Chapter Three Educating the Future Nursing Workforce for North...

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Educating the Future Nursing Workforce for North Carolina Task Force on the North Carolina Nursing Workforce Report 21 Chapter Three Educating the Future Nursing Workforce for North Carolina * The critical issue confronting the Task Force with regard to nursing education programs was whether existing programs (and educational systems) have the capacity to produce the numbers of additional nursing personnel with the appropriate levels of education likely to be needed in the future. But producing adequate numbers of nursing personnel must be coupled with a concern for the program quality for graduates who will represent the future of nursing practice in our state. The conditions under which nursing personnel must practice are changing rapidly, and, consequently, the diversity of nursing roles is also changing. Beyond concerns for meeting the demands of a rapidly changing practice environment (as described in Chapter 4), the Task Force and its Work Group on Nursing Education Program Capacity had to deal immediately with the impending shortage of faculty in nursing education programs at every level. This set of issues is the focus of the present chapter. The Task Force realized from the outset of its analysis of North Carolina nursing education programs that there are multiple routes to licensure as a nurse (see Figure 3.1 below) and these pathways provide individuals with many different options to obtain pre- and post-licensure education. In recognition of this complexity, the Task Force decided to focus its attention sequentially on various categories of licensure or certification, and for Registered Nurses, the various educational pathways to licensure and post-licensure opportunities for educational advancement. A Focus On The Registered Nurse (RN) Workforce Depending on whose voice is being heard, the term “nursing personnel” may (or may not) include persons working in healthcare settings as nurse aides, Licensed Practical Nurses (LPNs), Registered Nurses (RNs), Advance Practice Registered Nurses (APRNs), other master’s degree prepared nurses (MSNs) who work in a variety of non-clinical roles, or nurses holding PhD degrees. In order to minimize the confusion and potential for disagreement over the terms of reference in discussing various components of the nursing workforce, this report (especially this chapter on education programs) focuses first and predominantly on RN-licensed nurses (which includes graduates of hospital-based diploma programs, associate in applied sciences in nursing degree programs, baccalaureate degree programs, master’s degree programs and doctoral-level programs). We chose to focus on RNs because they comprise 81.6% of the more than 91,000 nurses (RNs and LPNs) holding a license to practice in the state. The chapter then presents separate, but less detailed, discussions of issues related to the education of other categories of the nursing workforce. There is no intent to suggest a lack of importance of LPNs or nursing assistants in the overall nursing workforce. However, the volume of material and the complexity of the issues necessitated some division of the work of the Task Force. Figure 3.1. Possible Educational Pathways in Nursing Licensure or listing** Nursing education program * The Task Force gratefully acknowledges the expert assistance of Barbara Knopp, RN, MSN, Education Consultant, NC Board of Nursing, and Linda Lacey, MA, BBA, Director of Research, NC Center for Nursing, for their extraordinary efforts in compiling the data presented in this chapter. **North Carolina does not “certify” nurse aides. These personnel are “listed” after successfully completing the required training and competency evaluation program of the Nurse Aide I or Nurse Aide II Registry.

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Chapter Three Educating the Future Nursing Workforce for North Carolina*

The critical issue confronting the Task Force withregard to nursing education programs was whetherexisting programs (and educational systems) have thecapacity to produce the numbers of additional nursingpersonnel with the appropriate levels of educationlikely to be needed in the future. But producing adequate numbers of nursing personnel must be coupled with a concern for the program quality forgraduates who will represent the future of nursingpractice in our state. The conditions under whichnursing personnel must practice are changing rapidly,and, consequently, the diversity of nursing roles is alsochanging. Beyond concerns for meeting the demandsof a rapidly changing practice environment (asdescribed in Chapter 4), the Task Force and its WorkGroup on Nursing Education Program Capacity hadto deal immediately with the impending shortage offaculty in nursing education programs at every level.This set of issues is the focus of the present chapter.

The Task Force realized from the outset of itsanalysis of North Carolina nursing education programsthat there are multiple routes to licensure as a nurse(see Figure 3.1 below) and these pathways provideindividuals with many different options to obtain pre- and post-licensure education.

In recognition of this complexity, the Task Forcedecided to focus its attention sequentially on variouscategories of licensure or certification, and forRegistered Nurses, the various educational pathwaysto licensure and post-licensure opportunities for educational advancement.

A Focus On The Registered Nurse(RN) Workforce

Depending on whose voice is being heard, theterm “nursing personnel” may (or may not) includepersons working in healthcare settings as nurse aides,Licensed Practical Nurses (LPNs), Registered Nurses(RNs), Advance Practice Registered Nurses (APRNs),

other master’s degree prepared nurses (MSNs) whowork in a variety of non-clinical roles, or nurses holdingPhD degrees. In order to minimize the confusion andpotential for disagreement over the terms of referencein discussing various components of the nursingworkforce, this report (especially this chapter on education programs) focuses first and predominantlyon RN-licensed nurses (which includes graduates ofhospital-based diploma programs, associate in appliedsciences in nursing degree programs, baccalaureatedegree programs, master’s degree programs and doctoral-level programs). We chose to focus on RNsbecause they comprise 81.6% of the more than 91,000nurses (RNs and LPNs) holding a license to practice inthe state. The chapter then presents separate, but lessdetailed, discussions of issues related to the educationof other categories of the nursing workforce. There isno intent to suggest a lack of importance of LPNs ornursing assistants in the overall nursing workforce.However, the volume of material and the complexityof the issues necessitated some division of the work ofthe Task Force.

Figure 3.1.Possible Educational Pathways in Nursing

Licensure or listing**

Nursing education program

* The Task Force gratefully acknowledges the expert assistance of Barbara Knopp, RN, MSN, Education Consultant, NC Board ofNursing, and Linda Lacey, MA, BBA, Director of Research, NC Center for Nursing, for their extraordinary efforts in compiling thedata presented in this chapter.

**North Carolina does not “certify” nurse aides. These personnel are “listed” after successfully completing the required trainingand competency evaluation program of the Nurse Aide I or Nurse Aide II Registry.

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Simultaneous with the initiation of the Task Forcehere in North Carolina, the Institute of Medicine ofthe National Academy of Sciences released its reportentitled Health Professions Education: A Bridge toQuality in 2003.1 This report underscored the impor-tance (for every healthcare profession) of five keypractice competencies anticipated to be highly relevantto the coming era of healthcare provision in theUnited States: (1) delivering patient-centered care, (2)working as part of interdisciplinary teams, (3) practic-ing evidence-based medicine (nursing), (4) focusingon quality improvement, and (5) effectively usinginformation technology. The Task Force endorsesthese ideas as critical dimensions of professional nursing education and practice. The Task Force furthercommends the NC Board of Nursing (NC BON) for itscurrent effort to strategically plan for the incorpora-tion of these areas of assessment in its approval andregulation of nursing education programs in the state.

Historically, there have been barriers to the collab-oration between different types of nurse educationprograms. It is a tribute to the leadership and wisdomof those chosen to serve on this Task Force, and theprocess through which these deliberations took place,that much of the previous difficulties in discussing the respective problems and potentials of differenteducational systems for educating the future nursingworkforce were set aside in favor of a coherent, goal-oriented approach that would enable North Carolinato achieve the most highly educated nursing work-force possible.

“RN”—Many Pathways to First-Level Licensure for Nursing Practice

The entry-level credential for nursing practice isthe basic license as a “Registered Nurse.” Nurses obtaintheir RN licensure by completing a basic course ofstudy (i.e., BSN, ADN, or hospital diploma) and passingthe National Council Licensure Examination (NCLEX-RN). For registered nurses, the basic entry-levelknowledge and skill are assumed to be that requiredto pass the NCLEX-RN examination.

Although there are some disagreements about therelative quality of preparation of graduates from dif-ferent types or levels of nursing education programs,the only recognized standard to measure preparationfor nursing practice is the NCLEX-RN examination.Yet, the NCLEX-RN examination “...is not intended todefine excellence or expertise at any level of nursing

practice. To use the NCLEX-RN as the vehicle to makeexplicit the distinctions that result from different academic preparation is to misunderstand its purpose and requirements.”2 As Cathcart points out,“(Though)...the academic requirements of associate’sdegree, diploma and baccalaureate programs mayvary widely...healthcare settings that employ nursinggraduates often make no distinction in the scope ofpractice among nurses who have different levels ofpreparation.” Taking this into account, the Task Forcemade no attempt to distinguish among the threepathways to RN licensure with regard to presumptivedifferences in preparation for various levels of nursingpractice at the point of entry to the profession.

However, as the Task Force went about its work,there was growing concern throughout the nationover reports of avoidable clinical errors and untowardoutcomes of health and medical care. Nurses are a significant, perhaps the most significant, providers ofday-to-day patient care in some healthcare settings.Despite growing evidence that both larger numbers of nursing personnel employed in these settings3,4,5

and the higher average levels of nursing education in a given facility6,7,8 make a difference in decreasing mortality rates, reducing medical errors and nursingpractice violations, and improving patient outcomes,nurses continue to be used interchangeably in mosthealthcare settings.9

The Task Force responded to these recent findingsby underscoring the following Nursing WorkforceDevelopment Goals for North Carolina:

1. to produce the numbers of nurses needed to meetNorth Carolina’s needs for the future,

2. to produce the best educated nursing workforcepossible, and

3. to promote those innovations that would enableany nurse practicing in North Carolina to gainadditional professional education and advance-ment opportunities throughout her/his career.

There was complete agreement that all categoriesof nursing education programs should be strength-ened, and that graduates of each should becomeincreasingly well-prepared to meet the nursing andpatient care challenges of the future. Given the factthat close to 70% of all nurses in the nation, and morethan 60% of nurses currently practicing in NorthCarolina, are graduates of ADN or hospital-based

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programs, these programs are abso-lutely essential to meeting the nursingneeds of our population now and inthe future. At the same time, however,programs preparing nurses at theBSN, MSN, and higher levels are meet-ing critical needs as the demands ofnursing practice, the needs for addi-tional nursing faculty, and profession-al leadership positions demand higherlevels of nursing education.

Every nursing education pro-gram, and every category of program,has its unique set of problems andissues, yet each has a critical role inmeeting some part of our overallneed for nurses in this state. Bothpublic and private financial invest-ments in the development of NorthCarolina’s nursing workforce need tobe managed with effectiveness andefficiency. The Task Force concluded that nursingworkforce development goals for the future willrequire a great deal of collaboration and cooperationacross all types of nursing education programs andwith the healthcare employer community. From thisperspective we began our examination of issues, prob-lems and possible options for change.

RN Nursing Education Programs in North CarolinaNorth Carolina has an abundance of nursing

education programs at every level. Few other stateshave as many separate programs offering pre-licen-sure educational opportunities for persons interestedin a nursing career. As of the year 2004, there were 64 nursing education programs in North Carolinaoffering credentials for entry-level RN licensure(BSN/ADN/Diploma). Among states in the Southeast-ern Region (i.e., those states served by the SouthernRegional Education Board), only Texas has morenursing education programs than North Carolina (see Table 3.1).

The issue isn’t just the number of programs, butthe mix of programs producing an eventual mix of

nurses with a range of educational credentials. This isimportant because one of the Task Force goals is toadvance the overall level of nursing education in thestate’s workforce by extending opportunities for higherlevels of educational credentials and avenues for careeradvancement to North Carolina nurses. When weexamine the mix of nursing education programs ineach state preparing nurses at various levels, we findthat North Carolina has the lowest proportion of BSNprograms of any of the SREB states. In Texas, the statewith the most nursing programs (83), 36% are BSNprograms. In Florida, 18 of 48 or 38% are BSN programs; and in Tennessee 61% of nursing educationprograms offer the BSN degree. In North Carolina,only 13 (20%) of its 64 programs prepare graduatesfor entry-level RN licensure in BSN programs.Likewise North Carolina has the highest percentage ofADN programs among the SREB states at 75%. Whiledata on RN program graduates are inconclusive, theysuggest that North Carolina with its many programsproduce no more nurses than states with fewer programs.A Two of the issues of concern to the TaskForce, therefore, were the capacity and efficiency of

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Table 3.1.Number of Entry-Level RN Nursing Education Programs by State in SouthernRegional Education Board (SREB) States, 2002 (2004, NC data only)

State Total BSN ADN Diploma Programs Programs Programs Programs

N N (%) N (%) N (%)

TX 83 30 (36) 51 (61) 2 ( 2)NC 64 13 (20) 48 (75) 3 ( 5)FL 48 18 (38) 29 (60) 1 ( 2)TN 33 20 (61) 12 (36) 1 ( 3)VA 38 14 (37) 17 (45) 7 (18)AL 37 13 (35) 22 (59) 2 ( 5)GA 39 19 (49) 19 (49) 1 ( 2)KY 37 14 (38) 23 (62) 0OK 31 14 (45) 17 (55) 0LA 22 13 (59) 6 (27) 3 (14)MD 27 10 (37) 14 (52) 3 (11)SC 22 9 (41) 13 (59) 0MS 22 7 (32) 15 (68) 0WV 25 14 (56) 10 (40) 1 ( 4)AR 26 9 (35) 14 (54) 3 (11)DE 9 4 (44) 4 (44) 1 (11)Sources: Southern Regional Education Board, 2003 and NC Board of Nursing, 2004.

A The Task Force attempted to acquire data from the SREB to make a more precise determination of this impression, but unfortunately SREB relies on annual or semi-annual surveys of state boards of nursing, for which response rates are disappointing and therefore unreliable. Anecdotal surveys of data published on the Internet sites for some state boards of nursing in SREB states do support this point, but one cannot at this point arrive at a conclusive statement of fact.

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existing nursing education programs. At a minimum,the Task Force attempted to understand whetherexisting programs, at every level, could produce thenumbers of nurses needed by our state’s growing population.

How Many RNs Are Current Programs Able to Produce?

Determining the capacity and efficiency of NorthCarolina’s nursing education programs are not newpolicy questions. These same questions were the focusof much of the effort leading to the findings of a special Consultation Report on Baccalaureate NursingEducation in the University of North Carolina: Reportto the President commissioned by the UNC System inApril of 1990. Reference to this report, although ren-dered 13 years ago, is important to set the context forthe work of the current Task Force. If for no other reason, it reminds us that much of what the Task Forcediscussed regarding nursing education programs wasa continuation of problems/issues which were identi-fied years ago and for which no effective or lastingsolutions have been found. It is hoped that 13 yearshence those reviewing the present report will not conclude that the same issues and problems still exist.

