registered Nurse Population: Findings From the 2008 National Sample Survey of Registered Nurses. Washington, DC: US Department of Health and Human Services; 2010. Accessed March 21, 2011.

6. US Bureau of Labor Statistics. Occupational Outlook Handbook: 2010-2011. Washington, DC: US Department of Labor; 2010. Accessed May 21, 2011.

7. Institute of Medicine of the National Academies. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.

8. Foundation for Nursing Excellence Web site. Accessed May 21, 2011.

R. Scott Ralls, PhD president, North Carolina Community College System, Raleigh, North Carolina.

Address correspondence to Dr. R. Scott Ralls, 5001 Mail Service Ctr, Raleigh, NC 27699-5001 (