In the 1990 report to the UNC Board of Governors,citing earlier data from the SREB, it was noted thatNorth Carolina had nine BSN programs, 48 ADN programs and four diploma programs. It was notedthat “articulation” programs through which associatedegree and diploma graduates may enter BSN programs in the state’s public universities were“...complicated by the number of ADN programs andthe differences among them.” Furthermore, the reportcalled attention to the fact that the neighboring state

of Tennessee, with 35 entry-level RN programs at thattime, prepared only 86 fewer nurses than did NorthCarolina with 56 programs. Most of the ADN programsin North Carolina were then, as they are now, small interms of numbers of graduates.

There have been some notable improvements inthe level of faculty credentials in community collegenursing programs over the past decade. In 1990 fewerthan 50% of the nursing faculty teaching in ADN programs in North Carolina held master’s degrees innursing. The NC Board of Nursing now reports thatthe number of full-time master’s-prepared nursingfaculty in these programs is 78%.

The 1990 report underscored the need for bettercoordinated planning for nursing education in ourstate as a means of making nurse education morecost-effective. Finally, the 1990 report called attentionto the need to achieve a higher level of gender andracial diversity in nursing education programs (ADN,BSN, and MSN) and the state’s nursing workforce, twoissues of concern to the present Task Force.

Though the number of entry-level RN nursingeducation programs in North Carolina has continuedto grow at a rapid pace, the issues and problems iden-tified more than a decade ago remain major concerns.

Prelicensure Nursing Education ProgramsThere are currently 64 programs offering creden-

tials for RN licensure (13 BSN/3 Diploma/48 ADN). All 13 prelicensure BSN programs are nationallyaccredited. Nine of the BSN programs are part of theUNC System and four are offered by private collegesand universities. Of the 48 ADN programs, 12 arenationally accredited. Forty-five of these programs areoffered through the NC Community College

System (NCCCS); twoare hospital-based; andone is offered througha private college.There are three hos-pital-based diplomaprograms; all arenationally accredited.One additional newBSN program (withinthe UNC System) isin the second phaseof development.

The mosaic of

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Table 3.2.North Carolina Nursing Education Programs Preparing Graduates for Entry-Level RN Licensure, 2003

An additional BSN program is in the second phase of development as of February 2004, within the UNC System.

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North Carolina nursing education programs prepar-ing graduates for entry-level RN licensure (dia-grammed in Figure 3.1) is complicated, reflecting thedifferent histories and rationales for the creation ofprograms within various sponsoring educationalinstitutions.

Many of the prelicensure programs are small. TheNC Board of Nursing reports that in 2002, 25 of the 63programs (40%) providing writers for the NCLEX-RNexamination each had fewer than 30 graduates takingthe exam for the first time; nine programs (14%) each had fewer than 20 first-time examinees. Twenty-five of these programs had fewer than 30 first-timeexaminees in 2003, and eight of these programs hadfewer than 20 first-time testers.

A detailed appendix (Appendix 3.2) to this chapterprovides important data for each of these programs. Inaddition, a separate appendix (Appendix 3.3) providestrend data on the capacity and productivity of NorthCarolina’s nursing education programs by type.

Accelerated BSN ProgramsOne of the innovative nursing education program

developments that has been offered in three of NorthCarolina’s collegiate schools of nursing (Duke, UNC-Chapel Hill and Winston-Salem State University) is theaccelerated BSN Program. Through such programs,individuals who already possess an undergraduatedegree from a four-year college or university and whohave already taken the appropriate science and otherprerequisite courses normally part of the initial twoyears of the baccalaureate curriculum can apply toenter a school of nursing offering the accelerated BSNoption. These programs, typically 14-16 months in dur-ation, provide an intensive exposure to the clinical skillscomponent of nursing, nursing practice theory and anorientation to the structure and functioning of thehealthcare system and the role of nursing as a profes-sion. Program graduates are awarded the BSN degreeand are eligible to sit for the NCLEX-RN examination.

Nationally, accelerated BSN programs are beingrecognized as an effective way to recruit a new “pool”of well-educated young and middle-aged, college-edu-cated persons into nursing, while at the same timeadding to the diversity of the nursing workforce. Forexample, the Duke University accelerated BSN programhas among its student population about 15% malesand 14% minority candidates. Because the timeframeto acquire the skills necessary for entry-level licensure

and employment is considerably less than half of whatit would take to acquire a four-year academic degreein any other field, these accelerated BSN programshave become attractive options to those who alreadyhave a college degree and who are considering careerchanges.

Post-Licensure Nursing Education ProgramsThere are currently 16 RN-to-BSN programs in

North Carolina. These programs enable licensed RNs,who received their basic entry-level education in anADN or hospital-based diploma program, to acquire abaccalaureate degree. All of these programs in NorthCarolina are nationally accredited. Ten of these programs are part of the UNC System, one is hospital-based, and five are offered by private colleges. Theseprograms do not add to the overall number of licensednurses, but do increase the overall educational levelsof the basic RN workforce while providing individualnurses with many options for career advancement,which is a central, overall goal advanced by the TaskForce. Strengthening and expanding these programsis an important strategy for nursing workforce devel-opment in North Carolina.

Master’s Degree ProgramsThere are ten institutions offering master’s degrees

in nursing. Seven of these institutions are part of theUNC System and three are offered by private colleges.Graduates of master’s degree programs are preparedfor faculty, administrative, informatics and a variety ofadvanced practice clinical nursing roles, includingnurse practitioner, clinical nurse specialist, nurse-midwife, and nurse anesthetist.

Doctoral Degree ProgramsThere are currently two institutions (East Carolina

University and UNC-Chapel Hill) offering a doctoral(PhD) degree in nursing. Additional doctoral programsin nursing are being planned at Duke University inDurham and UNC-Greensboro. Graduates of nursingdoctoral programs are prepared for faculty roles inuniversities, providing contributions to both teachingand research, and for leadership positions in health-care service and policy.

As the Task Force examined these data, it was clearthat North Carolina has an abundance of nursing education programs, some of these being very smallin terms of both faculty and student populations.

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Hence, the Task Force attempted to address the following questions:

1. Are there too many nursing education programsin North Carolina; are existing programs able tooperate at an acceptable level of efficiency andquality?

2. Do we have the right mix of nursing educationprograms, likely to yield the right mix of graduatesand practicing nursing personnel?

3. Is there a rationale for maintaining the presentnumber of nursing educational programs, orallowing additional programs to develop?

4. Are there cost-effective ways of reorganizing NorthCarolina’s existing array of nursing education pro-grams so that the overall quality and productivityof these programs could be enhanced?

5. What are the principal factors affecting the qualityand productive capacity of existing nursing educa-tional programs and how might these be improved?

Issues Regarding the Number and Capacity ofEntry-Level RN Nursing Education Programs inNorth Carolina

There are differences of opinion with regard towhether our state’s large, and growing, number ofentry-level RN nursing education programs is seen asa potential problem, or a positive accomplishment. Asthe Task Force considered these issues, it becameincreasingly clear that our discussion would have totake place separately for each of the types of programsand their respective sponsoring institutions. Hence,the report separately discusses issues related to (1)associate degree programs offered primarily throughthe state’s Community College System, (2) baccalau-reate programs offered through the state’s publicinstitutions, (3) baccalaureate programs offeredthrough private colleges and universities, and (4)diploma programs offered through hospital-basednursing education programs. In this way we hope tomake the set of recommendations which follow morelogical and specific to the needs and capacities of eachtype of program.

Four principal themes were central to the TaskForce’s consideration of the number of nursing educa-tion programs in North Carolina. These were:

� Capacity (i.e., the number of nursing studentsenrolled in these programs; the availability of

appropriate clinical sites for offering clinical nurs-ing education and experience; numbers of faculty;physical space to conduct the didactic portion ofthese curricula)

� Access (i.e., the extent to which educational oppor-tunities exist for persons interested in pursuing—or advancing in—a nursing career)

� Efficiency and Effectiveness (i.e., the extent towhich retention and graduation rates were high,attrition rates were low, and the extent to whichresources are used most efficiently to accomplishthese education goals, including the possibility ofconsolidation of programs where economies ofscale and duplication were considered)

� Quality (i.e., the performance of programs reflectedin pass rates for the NCLEX-RN exam, meetingnational standards of accreditation, and facultynumbers and their credentials).

The Task Force singled out faculty recruitmentand retention and securing appropriate clinical sitesfor nursing education as key components of nursingeducation programs that affect the capacity of theseprograms to educate students. The Task Force exam-ined the problems and issues surrounding facultyrecruitment and retention in North Carolina nursingeducation programs at some length. This is a nation-al issue as well, but in North Carolina the issue ismanifest in different ways depending on the nursingeducation program being considered. Faculty short-ages have much to do with the current and futurecapacity of nursing education programs to expand inorder to meet the state’s needs for additional nursingpersonnel. As noted in Chapter 2 of this report, a largenumber of prospective nursing students each year arebeing denied admission to the state’s nursing educa-tion programs due to nursing faculty shortages andonly a small number of such programs indicate thatthey could expand their student enrollments withoutadditional faculty.

Nursing education programs face a continuingproblem of identifying appropriate facilities wherepatient care is actively being given and where it is possible to integrate student learning opportunitiesunder direct faculty supervision. Education programsaffiliated with large academic health centers have aconsiderable advantage in this regard, but most hospitals, nursing homes and other clinical facilitiesmake learning opportunities available to students

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from several nursing education programs. Coordina-tion of the placement and supervision of these studentsis an on-going problem, both for the clinical facilityand for the school of nursing. The Task Force heardanecdotal accounts of nursing programs encounteringdifficulties in working out overlapping assignments ofstudents to the same clinical facilities and instances ofone nursing education program having preferentialaccess to clinical facilities in a certain geographicalarea. With so many nursing education programs inthe state, each with specific mandates for both thetypes and amounts of supervised patient care experience as part of their curricula, coordination ofaccess to these facilities is a major concern amongnursing educators, the Board of Nursing, and theseclinical facilities.

While the availability of nursing faculty and clinical sites affects the ability of nursing programs toeducate nursing students, there is no widely acceptedindex to measure the capacity of nursing educationprograms. While at first glance it was thought thatthe number of student “slots” approved by the NCBON could serve as such an index, many objectionswere raised over the meaning and interpretation ofthese NC BON approved slots as indicators of currentprogram capacity. Task Force members noted thatthe enrollment and capacity data provided by the NCBON indicate that only about 85% of available slots(i.e., BON-approved capacity) in BSN and ADNprogramsB preparing graduates for RN licensure arebeing used at the present time. If all slots in theseprograms could be filled, another 1,452 nursing stu-dents could be in the pipeline to obtain RN licensure.However, there has been no historical impetus toreduce BON-approved slots when conditions at aschool of nursing change in a way that reduces itscapacity to educate the approved number of students(due, for instance, to faculty position reductions orshortages, increased competition for clinical sites,etc.) These data raise important questions about thecapacity of these programs, but also about the meaning and utility of BON approval of slots in theseprograms as a measure (or index) of nursing educationprogram capacity. This issue will be discussed furtheras specific recommendations are presented in latersections of this chapter.

For each type of program, we will attempt to

address the principal themes in as much detail as wasavailable to the Task Force during its deliberations.

Associate Degree Programs offered through theCommunity College System

All but three Associate Degree (ADN) programs inNorth Carolina are offered through the CommunityCollege System. Two ADN programs are offered byhospital-based schools of nursing; one is offeredthrough a private college. Since 1998, approximately60% of all prelicensure RN graduates from NorthCarolina schools of nursing have received their entry-level nursing education through an ADN program.Because of the large number of ADN programs in thestate and their proportion of all nursing programs, agreat deal of the Task Force’s attention was directed tothese programs, their structure, performance, andfinancing.

CapacityAssociate Degree nursing education programs

preparing graduates for RN-licensure use about 77%of their 6,280 BON-approved slots (based on three-year average enrollments). Community-college programs do not request additional slots until suchtime as they have the funds approved and are able toidentify both students to enroll and clinical sites within which to educate these students.

Adequate faculty resources in North Carolina’sCommunity College System is an issue for the Systemin general and one of the key issues related to commu-nity college-sponsored nursing education programs inparticular. Faculty in many community college nursingeducation programs are older and nearing retirementage (36% of full-time nursing faculty in NorthCarolina community colleges are older than age 50;45% are between the ages of 40 and 50). Salary levelsfor faculty in these programs is not only lower than incommunity colleges elsewhere in the nation, butNorth Carolina community college faculty salaries aresubstantially below what nursing graduates (i.e., thestudents of these faculty) are routinely offered inentry-level nursing practice positions. The data inTable 3.3 show the relative discrepancy between levelsof salary compensation for faculty (in all disciplines)in North Carolina community colleges versus salariesin other SREB states.

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B No data were available on percent of NC BON capacity used in hospital-based programs.

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Although the percentage of ADN program facultywith master’s degrees and above has risen to 78%,these programs are still dependent on as many as one-fifth to one-fourth of their faculty who hold only abaccalaureate degree. At the time this report was written, there were 12 vacancies for full-time faculty inNorth Carolina community college nursing educationprograms, eight of which have been vacant for longerthan six months.C It should be pointed out that ADNprogram directors responding to the 2003 survey fromthe NC Center for Nursing (NCCN) reported vacancyrates for full-time and part-time faculty that were not thatdifferent from rates in thestate’s four-year collegiatenursing programs offering theBSN degree. Hence, facultyrecruiting and retention is ageneralized problem within alltypes of nursing programs inour state. With the current

difficulty of recruiting adequatelyprepared faculty, the low salariesoffered to community college fac-ulty, and the often rural locationof some community college cam-puses, extreme faculty shortagesare expected in nursing educationprograms of North Carolina’scommunity colleges in the decadeahead.

Beyond these salary level deficiencies, faculty in communitycollege nursing education pro-grams often have a number ofresponsibilities assigned to thembeyond their traditional class-room or clinical teaching roles.Many, if not most, nursing facultyin these programs also serve asstudent advisors and mentorsoutside the classroom on mattersunrelated to curriculum content.The non-traditional student typi-cally attending these programs isolder than most college age

students, (see Table 3.4) has other work and familyobligations, and requires support services of variouskinds in order to stay enrolled. A shortage of studentsupport services in North Carolina’s community colleges means nursing faculty often fill this void.

Aside from the Program Director, faculty membersin the Community College System are usually hired ona year-by-year basis. Community college nursing faculty experience no differentiation in academic rank(and associated salary increments) and no job securityequivalent to the tenure provisions available to some

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Table 3.3.Average Salary of Full-Time Instructional Faculty in Two-Year CommunityColleges in SREB States, the Nation, and North Carolina

State Average Salary for Percentage State All Ranks of Faculty of US Salary-Level

2001-2002 Average Rank

Maryland $53,271 115.6 1Delaware $51,113 110.9 2Virginia $46,668 101.9 3UNITED STATES $46,053 100.0Georgia $45,681 99.1 4Florida $44,694 97.0 5Texas $44,233 96.0 6Kentucky $43,429 94.3 7Alabama $43,387 94.2 816 SREB STATES $41,016 89.0West Virginia $40,927 88.8 9South Carolina $40,074 87.0 10Mississippi $40,054 86.9 11Oklahoma $39,959 86.7 12Tennessee $38,924 84.5 13Louisiana $38,147 82.8 14NORTH CAROLINA $36,809 79.9 15Arkansas $36,778 79.8 16

Sources: SREB State Data Exchange, National Center for Education Statistics, AmericanAssociation of University Professors, 2002.

Table 3.4.Student Age Group Distribution in BSN and ADN Programs in NC, 2003

Age Groups BSN Programs ADN Programs

< 30 86.5% 61.3%

31-40 8.4% 26.2%

> 40 6.8% 12.1%

Sources: NC Center for Nursing, 2003.

C The 2003 survey of nursing education programs by the NC Center for Nursing finds 16 unfilled full-time positions and twounfilled part-time positions in these ADN programs.

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(but not all) faculty in university and college programs,or to faculty in the state’s public school system.

The directors of nursing education programs inthe Community College System know from year-to-yearhow many faculty they can hire based on actual orprojected enrollment in these programs and on thebasis of faculty compensation levels established by theindividual community college as a whole. Communitycollege program expansions must occur “retrospec-tively,” through faculty overloads or seeking of externalfunds. Any new faculty hired to increase enrollmentmust be hired by having current faculty assume ahigher per-faculty teaching load in a given year, withthe prospect that in the subsequent year the per capitapayment of state funds to the community college willrecognize the additional enrollment and enable thelocal institution to extend an offer to an additional faculty member. This expansion is especially difficultwhen clinical courses are involved since the programmust not exceed the clinical faculty-to-student ratio(of 1:10) mandated by NC BON regulations.D Becauseexpansion of community college programs occurprior to funding increases, community colleges oftenseek external funding from the Kate B. ReynoldsCharitable Trust and other sources to support the initial expansion of the nursing program until theprogram obtains increased legislative funding. In contrast, expansion of programs in the state’s publicuniversities can normally depend on enrollmentgrowth funding to be available in the same year as theenrollment growth occurs.

The major problems at the moment related to faculty recruitment and retention within theCommunity College System appear to be concernedwith the availability of nurses with graduate-level(MSN) degrees to serve as faculty and the salary levelsof community college faculty positions, the latterbeing a System-wide problem for community collegefaculty recruitment and retention efforts. In responseto the first of these problems, the state’s colleges anduniversities offering graduate-level nursing educationprograms have responded by offering a number of off-campus and/or distance learning programs thatput these educational opportunities within reach ofnurses who must remain employed while pursuingadvanced degrees and who cannot relocate to a

university campus for full-time study. East CarolinaUniversity, UNC-Greensboro, UNC-Charlotte, UNC-Chapel Hill and Duke University have each offerednew master’s degree programs tailored specifically tothe needs of nurses who are only able to pursue master’s degrees through non-traditional programs.Further efforts to meet the needs of community college faculty expansion include the development ofspecial curricular components with an emphasis onadult education teaching methods and technologiesappropriate for persons choosing careers in nursingeducation. In addition, there was a proposal for thedevelopment of a North Carolina Nursing FacultyFellows Program introduced in the last session of theGeneral Assembly (House Bill 808) which, if enactedand funded, would assist persons with nursing educa-tion career goals in entering this field. This bill wouldprovide a two-year scholarship loan in the amount of$20,000 per year per recipient to persons who, aftercompleting their MSN, would work in a faculty posi-tion in a university, community college or hospitalschool of nursing.

AccessThere are important historical reasons why so

many nursing education programs have developedthrough the NC Community College System. Thereare important philosophical underpinnings of theSystem that provide at least part of the rationale forthe present number and any future growth in thenumber of such programs.

Though North Carolina is the 10th largest state, it isarguably one of the nation’s leaders in assuring accessi-ble and affordable higher education opportunities forall its citizens in close proximity to where they live.The distribution of community college programsthroughout the state is such that a North Carolina cit-izen who wants to pursue post-high school educationin almost any field has a program in his/her county orin an adjacent county. The philosophy which hasmotivated the expansion of community college pro-grams throughout our state, within a system that givesmost of the control over the content and structure ofthese programs to local (county) decision makers, hasa significant implication for the future prospects forchange in the state’s nursing education programs.

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D The ratio of 1:10 is a “clinical” ratio, which is often further reduced by the host clinical facilities to 1:8, and in specialty areas itmay be even smaller.

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Community college administrators point out thatnursing education programs, existing on virtually allof the System’s campuses, are expensive and drainresources from other programs sponsored by theseColleges. Community colleges, being locally governedbut state-supported, operate primarily to serve the localeconomic development needs of their communities,including the healthcare providers who employ nurs-ing personnel. It is in response to local demand fornursing personnel that community colleges havedeveloped nursing education programs. Some com-munity college administrators say that were thedemand not there, they would be motivated to discon-tinue nursing programs and reallocate these resourcesto other programs.

Efficiency and Effectiveness Problematic with the philosophy of assuring virtual

statewide access to nursing education is the fact thatnot enough resources are allocated to support equallyhigh quality programs in every community college.The fact that some of these programs produce veryfew graduates who sit for the licensure examinationeach year was cause for concern about the wisdom offurther expansion of the number of such small pro-grams. Though the Task Force did not do a detailed“cost/graduate” analysis for each ADN program (nordid it do a similar calculation for baccalaureate degreenursing education programs), observations of thiskind naturally led to questions about the feasibility ofprogram consolidation and the potential for inter-cam-pus consortia. Some consolidation of programs wouldpresumably help to maximize the efficiency ofresource utilization.

Representatives of the Community College Systemnoted that past attempts to regionalize or consolidatenursing education programs were not well-received bythe participating campuses and they were generallymore expensive than operating these programs sepa-rately, although there were no data available to docu-ment this. Despite the fact that the NC BON approveda single number of student slots for the combined pro-gram, and there was a single nursing program directorappointed, each community college in the consortiumappointed a campus coordinator of nursing educationin addition to the consortium director, thus increasingoverall faculty costs. Discussion of the potential for “re-structuring” nursing education programs, at leastwith regard to consolidation, was not conclusive.

The larger issues regarding the efficiency andeffectiveness of ADN programs offered through theNC Community College System have to do with highattrition/low retention rates in these programs.Depending on which data are used, and for whichcohort of students, only about 50% of those who enterADN programs in the community colleges actuallycomplete these programs within two years of enroll-ment and become eligible to sit for the NCLEX-RNexamination. The Office of the President of theCommunity College System has taken the lead inidentifying this problem and potential approaches toincreasing the rate of retention and graduation fromthese programs. One of the factors which was of concern to some Task Force members was the highlyvariable admission criteria among these programsand the fact that some (probably only a few) local col-leges were not employing a thoroughly “merit-based”system for student selection and admission decisionmaking. Although the admission criteria were foundto be highly variable, most North Carolina communitycolleges do in fact rank-order applicants in terms of anumber of conventional college-level admission criteria(e.g., high school grade point averages, high schooland college preparatory courses taken, SAT scores, theNurse Entrance Test, etc.) and do not use a “waitinglist” of persons compiled on the basis of one’s date ofapplication.

A larger problem contributing to the low comple-tion rates in some ADN programs may be due to thestudent’s family and economic needs. Many of the ADNstudents are older than typical undergraduate collegestudent populations and have other obligations (associated with employment and/or family), thatmake it difficult for them to focus exclusively on theirnursing education. As a result, some students need toextend the time taken to complete their degrees.Because of the complexity of student needs in theseprograms, student support services (e.g., academic and career counseling, financial support for tuitionand other educational expenses, child care and trans-portation) are critical to these student populations.Unfortunately, the NC General Assembly eliminatedsupport for much of the student support function inthe Community College System over the past two sessions and these types of services are no longer available. The case for reinstating the support for theseservices was compelling and the Task Force thereforeoffers a specific recommendation in this regard.

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QualityAt present, nine of the 45 ADN programs

within the Community College System arenationally accredited; three additional ADNprograms offered by private colleges arealso accredited, bringing the total numberaccredited to 12 out of a total of 48 (25%).

Data from the NC BON indicate thatpass rates on the NCLEX examination showonly minor differences between accreditedand non-accredited programs, althoughaccredited programs in fact do have higheroverall NCLEX-RN pass rates. The factremains that all of North Carolina’s nursingeducation programs score better thannational averages on this one criterion of programquality.

Summary: Community College System-sponsorednursing education programs have three significantproblems: First, community colleges have a problemwith nursing faculty salaries and the ability to assistindividual faculty who wish to pursue graduate-levelcredentials leading to the MSN degree. Second, com-munity colleges cannot expand their programs, evenwith significant student interest in nursing careers,without first finding non-state funds to cover theseprogram expansion costs. This retrospective fundingsituation makes community college-based nursingeducation programs dependent on the availability ofprivate philanthropic sources of funding for programexpansion. Third, there is a critical need for therestoration of student support services to enable ADNand PNE students enrolled in community college-based nursing education programs to pursue theireducation without undue interruption to their livesand families. If these ADN nursing education programscould increase their retention/graduation rates byjust 10%, given the fact that such a high proportionof these ADN graduates stay to practice in NorthCarolina, it could increase our annual number of newregistered nurses by over 450 per year. If the numberof filled slots in these programs could reach the num-ber currently approved by the NC BON, the numberof additional nurses graduating from these programsassuming the higher graduation rate, could increaseto more than 600 new registered nurses per year.

Baccalaureate Degree Programs offered through theUniversity of North Carolina System

In the mid-twentieth century, nursing graduallymoved its educational programs from hospitals touniversities in keeping with the nation’s growingcommitment to an educated citizenry. In the 1940s,healthcare in North Carolina was in a dismal state. Astudy of draft records during World War II revealedthat over half of North Carolina’s men had beenrejected for military service during the war due topoor health status. Lawmakers enacted legislation tocreate a hospital at the University of North Carolina,as well as to build local hospitals throughout the state,with the help of federal Hill-Burton funds. In addition,state funds were allocated to develop a five-unitDivision of Health Affairs at UNC-Chapel Hill thatwould include previously existing schools of medicine,pharmacy, and public health, while adding two newschools in dentistry and nursing. The state’s first bac-calaureate program in nursing was established atUNC-Chapel Hill in 1950, two years prior to the openingof North Carolina Memorial Hospital. Other BSN andhigher degree programs emerged thereafter in responseto state demands for collegiate-educated nurses.

Since BSN-level credentials are a prerequisite formore advanced education in the field of nursing (e.g.,MSN or PhD), and for many nursing roles beyond bed-side staff nursing care, strengthening these collegiateprograms at various public and private institutions inNorth Carolina opens opportunities for career ladderadvancement for persons wishing to pursue careers innursing. Healthcare agency employers cannot hire allthe BSN graduates they prefer to hire and with currentresearch showing the link between higher proportions

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Table 3.5.NCLEX-RN Five-Year Average Pass Rates by Type of Program and Program Accreditation

Type of Program NCLEX-RN Pass Rate

All Types (National) 85.15 %All Types (North Carolina) 88.96 %ADN (National) 85.09 %ADN (North Carolina) 88.90 %NCCCS Accredited 89.56 %NCCCS Non-Accredited 88.00 %Non-NCCCS Accredited 86.00 %

Data for this table provided by the NC Board of Nursing, 2002.

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of nursing staff who are BSN prepared and quality ofhospital care, the demand for BSN graduates is likelyto increase in the future.10 Moreover, most nursing faculty in the Community College System are BSN pro-gram graduates who have also earned MSN degrees. Asteady stream of BSN graduates who then pursue theMSN are critical to the Community College System’sability to expand nursing enrollments in the state.

The Task Force took note of the fact that, at present, there is a ratio of approximately 60:40 in theproportion of the state’s new graduates each year whocome from ADN/hospital diploma programs versusthose graduating from BSN programs. These ratiosmay suggest that we will not have sufficient numbersof nurses who can eventually assume leadership positions in nursing education, clinical practice andadministration where a broader undergraduate education better prepares them for some of these high-er-level roles and enables a quicker path to advancededucation opportunities in the nursing profession.Even more importantly, ADN program capacity andquality are contingent on an ever increasing numberof BSN graduates. The future need for nurses educatedat any level cannot be met without increases in thenumber of persons educated initially at the BSN leveleither through traditional or accelerated options andwithout increasing the numbers of RN-to-BSN graduates.

The majority of nurses with advanced degrees areoriginally educated in BSN programs. Data analysesprovided by the NC Board of Nursing in October 2003

(see Table 3.6) indicate that (1)the percentage of nurses whopursue advanced degrees whowere originally educated in BSNprograms increases if we lookonly at nurses who are 45 years ofage or younger. In other words,even during the time periodwhen articulation in RN-to-BSNprograms improved considerably,nurses with graduate degreeswere even more likely to havecome from pre-licensure educa-tion in BSN programs. Eventhough we may encourage moreADN-prepared nurses to pursueadvanced degrees, there is a con-cern that they will not do so insufficient numbers to meet the

state’s need for faculty, clinical leaders, administratorsand advanced practice nurses. For this reason, there isa need to expand the state’s baccalaureate and higherdegree programs in nursing.

CapacityPublic universities in the UNC System, use an

average of 68% of their NC BON-approved capacity in2003. These UNC System schools of nursing had 1,505prelicensure BSN students enrolled (in the final twoyears of the nursing BSN curriculum) as of October 1,2003, and graduated 601 in the most recent academicyear. A study of new graduates conducted by the NCCenter for Nursing in 1996 showed that approximately87% of new BSN graduates educated in the state begantheir nursing careers in North Carolina facilities.11

In the public university system, faculty with terminaldegrees (e.g., PhD or equivalent), or in some casesthose with MSN degrees, hired in a tenure track havethe possibility of career ladder advancement throughthe ranks from Instructor, to Assistant, Associate andFull Professor, with different salary opportunities,provided they achieve the requisite teaching andscholarship standards necessary for such advancement.There are, however, no guarantees of either academicadvancement or the awarding of tenure. Our state’suniversity system is highly competitive as each university attempts to meet both institutional andnational standards of excellence in their faculty andcurricula.

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Table 3.6.Age and Initial Educational Background of Nurses Pursuing AdvancedDegrees, 2002

MSN - 45 Years of Age and Younger Total MSN-Regardless of Age

Total MSN 2,556 % Total MSN 5,785 %DIPLOMA 173 7% DIPLOMA 864 15ADN 438 17% ADN 1,126 19BSN 1,858 73% BSN 3,576 62

2,469 97% 5,566 96%(3% are unknown or “other” degree) (4% are unknown or “other” degree)

Doctoral Degrees - 45 Years of Age Total Nurses with Doctoral Degrees

Total Doctoral 41 % Total Doctoral 206 %DIPLOMA 4 10% DIPLOMA 44 15ADN 4 10% ADN 28 19BSN 26 63% BSN 115 62

34 83% 187 96%(17% are unknown or “other” degree) (9% are unknown or “other” degree)

Source: NC Board of Nursing, 2003

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While the universities and colleges offering nursingeducation in North Carolina face the annual problemof budgetary support for faculty positions, the deansand directors of these collegiate programs operatethem in such a way that they are able to assure indi-vidual faculty of certain ranks (especially those withacademic tenure) continuing employment, as deansand directors adjust the number of students theyadmit in accordance with overall budgets available tosupport their faculty.

Collegiate schools of nursing in the UNC Systemreport being able to hire at least 60% of their facultieswith the degree level (MSN or PhD) they sought.Vacancy rates for faculty in these schools of nursingare similar to those in community college ADN pro-grams (7.4% for full-time positions and 11.7% forpart-time positions).

Seventy-eight percent (11 of 14) of North Carolina’scollegiate nursing education programs offering theBSN and/or MSN degrees and higher report difficultiesin recruiting and retaining faculty, and yet most ofthese programs report being able to compensate theirexisting faculty at salary levels at or above the nationalaverage in comparison with similar institutionalmembers of the American Association of Colleges ofNursing. However, faculty recruitment is a highlycompetitive endeavor. A salary offer at the nationalaverage level will not bring in a new faculty membersince many schools vie for the same faculty candidate.Further, many other benefits in addition to a compet-itive salary are needed to recruit the few available faculty each year.

Most of the North Carolina collegiate nursing edu-cation programs within the UNC System have facedthe problems of budget reductions in recent years,which have necessitated retrenchment. Few faculty inthese programs have had real salary increases in thepast three years due to state budget constraints.Consequently, nursing education programs from theUNC System represented among the membership ofthe Task Force reported having to reduce the numberof faculty positions as budget cuts have been mandatedby the General Assembly in order to meet state budgetrescission goals. Yet, data from the NC Center forNursing Survey of Schools of Nursing reported thatthe actual number of budgeted positions in these programs actually increased from 2000-2002. Theelimination of faculty positions has been coupled withreductions in the number of students admitted (in

part because the supervision of students in the clinical portion of their curricula must meet strictstudent-to-faculty ratios). In combination withdemands for greater diversity of MSN and doctoralprogram offerings and the resulting diversion of facultyresources to those efforts, 20-30% of NC Board ofNursing-approved slots in these UNC System programsoffering the BSN degree have not been filled.12

Collegiate nursing education programs offeringthe BSN, MSN and PhD degrees in North Carolina’spublic universities do not have a major problem withsalary levels compared to other academic disciplines,however, if salary levels continue to remain flat,recruitment as well as retention of quality faculty willbe a serious issue.

AccessCampuses of the UNC System are geographically

dispersed throughout the state, and this is especiallytrue of campuses with schools of nursing. However, itcannot be said that there is a public university-basedschool of nursing offering a BSN degree option withindaily commuting distance of every resident in thestate who may choose nursing as a career. For thisreason, several UNC System campuses have developedinnovative distance learning and Internet-based curricula to enable persons wishing to pursue sucheducational opportunities to access these programswithout being completely uprooted from their homes,families and communities. Since the late 1970s, the NCAHEC Program began supporting collegiate nursingprograms in the state offering the opportunity to pur-sue BSN degrees to RNs in areas where on-campusprograms were not readily available. This was inresponse to a growing demand for baccalaureatedegrees from practicing RNs who held a nursingdiploma or two-year associate degree. In 1982, the NCGeneral Assembly provided a special appropriation tothe NC AHEC Program to expand RN-to-BSN and RN-to-MSN programs for nurses in underservedregions of the state. There was a growing recognitionby hospitals that nurses with BSN and MSN degreeswere needed for nursing management positions andleadership roles in their hospitals and communities.Working in partnership with ten universities (i.e.,Duke University, East Carolina University, FayettevilleState University, NC Central University, UNC-ChapelHill, UNC-Charlotte, UNC-Greensboro, UNC-Pembroke,Western Carolina University, and Winston-Salem

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State University) and in collaboration with the UNCOffice of the President, the NC AHEC Program’s off-campus degree programs have graduated over1,000 nurses with BSN and MSN degrees and have120 nurses currently enrolled in 2003-2004. AHECsthroughout the state provide financial support, needsassessments, classrooms, library support, and clinicalsites that support the needs of these non-traditionalstudents.

Two of the collegiate schools of nursing (DukeUniversity and East Carolina University) developed, inpartnership with the NC AHEC Program, the“Partnership for Training” program with supportfrom the Robert Wood Johnson Foundation thatoffered off-campus training for nurse practitioners,physician assistants, and certified nurse midwives inseveral Eastern North Carolina counties. Some ofthese programs are continuing and have enabledmany of these counties to acquire the skills ofadvanced practice nurses and physician assistantswithout these individuals having to relocate toDurham or Greenville.

The NC AHEC Program’s RN Refresher Program isa successful option for RNs who are no longer activelyin practice, but who would consider employmentwere their skills and knowledge updated. RNRefresher coordinators in each of the nine AHECs andthe coordinator at UNC-Chapel Hill’s School ofNursing support students during the didactic modules

and then arrange precepted clinical experiences in over50 healthcare organizations, ensuring that studentscan be assigned close to home or in their preferredpractice site. Over 200 RNs are actively participatingin the program this year. Since 1990, there have been738 graduates of these programs who have re-enteredthe North Carolina nursing workforce.

Efficiency and EffectivenessUNC System colleges of nursing have consistently

recorded very high graduation rates. Individualsadmitted to these programs typically are selected aftercompletion of the first two years of undergraduatecollege coursework, hence these nursing schools havethe advantage of considerable certainty that an applicant can complete, and already has completed,college-level coursework related to the highly technicalfield of nursing.

The schools of nursing at UNC-Chapel Hill,Winston-Salem State University and Duke Universityhave begun to offer “Accelerated BSN” optionsthrough which they admit individuals who havealready completed a baccalaureate degree in anotherfield to a special 14-16 month intensive programthrough which these individuals acquire a BSNdegree and become eligible to sit for the NCLEX-RNexamination. These programs are highly efficient, useexisting resources and faculty, are able to attract ahighly diverse group of applicants with regard to both

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Figure 3.2.Distribution of On- and Off-Campus BSN Degree Programs at Public and Private Institutions andin Partnership with the NC Area Health Education Centers Program

Prelicensure BSN and RN-to-BSN Programs

Off-Campus Nursing Degree Programs

O

O

O

OOO

O OOO

O

O O

O

O

O

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gender and racial/ethnic characteristics, and they attractindividuals with impressive academic capabilities intoprofessional nursing. The Task Force views these pro-grams as the most effective and most rapid means ofincreasing the number of nurses at the present time.

In order to stimulate the more effective use of clinicalfacilities for nursing training in the state, the NC AHECProgram, following a legislative mandate, has collaborat-ed with the North Carolina community colleges andUNC System schools of nursing to develop a program tofund innovative efforts in clinical site development. Thiseffort gives emphasis to high-need specialty areas ofnursing (e.g., mental health and geriatrics) and rural andunderserved areas. Grants for two or three years aremade to schools of nursing for this purpose. Throughthese grants, over 250 additional clinical training siteshave been identified and developed for nursing educationin North Carolina, and 52 new sites are currently underdevelopment with AHEC grant support.

QualityAn overall average of 89% (2000: 87%; 2001: 91%;

2002: 91%; 2003: 87%) of the graduates of NorthCarolina’s BSN programs in public universities whosat for the NCLEX-RN exam in 2003 passed the exam.Of the 9 public prelicensure BSN programs, only onefailed to achieve the minimal 75% pass rate on theNCLEX-RN exam in 2003. All of the public universitynursing education programs in the UNC System arenationally accredited, indicating that they meet quality standards of the nursing profession. The UNCBoard of Governors has established an 85% NCLEX-RN pass rate as the standard for UNC nursing programs and if programs fail to meet this standardtwo years in a row the programs will be reviewed.

Baccalaureate Degree Programs offered throughPrivate Colleges and Universities

Independent higher education in North Carolinatraces its roots to the late 1700’s when the oldest institution in the state opened its doors. Private collegesand universities also had been driven throughouttheir history in North Carolina by a sense of responsi-bility to respond to the needs of the public from theearliest days of teacher education to today’s computertechnology programs. Nursing education has been amajor part of the curriculum in private colleges anduniversities throughout their history.

CapacitySeven of the 37 private colleges and universities in

North Carolina offer nursing education programs.Three of these institutions offer prelicensure BSNprograms and six of them offer BSN completion programs. The private BSN programs contributed8.8% of the total prelicensure BSN graduates (60 out of 682), and 14.8% of the RN-to-BSN graduates(45 out of 305) in 2003. Duke University, QueensUniversity and Gardner-Webb University offer MSNdegrees and estimate that they produce about a thirdof all MSN graduates in the state each year.13 Two pri-vate institutions (Cabarrus College of Health Sciencesand Gardner-Webb University) offer the Associate inScience Degree (ADN) in nursing.

Program expansions in the private institutions aremanaged differently in different schools. For the mostpart, private colleges and universities are enrollmentdriven, and new faculty hires are tied to an increase inenrolled students; and sometimes to the overall finan-cial health of the college. All of the private collegesand universities offering the BSN degree couldincrease or have increased their capacities. However,their difficulties in expanding are similar to those ofcommunity college nursing programs. First, enroll-ment is increased while faculty take on an even biggerworkload with the hope of increasing faculty in thenext year. All of these private nursing education pro-grams face serious difficulty in providing scholarshipsupport for students, which is another factor to beconsidered when increasing enrollment.

The level of faculty preparation varies by the type ofinstitution, with faculty with doctorates ranging from70% of the total faculty in a private academic healthcenter, to 25% in one liberal arts college. The privatecolleges and universities face the same issues regardingfaculty recruitment as does our public UNC system.Faculty salaries often lag behind the salaries of those inservice, and the national faculty shortage has resultedin recruitment difficulties as well as “faculty raids” byother colleges and universities. Faculty salaries in smallprivate colleges are less than those in the public UNCsystem. As is true in the community colleges and UNC System schools of nursing, the use of part-timeadjunct faculty to teach students clinically is common;however, it is increasingly difficult to hire such facultybecause practice salaries greatly exceed faculty salaries.

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AccessThe private colleges of nursing exist in widely dis-

persed regions of the state, and while they do recruitnationally, over three-fourths of their students areNorth Carolinians. The private colleges and universi-ties have also extended their geographic reach throughdistance education programs. These programs havehad a marked impact on increasing the number offamily nurse practitioners in health professional short-age areas and in educating nurse educators for ruralcommunity colleges and hospitals.

Tuition at private institutions can be more expen-sive than at one of the UNC System campuses.Although tuition costs vary, the average cost of tuitionand fees at North Carolina’s private colleges is about11% below the national average for private colleges and universities. North Carolina residents in privatecolleges and universities are usually eligible for tuitionsupport of $1,800 (in 2003) from the state of NorthCarolina. This tuition support, however, is not availablefor students enrolling in second degree acceleratedBSN programs, or for students enrolling in master’sprograms. Extending this benefit to these NorthCarolinians would help improve the number and diver-sity of new nurses, and the education level of our nurs-ing workforce. Nearly all students enrolled in privatecolleges of nursing are in need of scholarship support.In addition to the tuition assistance available to NorthCarolina residents attending these programs, philan-thropic dollars from North Carolina Foundations areneeded to provide this scholarship support and buildcapacity in nursing programs in our private collegesand universities.

Nineteen of the private colleges and universities inNorth Carolina (seven of these institutions havingnursing education programs) have voluntarily partic-ipated in the comprehensive articulation programdeveloped originally between the Community CollegeSystem and the UNC System.

Efficiency and EffectivenessGraduation rates for nursing students in the state’s

private colleges average around 60%.14 The pass rateson the NCLEX-RN examination for graduates average88% in 2003. What is less well known, but criticallyimportant to the numbers of nurses in North Carolinais whether or not most graduates are North Carolinians,and whether or not most stay in North Carolina.Generally, 75% to 95% of nursing students in private

institutions are North Carolinians, and 85% to 92%stay and practice in North Carolina. More than 75% ofMSN graduates stay and practice in North Carolina.Increasing capacity in the private sector would posi-tively impact the current and projected shortage ofnurses in North Carolina.

QualityThe nursing programs offered by North Carolina’s

private colleges and universities are all nationallyaccredited, with all faculty holding advanced degreesin nursing.

Nursing Education Offered ThroughHospital-Based Nursing EducationPrograms

CapacityHospital-based nursing education programs,

although far less common than they were two or threedecades ago, continue to exist in some of the state’slarger hospitals. While it is generally presumed thatthe graduates of these programs predominantly workfor the hospitals where they received their nursingeducation, the Task Force was unable to obtain reliabledata by which to verify this assumption. It is known,however, that graduates of these programs migrateboth within North Carolina and to other states. Thereare actually five hospital-based nursing education pro-grams in the state, but two of these (Carolinas Collegeof Health Sciences and Cabarrus College of HealthSciences) award associate degrees in nursing, so arenot counted as “diploma” programs. Cabarrus Collegeof Health Sciences also awards the BSN through aBSN-completion program. These hospital-based pro-grams do not receive state funds for their institutionalsupport, but they do benefit from the allocation of fed-eral funds for Graduate Medical Education (GME)received by their host institutions through theMedicare program. These funds generally account foronly one-third of the overall budget of these programs,with the remainder coming from a combination oftuition payments, foundation support and other typesof fundraising. Though these funds are of criticalimportance to those hospital-based education programsreceiving them, they are not sufficient to serve as anexclusive source of program support.

AccessStudents in these programs, with the exception of

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those enrolled in the Carolinas College of HealthSciences, are eligible to receive tuition assistance sup-port from the State of North Carolina available for in-state residents attending a private college or university.Because the Carolinas College of Health Sciences isaffiliated with a public hospital system which operatesas a “hospital authority,” it is considered a “public”nursing school, and therefore its students are not eli-gible for tuition assistance through the state programfor North Carolina residents attending private highereducation institutions in North Carolina.

Efficiency and EffectivenessHospital-based nursing education programs use

77% of their NC BON-approved slots. Because of theexpense of operating such programs, and the uncer-tainties of the hospital industry generally, the programat Presbyterian Hospital Medical Center will mergewith the program at Queens University in Charlotte in2004.

The ADN program offered through the CarolinasCollege of Health Sciences was the largest ADN program in the state last year, when measured interms of the number of first-time takers of theNCLEX-RN examination. This program is even largerthan most four-year BSN programs in the state (with208 students enrolled in the fall of 2003, only twoother ADN programs in the state have more studentsenrolled). Nurses who graduate from these hospital-based programs, contrary to expectation, do not stayin North Carolina in any greater proportion than dograduates of other nursing education programs. Infact, the percentages of graduates of these programswho eventually practice in North Carolina is slightlyless than for ADN and BSN programs, although it isdifficult to obtain data that groups information forCarolinas College of Health Sciences and CabarrusCollege of Health Sciences with data from other hospital-based programs.15 The five hospital-basedprograms educated 260 (9%) of the 2882 newlylicensed by exam RNs in North Carolina in 2003.

QualityThese hospital-based programs are all nationally

accredited and have high pass rates (an average of91.3%) on the NCLEX-RN examination. When the twohospital-based programs are grouped with the threediploma programs, the five-year average NCLEX-RNpass rate is 89.5%.

A Focus on the Licensed PracticalNurse (LPN) WorkforceThe LPN Role Defined

The role of the LPN, as defined by the NC NursingPractice Act, is a dependent role in that a legallyauthorized RN, physician or other person defined bythe Nurse Practice Act must provide supervision forthe LPN. The primary role for the entry-level LPN isto provide nursing care in structured healthcare set-tings for individual clients who are experiencing com-mon, well-defined health problems with predictableoutcomes under the direction and supervision of anRN, MD or other person authorized in law. The actualduties assigned to an LPN, even within the legallyspecified scope of practice, may vary depending on thespecific clinical situation, the supervisory relationshipbetween RN and LPN staff, the complexity of the nurs-ing task, the stability of the patient/client’s clinicalcondition, and other factors having to do with theavailability of other personnel and resources in a givenclinical care setting. LPNs fill a critical need in somehealthcare settings, especially in long-term care.

With specific regard to Practical Nurse Education(PNE) programs in North Carolina, the followingobservations and findings are presented:

CapacityThirty-two of the 33 North Carolina PN education

programs are a part of the NC Community CollegeSystem. The one exception is the Department of theArmy program. Two new PN programs are presentlyunder development by private entities. There are1,144 slots for PNE students as of October 1, 2003 inthe approved PNE programs. Of these, 924 (80.7%)slots were filled. Six-hundred and thirty-six PNE stu-dents graduated in the past academic year. Adequatefaculty, resources, and clinical sites are the reasons forunfilled slots. As previously discussed with regard toADN education programs, program and facultyexpansions are funded in the same “retrospective”

manner. Many PNE programs have higher facultyturnover rates than the ADN programs as faculty areinternally promoted to fill ADN program vacancies.

Students applying to PN programs come from verydiverse backgrounds. Many enter with GED back-grounds having never had academic success at a highereducation level. They bring economic, family and lifeissues with them that often need resolving or remainunresolved during their education tenure. Adequate

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student support services are a key factor in the attrition,success or failure of these students.

Seven of the ADN nursing education programsallow for an LPN “exit point” after one year. In theseprograms, coursework in the initial year of the ADNcurriculum has been determined to be equivalent tothe requirements of the one-year LPN curriculum,and has been accepted by the NC Board of Nursing aseligibility to take the NCLEX-PN examination.Persons who opt for the PN-Exit Point do not receivea “diploma” signifying graduation from the PNE program, as do other graduates; however, they are eligible to sit for the NCLEX-PN examination andobtain licensure as an LPN upon passing the exam.Only a small number of ADN students take this existpoint option; the majority continue in the ADN pro-gram and enter the nursing workforce as RNs.

AccessNorth Carolina has a higher number of LPNs-per-

10,000 population than the national average (21.8LPNs/10,000 population vs. 15.1/10,000), and an evenhigher ratio of LPNs-per-population in its more ruralcounties. The demand for educating LPNs comesfrom certain sectors of the North Carolina healthcareindustry, such as public hospitals and long-term care.With the existing PN programs, most North Carolinacitizens can access a PN education program within a100 mile commute from their home making PN education extremely accessible without the utilizationof advanced educational technology. The graduatesreceive a diploma and are eligible to take the NCLEX-PN licensure examination. Practice and licensureissues are regulated by the NC BON.

Effectiveness and EfficiencyPNE programs are offered by post-secondary edu-

cational institutions, primarily the NC CommunityCollege System. The curriculum includes classroomand clinical experiences on caring for patients acrossthe lifespan in hospital, long-term care, and commu-nity settings. Upon graduation, the student receives adiploma and is eligible to take the NCLEX-PN andapply for licensure as an LPN. Graduates of PNE programs in North Carolina have relatively high passrates on the NCLEX-PN examination (average of94.5% in 2003). Attrition rates from these one-yearprograms vary from 10%-80%, with an average of34%. In 2003, only 5 PNE programs produced more

than 30 first-time examinees for the NCLEX-RNexam, while 17 produced 20 or fewer first-time examinees.

For adults, with or without family commitments,wishing to enter the nursing workforce, the PNE program is an efficient way of doing so. It assuresaccess into the nursing profession for nontraditional,high school and adult students who do not have morethan 12 months to invest in educational pursuitsbecause they must support a family. LPNs have limitedopportunity with regard to career ladders and educa-tional programs that allow them to advance theirnursing careers. Considering the need for nurses atthe bedside, program length and accessibility, the PNeducation may be one of the more cost-effective waysto increase direct care nursing workforce numbers.

QualityNone of the PNE programs in the state are accred-

ited, although accreditation is available for PracticalNurse Education through the National League forNursing Accrediting Commission. The reason for lackof accreditation status does not necessarily reflect apoor quality of educational programs in the state, butthe lack of financing to hire properly credentialed faculty, develop the support structure and pay theaccreditation fees. NCLEX-PN pass rates for thosePNE programs operated by the Community CollegeSystem average 97.6% (for 2003), but, by themselves,these rates do not measure or provide informationregarding the quality of the programs in the state.NCLEX-PN rates only reflect the extent to which graduates of these programs meet the minimum standards for licensure. Presently NC BON approval isthe only measure of quality outside the review ofNCLEX-PN pass rates.

An average of 49% of full-time community collegefaculty in PNE programs have master’s degrees orabove.

A Focus on the Nursing Assistant (NA-I AND NA-II) Workforce

Based on 2002 data, there are 507 training andcompetency evaluation programs for nursing assistantsin North Carolina. Two-hundred and six of these pro-grams are offered through the Community CollegeSystem; 177 are offered through public high schools.There were 21,885 new, first-time examinees or prac-ticing nursing assistants who renewed their listing in

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2002. While many of the graduates of these programsnever work as nurse aides in North Carolina (somecomplete their training in order to establish eligibilityfor ADN programs in nursing and other fields, or forBSN students to work as nursing assistants while students in BSN programs), nurse assistants representan important part of the overall healthcare workforcein our state. There is tremendous instability andvolatility in this component of the North Carolinahealthcare workforce. Long-term care is particularlydependent on the stream of graduates from thesetraining programs and has experienced greater than100% annual turnover among personnel hired inthese positions.16 Detailed studies of the labor marketin these occupations within the long-term care fieldhave been completed by the Division of FacilityServices of the NC Department of Health and HumanServices (NC DHHS).17 Those analyses indicated aneed for additional direct care workers between 1998and 2008 of 30,850, which puts North Carolina amongthe top ten states with regard to workforce needs for

this level of worker to serve its healthcare industry.The NC Institute of Medicine also published a specialissue of the North Carolina Medical Journal in 2002on the “Critical Shortage of Direct Care Workers inLong-Term Care.”18 There is a need for similar analyseswithin the hospital industry.

The Task Force did not adequately address theseissues and has not offered many recommendations inthis regard. The NC Institute of Medicine convened astatewide task force on long-term care in 2000, whichrendered its report in March of 2001. The report ofthat task force19 discussed the labor market for nurseaides in that industry and offered systematic recom-mendations in that regard. For the most part, thoughconcrete steps have been taken to address these issues by NC DHHS, private foundations, and thetrade associations for home health, assisted living, andnursing facilities, this remains one of the major issuesrelated to the healthcare workforce in our state.

The NC Department of Health and Human Servicesis working with the UNC Institute on Aging on a

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Table 3.7.Numbers and Sponsorship of Nursing Assistant Programs in NC, 2003

Nursing Program UNC System Independent NC HospitalProgram Characteristics Programs Colleges & Community Based TotalsType Universities College System Programs

Nurse Aide Programs: Not Applicable Not Applicable 206 Not Applicable 507Enrolled: 16,668Graduates: 21,885

Nurse Aide Training and Competency Evaluation Graduates and Programs (based on 2002 data)

Setting NAI NAII CEP* NAI/II Total Total Programs

Cont. Educ. Cont. Educ. Cont. Educ. Curriculum Enrolled Listed

Community College 12,394 1,762 1,652 860 16,668 12,902 206High School 2,287 177Home Care 67 2Hospital 85 5Mental Health Hospitals† 95 4Nursing School 2,537 97Proprietary 3,540 16Unknown 372Total 21,885 507* Competency Evaluation Program† Four state-supported

Source: NC Department of Health and Human Services, Division of Facility Services

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“Win-A-Step-Up” project designed to provide continuingeducation to nurse aides working in long term care inareas identified by nurse aides and their supervisorsfor additional skill development. This project involvescommitments from nursing facilities to teach thesecourses to a selected number of employed nurse aides,and from nurse aides to commit to remainingemployed at the facility for nine month after the completion of the first educational module. The aidesreceive a stipend for successful completion of eacheducational module. Payment is made at the end ofeach successfully completed module. Facilities areencouraged and can receive an incentive payment ifthey give aides who remain employed after the pro-gram’s completion either a raise in hourly wage or aretention bonus in addition to the course completionbonuses. This is described more fully in Chapter 4.

RecommendationsAfter reviewing all of the nursing education issues

and problems discussed throughout this chapter, theTask Force came to the conclusion that three goalswere of paramount importance if our state is to avoidserous nursing workforce shortages and achieve thehighest possible quality of nursing care in the future.These are:

� North Carolina must increase the number of nursesin every category (LPN, ADN, BSN, Diploma, MSNand PhD), expanding those education programswhich have demonstrated acceptable levels of quality, accessibility, effectiveness and efficiency;

� North Carolina must find ways of enabling thosenurses in practice to pursue advanced education,no matter what portal to nursing practice mayhave been their entry level; and

� North Carolina must increase the overall level ofeducation of the entire nursing workforce.

Through this approach, the Task Force is recog-nizing the importance of each of several pathways tonursing practice. Each of the pathways to RN licen-sure should remain viable, efficient, and offer highquality nursing education. Educational opportunitiesshould be available throughout one’s career and eachshould open new doors for those who choose them. Bystrengthening each of these pathways, while greatlyexpanding opportunities for pursuing education athigher levels, the overall educational level of North

Carolina nursing can increase, while giving a varietyof nursing career options to a broad spectrum ofNorth Carolina citizens. Through this broad strategy,it is envisioned that over the next 10-15 years it is possible that the current ratio of 60% ADN/Diplomato 40% BSN could become 40% ADN/Diploma to 60%BSN, particularly if North Carolina is able to expandprelicensure BSN, RN-to-BSN, and accelerated BSNprograms beyond their current capacities.

It is the conclusion of the Task Force that if NorthCarolina is to meet the challenges of any projectedshortfall in the supply of qualified nursing personnel in the years ahead, we need high quality, accessible,effective and efficient nursing education programs.Moreover, the number of graduates of each of theseprograms who successfully complete both their educa-tional programs and the relevant licensing examinationmust increase substantially. Furthermore, the numberof qualified faculty must increase substantially toenable program expansion. If new resources are to beinvested toward these ends, it is important to deter-mine where best to make those investments. In makingsuch recommendations, it is also important to deter-mine not only where we are likely to produce thegreatest number of additional graduates, but where weare likely to gain new entry-level nursing practitionerswho are best prepared to meet the challenges of NorthCarolina’s changing population and the technologicaldemands of patient care in the years ahead.

The recommendations offered in this section of thereport are ones for which the strong support andencouragement of the state’s healthcare industry(especially the employers of nursing personnel) arecrucial. Moreover, federal, state and private healthcareinsurers (third party payers) must recognize the needfor the inclusion of higher costs for nursing care inthe reimbursable cost of healthcare services generally.

Establishing a Goal for the Number ofNew Nurses Entering the Profession

Based on US Bureau of Labor Statistics estimatesof need, the Task Force anticipated that NorthCarolina may need to increase RN production by atleast 50% from 2003 production levels by 2010 (See Table 2.6). Changes in RN production can beaccomplished through increased enrollment,decreased attrition or some combination thereof.Unfortunately, the need for new nurses is a “movingtarget,” as it is affected by in-migration of nurses from

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other states, retention of existing nurses in the work-force, and changes in demands for nurses. The actualnumber of nurses is likely to change over the next tenyears as a result of these factors. Therefore, the TaskForce set more modest immediate goals to expand theproduction of new nurses, along with a method tocontinue monitoring need and production. The TaskForce recommends that:

3.1 NC Nursing Programs increase the productionof prelicensure RN and LPN nurses.

a. Production of prelicensure RNs should beincreased by 25% from the 2002-03 graduation levels by 2007-08. This is astatewide productivity goal, not necessarilya goal for individual nursing educationprograms.

b. The NC Community College System,University of North Carolina System, privatecolleges and universities, and hospital-based programs affected by these goalsshould develop a plan for how they willmeet this increased production need. Arepresentative of each system or associationshould jointly convene a planning groupto address these issues. The plan shouldbe reported to the NC General Assembly inthe 2005 session. Each year thereafter,the nursing education programs shouldprovide a status report to the NC GeneralAssembly showing the extent to whichthey are meeting these goals; and whetherproduction needs should be modifiedbased on job availability for new graduates,changes in in-migration, retention oroverall changes in the demand for nursesin North Carolina.

c. Greater priority should be placed onincreasing production of BSN-educatednurses in order to achieve the overall TaskForce goal of developing a nursing work-force with a ratio of 60% BSN: 40%ADN/hospital diploma graduates.

Similarly, the Bureau of Labor Statistics estimatessuggest that North Carolina will need to increase PNproduction by at least 16% from 2003 production levelsby 2010 (See Table 2.7). The same factors that affectsupply and need for RNs also apply to LPNs.Therefore, the Task Force recommends that:

d. Production of prelicensure PNs should beincreased by 8% from 2002-03 graduationlevels by 2007-08. This is a statewide pro-ductivity goal, not necessarily a goal forindividual nursing education programs.

e. The NC Community College System andprivate institutions affected by this goalshould develop a plan for how they willmeet these increases. The NC CommunityCollege System should convene this plan-ning group, including representatives ofprivate institutions offering these nursingprograms, and a plan should be reported tothe NC General Assembly in the 2005 session. Each year thereafter, the PNEprograms should provide a status report tothe NC General Assembly showing theextent to which they are meeting thesegoals; and whether production needsshould be modified based on job availabilityfor new graduates, changes in in-migration,retention or overall changes in demand forpractical nurses in North Carolina.

Building the Capacity of NursingEducation Programs in General

The Task Force considered the prospect of futureinvestments in nursing education programs in NorthCarolina, particularly the investment of public funds,and came to the conclusion that such investmentsshould be tied to the performance of these programsin terms of quality and productivity. The Task Forcenoted the varying number of individual nursing pro-gram graduates who sit for the licensure examinationand the rates of attrition from (or failure to complete)some programs. Based on these observations, the TaskForce recommended that funding to expand programsbe targeted to those programs with a demonstratedhistory of graduating a high percentage of enrolledstudents who pass the basic licensure examination.Accordingly, the Task Force recommends:

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3.2 The NC General Assembly, NC Board ofNursing, and other relevant educationalauthorities limit approval for (and funding tosupport) enrollment growth to those nursingeducation programs where attrition (failureto complete) rates are lower than the three-year average attrition rate for that category ofeducation program (BSN, ADN, or PNE) andthe pass rates on the NCLEX-RN or NCLEX-PN examination exceed 80%.

Although there was disagreement among the TaskForce over the value of having the NC Board ofNursing continue to review and approve slots in nursingeducation programs, the Task Force felt the NC BONshould continue to have a role in assessing capacityamong these programs. The NC Board of Nursingassesses the capacity of nursing education programsto accommodate additional students in each approvedcurriculum, based on the number of appropriate faculty and physical space to support the curricula, aswell as the availability and accessibility of appropriateclinical sites for nursing education. Accordingly, theTask Force recommends:

3.3 In order to accurately reflect nursing educa-tion program capacity, nursing educationprograms, in consultation with the NC BON,should realign the number of enrollmentslots approved for each nursing educationprogram. Nursing programs that are unableto fill their approved enrollment slots withina range of 85% to 115% (100 +/- 15%) fora period of three consecutive years shouldeliminate these slots from the total numberof approved slots by December 31, 2006.The NC BON should mandate that all nurs-ing education programs submit updatedinformation by January 2006 verifying thesupport for their approved slots after elimi-nation of those slots unfilled for three years(since December 31, 2001). These adjust-ments will be reviewed by the NC BON in2007.

Basically, the NC Board of Nursing allows schoolsof nursing to make their own decisions for either theenlargement or contraction of the size of their enteringclasses. Applications to the NC BON for approval of

additional slots are generally approved, unless theschool has experienced other performance or qualitydeficiencies, once the school demonstrates adequatefaculty and clinical site availability. Few programshave ever asked to have the number of approved slotsreduced, hence the need for realignment if approvedslots are to be used as a meaningful index of programcapacity.

Due to the importance of identifying appropriateclinical education sites for nursing education pro-grams, the Task Force was concerned that thereshould be some more focused statewide or regionaleffort to identify sites that took place in conjunctionwith the chief executive officers of major clinical carefacilities throughout the state. Accordingly, the TaskForce recommends that:

3.4 Clinical facilities (hospitals and nursinghomes, particularly), through their statewidetrade associations, and in collaboration withall nursing education programs in theirrespective geographic areas/regions, shouldundertake to foster a more transparent andequitable system for the allocation of clinicaltraining sites among nursing education programs on a sub-state regional basis.

3.5 Nursing education programs and clinicalagencies should work together to developcreative partnerships to enhance/expandnursing education programs and help ensurethe availability and accessibility of sufficientclinical sites:

a. AHEC should convene regional meetingsof nursing educational programs and clinicalagencies to develop creative educationalopportunities for clinical nursing training.

b. Nursing education programs of all types,at every level, should work together todevelop creative educational collaborationswith clinical facilities and programs thatpromote educational quality, efficiency andeffectiveness.

In many areas of the state, all regional nursing pro-grams sit at the same table with clinical care agenciesand work out clinical rotations for nursing students

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with few or no problems. It is important to emphasizethat the Task Force encourages these efforts and doesnot propose any disruption of these existing patternsof dealing with these matters.

Strengthening the Capacity of NC’sCommunity College Associate DegreeNursing Programs

The Task Force recognized the need to strengthennursing education programs within the state’sCommunity College System. The Task Force observedthat nursing education programs are not classified as“high-cost” programs within the System, despite theexpense of increasingly sophisticated healthcare tech-nology and the need for higher salary incentives toattract and retain qualified faculty for these programs.Therefore, the Task Force recommends:

3.6 The NC General Assembly should reclassifycommunity college-based nursing educationprograms (ADN and PNE) as “high-cost” programs and provide additional funds($1,543.39) per FTE student to cover actualcosts of operating these programs.

3.7 Recognizing the current retrospective way inwhich the community college programs develop and fund new initiatives, the NCGeneral Assembly should give considerationto an alternative method of funding prospective program expansions within theCommunity College System that will allowthese institutions to add students to existingprograms or add new programs where needed(and where past program performance, quality, and efficiencies meet minimum standards for expansion and approval of theNC BON) without the necessity of securing outside (private or local) funding for programinitiation.

With this additional flexibility, the community colleges may become more responsive to local need foradditional nursing personnel when the need arises.

3.8 The NC General Assembly and/or private philanthropies should invest funds to enableNC community colleges to employ studentsupport counselors specifically for nursing

students and to provide emergency funds toreduce the risk of attrition for students inADN and PNE programs.

The Task Force also supports the goal of seekingaccreditation for all community college ADN nursingprograms. The Task Force members generally believethat the process required for national accreditation aswell as the demonstration of having met the specificcriteria for being nationally accredited are worthygoals of any professional education program or institution. However, the Task Force recognizes thatcurrently the resources simply do not exist within theCommunity College System to facilitate every nursingeducation program achieving such standards. The TaskForce maintains that enabling all nursing educationprograms to acquire the resources to meet the stan-dards implied in national accreditation would be agoal of which we could all be proud, and somethingwhich we could extend to all our graduates of theseprograms. Moreover, it is presumed that the prestigeof being a faculty member in a nationally accreditedprogram could assist in faculty recruitment andretention. Therefore, the Task Force recommends:

3.9 NC should create incentives, and provide thenecessary infrastructural supports, to enableany non-accredited nursing education pro-grams operating within the NC CommunityCollege System to pursue and attain nationalaccreditation by 2015.

The Task Force was frustrated throughout muchof its deliberations by the inability to access detailedprogram data on nursing education programsoffered through the NC Community College System.It is recognized that an expanded information system is in development and should address manyof these problems in the near future. Hence, the following recommendation:

3.10 The Community College System shouldinclude in the comprehensive data and information system currently under develop-ment data on nursing student applications,admissions, retention and graduation for useby the Community College System and theNC Board of Nursing.

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Because of the extraordinary attrition rate in manycommunity college-sponsored nursing education programs, the Task Force recommends:

3.11 A consistent definition of “retention” (or“attrition”) should be developed by the NCCommunity College System and used withinall community college nursing educationprograms.

3.12 A consistent standard should be developedfor the evaluation of retention-specific datastatewide across all community college-spon-sored nursing programs. It is proposed thatretention data be analyzed and reported asthree-year averages and that all communitycollege nursing programs be expected toattain a standard retention rate for allAssociate Degree programs within the state(this standard rate to be set by theCommunity College System in consultationwith the NC Board of Nursing).

There was strong support for merit-based andcompetitive admission procedures in all nursing education programs, with the presumption that suchprocedures would help assure that the applicants whowere better-prepared for college-level academic workwould be given preference for admission and there-fore reduce what were seen as very high rates of attri-tion in these programs. However, the Task Force wasunable to locate data to support its presumed relationbetween competitive admission policies and lowerattrition (higher graduation) rates. Therefore, theTask Force recommends:

3.13 The NC General Assembly or private philan-thropies should fund the NC CommunityCollege System to undertake a systematicinstitutional evaluative study of the relation-ship between competitive, merit-basedadmission policies and graduation/attritionrates in its nursing education programs.

3.14 To reduce the likelihood of attrition fromcommunity college nursing programs due toacademic performance or ability, admissioncriteria should be coupled with “competitive,merit-based” admission procedures in all

community college-based nursing educationprograms.

Building the Capacity of North Carolina’sUniversity- and College-BasedBaccalaureate and Advanced DegreeNursing (BSN, MSN, and PhD) Programs

In its examination of nursing education programsthroughout North Carolina, the Task Force was awareof the different needs of nursing education programsbased in our state’s public and private colleges and uni-versities. Even within this set of programs, there is con-siderable diversity. Although most of these institutionsoffer the BSN degree, some do not. Ten offer the MSN,and only two currently offer the PhD in nursing. Giventhe diversity of these programs and host institutions,the needs of these programs differ as well. The followingrepresent recommended strategies for strengtheningthese collegiate programs in North Carolina.

3.15 The NC General Assembly should restoreand increase appropriations to enable UNCSystem institutions to expand enrollmentsin their prelicensure BSN programs abovecurrent levels. These funds should be ear-marked for nursing program support andfunneled to university programs through theOffice of the President of the UNC System.Funds should be allocated on the basis ofperformance standards related to graduationrates, faculty resources, and NCLEX-RNexam pass rates.

3.16 The UNC Office of the President, utilizingdata provided by the NC Board of Nursing,should examine the percentage of first-timetakers of the NCLEX-RN exam who are BSN,ADN and hospital-based school of nursinggraduates. If necessary, the UNC Office of thePresident should convene the UNC Systemdeans/directors of nursing for baccalaureateand higher degree programs to plan forincreases in funding to support enrollmentthat will assure, at a minimum, a 40% orgreater ratio of BSN prelicensure graduates(in relation to ADN and hospital graduates)and, where possible, a gradual increase in theBSN ratio over the next decade. These ratioincreases should take into consideration

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increases in prelicensure BSN programenrollment, as well as ADN-to-BSN andaccelerated BSN program productivity.

3.17 Private institutions offering the BSN degreeshould be encouraged to expand their enrollments.

3.18 North Carolina residents with a baccalaureatedegree who enroll in an accelerated BSN orMSN program at a NC private college ofnursing should be eligible for state tuitionsupport equivalent to students in these insti-tutions pursuing the initial undergraduatedegree.

Increasing scholarship support is an effective strat-egy for increasing enrollment in all schools and it isparticularly important for private institutions.

3.19 The NC General Assembly and private foundations are encouraged to explore new scholarship support for students in NC’sschools of nursing.

3.20 The NC General Assembly should increasefunding to the NC AHEC to offer off-campusRN-to-BSN and MSN nursing programs usinga competitive grant approach which is avail-able to both public and private institutionsstatewide.

3.21 Nursing doctoral (PhD) programs should beexpanded.

Building an Interest in Nursing as a Career

The Task Force also recognized the need to recruitnew people into the nursing profession, especiallyamong men and racially diverse populations. Toaddress this issue, the Task Force recommends that:

3.22 Programs already in place via AHEC, the healthscience programs in community colleges, four-year universities and colleges, the NC

Center for Nursing, and employers (e.g., “CodeBlue”E), that target a diverse mix of middle andhigh school students to encourage them to consider health careers and prepare them forentry into programs of higher learning need tobe strengthened and expanded.

Specifically:a. The NC General Assembly should appropri-

ate funds to create a new grant programadministered jointly by the NC AHECProgram and the NCCN, to foster innovativeefforts in the community colleges and universities to recruit a more diverse set ofstudents into nursing education programs.Grants would be made through an applica-tion process on an annual basis to supportprograms to recruit more underrepresentedminorities and men into nursing careers.

b. Private foundations should continuefunding for innovative community-basedprograms to recruit more young peopleinto nursing and other health careers.These include programs such as “CodeBlue,” health academies, and efforts towork with faith-based groups to strengthenentry into health careers for a morediverse group of students.

c. The NC General Assembly should increasefunding to NC AHEC to add one additionalhealth careers recruitment coordinator ateach of the nine regional AHECs in orderto expand activities in middle and highschools through summer enrichment programs, weekend activities and othereducational and mentoring efforts targetedat recruiting young people into nursingand other health careers. This effortshould be developed in tandem with the“virtual advising center” being developedby the NCCN (in partnership with theCollege Foundation of North Carolina).

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E Code Blue (www.codebluecareers.com) is a Piedmont Triad health careers awareness program jointly sponsored by ForsythMedical Center/Novant Health, High Point Regional Health System, Moses Cone Health System, and Wake Forest UniversityBaptist Medical Center.

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d. The NC General Assembly should increasefunding to the NC Center for Nursing tofurther develop and distribute recruitmentmaterials aimed at racial minorities andmen with a target goal of doubling the2003 levels of minority and male RNsentering the workforce by 2010.

3.23 High school, community college and universityguidance counselors should receive additionaltraining in the requirements of NorthCarolina’s nursing educational programs.North Carolina should provide resources forcounselors designated to provide student support for nursing and allied health students.

3.24 The NC General Assembly should increasefunding to the Nurse Scholars Program toexpand the number and types of awards andamount of support given.

Specifically:a. Increase the award amount for each

bachelor’s degree category to $6,500,which is equal to the award amount forthe Teaching Fellows Program, andincrease each half-time slot from $2,500to $3,250. (Sixty-five hundred dollarswould cover approximately 47% of the$13,815F estimated cost of education foran undergraduate nursing student in apublic university in North Carolina).

b. Increase the award amount for associatedegree and hospital diploma categoriesfrom $3,000 to $5,600 per award to coverapproximately 47% of the $11,986F costof education.

c. Increase the maximum full-time awardamount for each master’s level slot from$6,000 to $6,300 to cover approximately47% of the total $13,4816 estimated annual cost of these programs, and increaseeach half-time slot from $3,000 to $3,150.

d. If items a - c above are rejected, it is recommended that all bachelor’s levelawards be made equal in value.

Presently, depending upon the specific bachelor’sfunding category, the maximum award may beeither $3,000 or $5,000. To make all of the full-timebachelor’s level awards equal would cost roughly anadditional $450,000 per year or would necessitatereducing the numbers served by approximately 100participants.

e. Funding categories of the Nurse ScholarsProgram should be expanded to includestudents enrolled at least half-time instudy leading to an RN-to-MSN degree andto recipients enrolled at least half-time instudy leading to a diploma, ADN, or BSNdegree.

f. The Nurse Scholars Program needs to beexpanded to grant support to both full- andpart-time students in nursing doctoralprograms.

The current legislation omits the funding ofawards to students who pursue RN-to-MSN programs,perhaps because such programs did not exist whenthe legislation was first written. Also, part-timeawards for undergraduates are limited to the RN-to-BSN programs (also known as “bridge programs” orBSN completion programs) only. Recently, there hasbeen significant interest from nursing school officialsand students regarding both the bridge programs andundergraduate awards for part-time school attendance.

3.25 A NC Nursing Faculty Fellows Programshould be enacted and funded as specified inHouse Bill 808 in the 2003 session of theNC General Assembly.

House Bill 808 would have provided a scholarshipin the amount of $20,000 per year for an individualwho expressed an intention to prepare for a career innursing education and chose to pursue full-time studytoward the MSN degree. Individuals selected for this

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F This educational cost data reflects the average cost of attendance at North Carolina public institutions for FY 2001-2002 asreported in a State Auditor’s Performance Report of nursing scholarship loan programs.

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program would repay their loans by teaching in anapproved North Carolina school of nursing for a periodof two years for each year of scholarship support.

Career Development for Practicing Nurses3.26 Any North Carolina resident enrolled in a North

Carolina public or private nursing educationprogram should receive a state income taxcredit to offset these educational expenses.

3.27 Hospitals and other nursing employers areencouraged to consider tuition remissionprograms to encourage their nursingemployees to pursue LPN-to-RN, RN-to-BSN,MSN or PhD degrees.

Though there is a Comprehensive ArticulationAgreement between the UNC System and theCommunity College System with the intent ofenabling students who begin their college experiencein a community college with plans to progress to afour-year campus, the Task Force identified problemsthat prevent some students from realizing theseopportunities. Hence, the Task Force proposed severalspecific steps that would greatly facilitate theseintended articulation arrangements.

3.28 The Comprehensive Articulation Agreementbetween the Community College System andthe UNC System campuses (Associate in Arts degree), and the bilateral articulationagreements for students with an Associate inApplied Science degree (AAS) in Nursing andthe UNC System, should be carefully evaluatedand improved by the Transfer AdvisoryCommittee (TAC) so that students wishing toadvance from one level of nursing education to another will experience these transitionswithout course duplication.

a. Associate Degree nursing curriculashould include non-nursing courses thatare part of the Comprehensive ArticulationAgreement (CAA) between the NC

Community College System and the UNCSystem.

b. The UNC System and IndependentColleges and Universities offering the BSNdegree should establish (and accept foradmission purposes, UNC System-wide)General Education and Nursing EducationCore Requirements for the RN-to-BSNstudents who completed their nursingeducation in a NC Community College orhospital-based program after 1999.

3.29 An RN-to-BSN statewide consortium shouldbe established to promote accessibility, cost-effectiveness and consistency for RN-to-BSN education in North Carolina.

Practical Nurse Education Programs3.30 North Carolina nursing education programs

should encourage LPN-to-ADN pathways(within community college nursing educationprograms) and LPN-to-BSN cooperativearrangements between community collegesand campuses of the UNC System to facilitatecareer advancement and to avoid unnecessaryduplication of content in these curricula.

3.31 The State Board of Education and the NCCommunity College System should promotedual enrollmentG programs for PracticalNursing Education Programs and theGeneral Assembly should appropriate fundsto support these programs enabling highschool students to advance to LPN, ADN,and BSN programs in pursuit of a nursingcareer.

3.32 All PNE programs in North Carolina shouldseek and attain national accreditation statusby 2015 with adequate funding provided bythe NC General Assembly for facultyresources, student support services and NLNaccreditation application fees.

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G Dual enrollment programs allow high school students to take college level academic, technical and advanced courses not otherwise available to them and to effect an uninterrupted education flow from the high school into the community college orfour-year college or university.

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Nursing Assistant (NA-I and NA-II)Education Programs3.33 The Nursing Workforce Task Force supports

the efforts of the NC Department of Health andHuman Services, the NC Board of Nursing, theNC Community College System, and applica-ble private and hospital-based programs tocreate “medication aide” and “geriatric aide”classifications in North Carolina.

While the overall issues concerning the nurse aideworkforce were not adequately addressed, the TaskForce does recognize several major efforts currentlyunder development in North Carolina. First, the NCDepartment of Health and Human Services and theNC Board of Nursing are leading a broad-based initiativeto develop a Medication Aide training and competencyprogram. This effort involves three stakeholder work-groups to develop standards for the following:

� Prerequisites and Training Requirements for Facultyand Students

� Statewide Competency Testing� Statewide Registry

All workgroups have been meeting for the past year.Pilot testing is expected to begin in the spring of 2004.Legislative changes will be developed for introductionin the 2005 session.

Second, the NC Department of Health and HumanServices and the NC Community College System areworking cooperatively on the development of aGeriatric Aide education program. The curriculum iscurrently under development and will be focused onmore in-depth education for nurse aides in the areasof prevention and care of pressure ulcers, unplannedweight loss/dehydration, infection control, pain management, behavioral management, residentdepression, safe mobility, care of the terminally ill andcare of the caregiver. This training program will requireNurse Aide I training as a prerequisite and will be akey component of the career ladder initiative.

In addition to these initiatives, the Department hascreated workplace initiatives and continuing educa-tion programs, which are addressed more fully inChapter 4. These North Carolina initiatives are seen ascornerstones to address the nurse aide workforcerecruitment, retention and career ladder issues.

3.34 North Carolina should develop a standardizedNurse Aide I competency evaluation pro-gram, to include a standardized exam andskills demonstration process.

The NC Department of Health and HumanServices has responsibility for the review and approvalof all Nurse Aide I training and competency evaluationprograms and Nurse Aide I competency evaluationprograms. These programs have the responsibility todevelop their own competency evaluation process,which must be approved by the Department. This cur-rent process, which is allowable by federal regulations,has led to inconsistencies in the competency evaluation of nurse aides and the level of concern byproviders that many persons completing these evalua-tions are not adequately prepared to function as nurseaides. The Task Force has concluded that to addressthese concerns, the Department should develop andadminister a standardized Nurse Aide I competencyevaluation process that includes a standardized writtenexam and a skills demonstration process.

Summary: North Carolina’sChallenges in Nursing Education

After examining the issues surrounding nursingeducation in our state, the Task Force reached severalconclusions that should guide future policy develop-ment. First, the number and variety of nursing edu-cation programs in our state is large and the diversityof these programs is difficult to comprehend withoutcareful study. The Task Force was unable to suggestways of reducing the number of such programs, andno recommendation for expanding the number ofsuch programs is proposed. Further expansion ofexisting programs should take place at all educationallevels, but only those programs with proven capabilityto utilize their faculty and other resources effectivelyand efficiently (i.e., those with high graduation/completion rates, high pass rates on the relevantNCLEX examination, and those with faculty and otherresources adequate to meet national accreditationstandards) should be encouraged and financially supported to expand.

At the same time, there were general observationsabout the nature of nursing education programs spon-sored by our collegiate institutions (both public andprivate) and by our community colleges and hospitals

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that suggested the need for both immediate andlonger-range approaches to the enhancement of boththe quality and increasing the number of nursinggraduates likely to come from these institutions.

University and college-sponsored nursing educationprograms have been severely reduced in their effectivecapacities through state governmental mandated budg-etary cuts in recent years. These funds, and the facultypositions they would support, need to be restored andenhanced in order to increase the numbers and ratio ofBSN prelicensure graduates annually. Moreover, theseinstitutions need to expand (in several formats) thenumber of programs they offer for MSN-level trainingfor those wishing to enter the field of nursing educationand advanced practice nursing roles.

Community College System-sponsored nursingeducation programs need to be enhanced throughthree specific steps: (1) reclassifying these programsas “high cost” programs within the per capita alloca-tion formulas for the Community College System’sallocations with these additional funds earmarked forfaculty salary enhancement; (2) increasing (or restor-ing previously eliminated) student support services,such as counseling and guidance programs which arenecessary for assisting the modal type of (often older)student served by these institutions in moving with all

deliberate speed through a nursing education programtoward graduation and eventual nursing practice; and(3) changing the way in which funding for nursingeducation program expansion takes place from thepresent “retrospective” system to one that can allowmore “prospective” enrollment growth and programplanning. With regard to the latter of these steps, waysshould be explored for doing this without disruptingCommunity College System-wide fiscal managementprocedures, but with the clear goal of expanding the capacity of these institutions to meet what isanticipated to be an imminent and continuing needfor additional nurses in our state.

Both our collegiate and community college pro-grams need additional sources of student financial sup-port to encourage young persons with the appropriateacademic abilities to consider and pursue career oppor-tunities in nursing. Expansion and some refinement ofthe NC Nurse Scholars Program are recommended andwould meet an important need in our state.

Guidance counselors at the high school levelshould be better informed and motivated to encouragecapable young persons to consider careers in nursingand be able to assist interested students in locating thetype of nursing education program most appropriatefor their needs, personal situations and abilities.

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REFERENCES

1 Institute of Medicine (2003). Health professions education: a bridge to quality. National Academy of Sciences. Washington,DC: Academy Press.

2 Cathcart EB (2003) Using the NCLEX-RN to argue for BSN preparation: barking up the wrong tree. Journal of ProfessionalNursing, 19, 3 (May-June):121-122.

3 Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K (2002) Nurse-staffing levels and the quality of care in hospitals.New England Journal of Medicine 346, 22:1715-1722.

4 Steinbrook R (2002) Nursing in the crossfire. New England Journal of Medicine 346, 22:1757-1766.5 Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH (2002) Hospital nurse staffing and patient mobility, nurse burnout, and

job dissatisfaction. Journal of the American Medical Association. 288, 16:1987-1993.6 Fagin CM (2001). When care becomes a burden. New York: Milbank Memorial Fund.7 Delgado C. (2002). A profile of disciplined registered nurses. Nurse Educator 27:159-161.8 Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH (2003). Educational levels of hospital nurses and surgical patient

mortality. Journal of the American Medical Association. 290, 12:1617-1632.9 Long KA (2003) Licensure matters: Better patient care requires change in regulation as well as education. Journal of

Professional Nursing, 19, 3 (May-June):123-125.10 Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH (2003). Educational levels of hospital nurses and surgical patient

mortality. Journal of the American Medical Association. 290, 12:1617-1632.11 North Carolina Center for Nursing, unpublished data from the 1995 Survey of New Graduates.12 While the appendix tables to this chapter indicate that 32% of BON-approved capacity in these programs is unused, the 2003

Survey of Schools of Nursing conducted by the NC Center for Nursing reports that only 21.5% of capacity is unused. 13 The Task Force was unable to verify this figure. 14 Attrition rates for Duke University’s program were not available at the time this report was written. 15 These data provided by Katie Delgado and Gwen Metz, March 4, 2003, unpublished manuscript prepared using data from the

NC Health Professions Data and Analysis System maintained by the Cecil G. Sheps Center for Health Services Research,University of North Carolina at Chapel Hill. Data come from the annual licensure files of the NC Board of Nursing, 1998-2001.

16 Harmuth S (2002). The direct care workforce crisis in long-term care. North Carolina Medical Journal 63, 2 (March/April):87-94.

17 Ibid.18 North Carolina Medical Journal (2002). Critical Shortage of Direct Care Workers in Long-Term Care. 63, 2 (March/April). 19 North Carolina Institute of Medicine (2002). A Long-Term Care Plan for North Carolina: Final Report. Durham, North Carolina.

March.

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Appendix 3.1 List of NC Nursing Education Programs

A p p e n d i x 3 . 1

Nursing Programs Leading to Baccalaureate DegreeA program leading to a baccalaureate degree in nursing is generally four years in length and is offered by a

college or university which provides baccalaureate and/or higher degree education. The nursing curriculumincludes classroom and clinical experiences for patients across the lifespan in hospital and community/publicsettings. The program prepares a minimally competent, independent nursing practitioner for these settings.

Graduates of approved baccalaureate programs earn a college degree and are eligible to apply to take theNCLEX-RN. An RN license is awarded upon successful “Pass” on NCLEX and satisfaction of other licensurerequirements.

Chapel Hill: University of North Carolina at Chapel HillCharlotte: Queens University of CharlotteCharlotte: University of North Carolina at CharlotteCullowhee: Western Carolina UniversityDurham: Duke UniversityDurham: North Carolina Central UniversityGreensboro: North Carolina Agricultural and Technical State UniversityGreensboro: University of North Carolina at GreensboroGreenville: East Carolina UniversityHickory: Lenoir Rhyne CollegeWilmington: University of North Carolina at WilmingtonWilson: Barton CollegeWinston-Salem: Winston-Salem State University

Nursing Programs Leading to Associate DegreeA nursing program leading to an associate degree is generally two years in length and is offered by a college

that awards associate and/or applied science degrees. The nursing curriculum includes classroom and clinicalexperiences for patients across the lifespan in hospital, long-term care, and community settings. The programprepares a minimally competent, independent nursing practitioner for these settings.

Graduates of approved associate/applied science programs earn a college degree and are eligible to apply totake the NCLEX-RN. An RN license is awarded upon successful “Pass” on NCLEX and satisfaction of other licensure requirements.

Ahoskie: Roanoke-Chowan Community CollegeAlbemarle: Stanly Community CollegeAsheboro: Randolph Community CollegeAsheville: Asheville-Buncombe Technical Community CollegeBoiling Springs: Gardner-Webb UniversityCharlotte: Carolinas College of Health SciencesCharlotte: Central Piedmont Community CollegeClinton: Sampson Community CollegeClyde: Region A Nursing ConsortiumConcord: Cabarrus College of Health SciencesDallas: Gaston CollegeDobson: Surry Community College

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Durham: DurhamTechnical Community CollegeElizabeth City: College of The AlbemarleFayetteville: Fayetteville Technical Community CollegeFlat Rock: Blue Ridge Community CollegeGoldsboro: Wayne Community CollegeGraham: Alamance Community CollegeGreenville: Pitt Community CollegeHamlet: Richmond Community CollegeHenderson: Vance-Granville Community CollegeHickory: Catawba Valley Community CollegeHudson: Caldwell Community College & Technical InstituteJacksonville: Coastal Carolina Community CollegeJamestown: Guilford Technical Community CollegeKenansville: James Sprunt Community CollegeKinston: Lenoir Community CollegeLexington: Davidson County Community CollegeLumberton: Robeson Community CollegeMorganton: Western Piedmont Community CollegeNew Bern: Craven Community CollegePinehurst: Sandhills Community CollegeRaleigh: Wake Technical Community CollegeRocky Mount: NEWH Nursing ConsortiumRoxboro: Piedmont Community CollegeSalisbury: Rowan-Cabarrus Community CollegeSanford: Central Carolina Community CollegeSmithfield: Johnston Community CollegeSpindale: Foothills Nursing ConsortiumSpruce Pine: Mayland Community CollegeStatesville: Mitchell Community CollegeWashington: Beaufort County Community CollegeWentworth: Rockingham Community CollegeWhiteville: Southeastern Community CollegeWilkesboro: Wilkes Community CollegeWilmington: Cape Fear Community CollegeWinston-Salem: Forsyth Technical Community College

Hospital-based Nursing Programs Leading to Diploma in Nursing A program leading to a diploma in nursing is generally 18-32 months in length and is offered by a hospital.

The nursing curriculum includes classroom and clinical experiences for patients across the lifespan in hospital,long term care, and community settings. The program prepares a minimally competent, independent nursingpractitioner for these settings.

Graduates of the hospital-based programs receive a diploma and are eligible to apply to take NCLEX-RN. AnRN license is awarded upon successful “Pass” on NCLEX and satisfaction of other licensure requirements.

Charlotte: Mercy School of NursingCharlotte: Presbyterian HospitalDurham: Watts School of Nursing

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Programs Enabling Practicing Nurses without Baccalaureate Degrees to Move from RN-to-BSN

Barton College Cabarrus College of Health Sciences East Carolina University Gardner Webb UniversityLees-McRae College Lenoir-Rhyne College North Carolina Agricultural and Technical State University North Carolina Central University Queens University of Charlotte Southeastern North Carolina Nursing Consortium Fayetteville State UniversityUniversity of North Carolina at PembrokeUniversity of North Carolina at Chapel Hill University of North Carolina at Charlotte University of North Carolina at Greensboro University of North Carolina at Wilmington Western Carolina UniversityWinston-Salem State University

Programs Offering the Master’s Degree in NursingDuke University (Durham) East Carolina University (Greenville)Queens University of Charlotte Gardner-Webb University (Boiling Springs)University of North Carolina at Chapel HillUniversity of North Carolina at GreensboroUniversity of North Carolina at WilmingtonUniversity of North Carolina at CharlotteWestern Carolina University (Cullowhee)Wake Forest University (CRNA) (Winston-Salem)Raleigh School of Nurse Anesthesia (in conjunction with UNC-Greensboro)

Programs Offering the Doctoral Degree (PhD) Degree in NursingEast Carolina University (Greenville)University of North Carolina at Chapel Hill

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54 C h a p t e r T h r e e

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55A p p e n d i x 3 . 2

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56 C h a p t e r T h r e e

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Conc

ord:

Cab

arru

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llege

of H

ealth

Sci

ence

s N/

A3

13

N/A

190

CCNE

1So

uthe

aste

rn N

orth

Car

olin

a Nu

rsin

g Co

nsor

tium

(F

ayet

tevil

le St

ate

Unive

rsity

and

UNC

-Pem

brok

e)N/

A3

81

N/A

112

04

TOTA

L12

520

83

16To

tal R

N-BS

N Pr

ogra

ms

846

42327 Chapter3 5/18/04 10:41 AM Page 57

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T a s k F o r c e o n t h e N o r t h C a r o l i n a N u r s i n g W o r k f o r c e R e p o r t

58 C h a p t e r T h r e e

NC B

ONLe

ngth

of

Tota

lNa

tiona

lAp

prov

edPr

ogra

mNu

mbe

r of

Num

ber

ofSt

uden

t#

Qua

lifie

dNu

rsin

gEn

rollm

ent

in S

emes

ters

Full-

Tim

ePa

rt-T

ime

Enro

llmen

tsAp

plic

ants

Accr

edi-

as o

f Jan

1Ty

pe o

f Fa

culty

Facu

ltyas

of

Not

tatio

n#

Prog

ram

Loc

atio

n/Na

me

2004

Stud

ent

Oct.

1, 2

003

Oct.

1, 2

003

Oct.

1, 2

003

Adm

itted

MSN

Pro

gram

sNL

NAC

1Bo

iling

Sprin

gs: G

ardn

er-W

ebb

Unive

rsity

Only

thos

e nu

rsin

g pr

ogra

ms

prep

arin

g pr

elice

nsur

e st

uden

ts (R

Ns o

r LPN

s)NL

NAC

1Ch

apel

Hill:

Unive

rsity

of N

orth

Car

olin

aar

e re

gulat

ed b

y th

e NC

Boa

rd o

f Nur

sing

and

are

requ

ired

to re

port

CCNE

1Ch

arlo

tte: Q

ueen

s Un

ivers

ity o

f Cha

rlotte

stud

ent a

nd fa

culty

sta

tistic

s to

the

NC B

oard

of N

ursin

g on

an

annu

al ba

sis.

CCNE

1Ch

arlo

tte: U

nive

rsity

of N

orth

Car

olin

aCC

NE1

Cullo

whe

e: W

este

rn C

arol

ina

Unive

rsity

Unre

gulat

ed n

ursin

g ed

ucat

ion

prog

ram

s ar

e no

t ass

esse

d fo

r the

ir en

rollm

ent c

apac

ity.

NLNA

C1

Durh

am: D

uke

Unive

rsity

NL

NAC

1Gr

eens

boro

,: Un

ivers

ity o

f Nor

th C

arol

ina

Thes

e pr

ogra

ms

are

liste

d he

re to

pro

vide

a co

mpl

ete

acco

untin

g of

the

num

ber

NLNA

C1

Gree

nville

: Eas

t Car

olin

a Un

ivers

ityan

d ty

pe o

f nur

sing

educ

atio

n pr

ogra

m a

vaila

ble

in N

orth

Car

olin

a at

this

time.

NLNA

C1

Wilm

ingt

on: U

nive

rsity

of N

orth

Car

olin

a9

TOTA

L Ph

D Pr

ogra

ms

1Ch

apel

Hill:

Unive

rsity

of N

orth

Car

olin

a1

Gree

nville

: Eas

t Car

olin

a Un

ivers

ity2

TOTA

L

Note

: Thi

s in

form

atio

n co

mes

from

the

NC B

oard

of N

ursi

ng A

nnua

l Rep

orts

file

d by

eac

h pr

elic

ensu

re n

ursi

ng p

rogr

am a

s of

Nov

embe

r 1 e

ach

year

.

The

num

ber o

f ful

l- an

d pa

rt-tim

e fa

culty

is b

ased

on

the

num

ber o

f bud

gete

d an

d fil

led

posi

tions

as

of O

ctob

er 1

, 200

3. If

that

dat

a w

as n

ot a

vaila

ble,

full-

time

and

part-

time

facu

lty c

ount

bas

ed o

nhi

ghes

t deg

ree

type

was

sub

stitu

ted.

42327 Chapter3 5/18/04 10:41 AM Page 58

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59A p p e n d i x 3 . 2

Num

ber

of G

radu

ates

by

Stud

ent

Attr

ition

rat

e fo

rNu

mbe

r Fi

rst-t

ime

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ss

Type

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ober

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ecen

tNC

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Writ

ers

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Rate

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of

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ram

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atio

n/Na

me

Sept

embe

r 30

, 200

3 Gr

adua

ting

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s**

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seTo

tal

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ms

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licen

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ads

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Chap

el Hi

ll: Un

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th C

arol

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hape

l Hill

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Chap

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th C

arol

ina

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hape

l Hill

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367.

7N/

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incl

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tte: Q

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ivers

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f Cha

rlotte

156

2117

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79Ch

arlo

tte: U

nive

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orth

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olin

a at

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7914

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este

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arol

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rham

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rate

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am: N

C Ce

ntra

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C Ag

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75Gr

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boro

: Uni

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f Nor

th C

arol

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reen

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o77

4312

09.

994

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95Gr

eenv

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ast C

arol

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rsity

132

3917

128

.973

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481

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ory:

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oir R

hyne

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lege

250

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.1N/

A25

88W

ilmin

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: Uni

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th C

arol

ina

at W

ilmin

gton

385

4320

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89W

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ton

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ge20

1030

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ston

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m: W

inst

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nive

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AN/

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elic

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re B

SN T

otal

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224

392

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kie: *

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omm

unity

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90

970

.0N/

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91Al

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mun

ity C

olleg

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1047

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: Ran

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lege

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hevil

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97Bo

iling

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ardn

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85Ch

arlo

tte: C

arol

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lege

of H

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: Cen

tral P

iedm

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omm

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210

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91

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T a s k F o r c e o n t h e N o r t h C a r o l i n a N u r s i n g W o r k f o r c e R e p o r t

60 C h a p t e r T h r e e

Num

ber

of G

radu

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by

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e fo

rNu

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as

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me

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ting

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2391

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61A p p e n d i x 3 . 2

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lbem

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unity

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1377

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62 C h a p t e r T h r e e

Num

ber

of G

radu

ates

Nu

mbe

r Fi

rst-

by S

tude

nt T

ype

Attr

ition

rat

e fo

rtim

e NC

LEX

NCLE

X Pa

ss

Octo

ber

1, 2

002

– m

ost r

ecen

tW

riter

s 20

03 a

s of

Rate

as

of

Prog

ram

Loc

atio

n/Na

me

Sept

embe

r 30

, 200

3Gr

adua

ting

Clas

s**

Dec.

31s

tDe

c. 3

1, 2

003

Entry

Tota

lHP

NE/L

PN P

rogr

ams

PNE

Grad

s

Kins

ton:

Len

oir C

omm

unity

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lege

99

52.6

1210

0Li

llingt

on &

Pitt

sbor

o: C

entra

l Car

olin

a Co

mm

unity

Col

lege

2222

55.6

2796

Linc

olnt

on: G

asto

n Co

llege

(Lin

coln

Cam

pus)

2727

32.5

2793

Mar

ion:

McD

owell

Tec

hnic

al Co

mm

unity

Col

lege

2020

16.7

2195

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ehea

d Ci

ty: C

arte

ret C

omm

unity

Col

lege

2020

20.0

2085

New

Ber

n: C

rave

n Co

mm

unity

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lege

1919

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Pine

hurs

t: Sa

ndhi

lls C

omm

unity

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lege

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1910

0En

tryTo

tal

PNE/

LPN

Prog

ram

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EGr

ads

Polkt

on: S

outh

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mon

t Com

mun

ity C

olleg

e5

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cky

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nt: N

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m45

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eland

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mun

ity C

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dale:

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herm

al Co

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unity

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lege

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ly: B

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wic

k Co

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unity

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lege

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0Sy

lva: S

outh

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tern

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mun

ity C

olleg

e0

0N/

A0

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: Mon

tgom

ery

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mun

ity C

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e26

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ashi

ngto

n: B

eauf

ort C

ount

y Co

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lege

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0W

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orth

: Roc

kingh

am C

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unity

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lege

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tevil

le: S

outh

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ern

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mun

ity C

olleg

e8

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.38

100

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ingt

on: C

ape

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mun

ity C

olleg

e20

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ston

-Sale

m: F

orsy

th T

echn

ical

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mun

ity C

olleg

e45

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ram

Tot

als

636

636

681

Note

: Thi

s in

form

atio

n co

mes

from

the

NC B

oard

of N

ursi

ng A

nnua

l Rep

orts

file

d by

eac

h pr

elic

ensu

re n

ursi

ng p

rogr

am a

s of

Nov

embe

r 1 e

ach

year

.

* Nu

mbe

r of g

radu

ates

repo

rted

appe

ars

smal

l bec

ause

the

prog

ram

had

just

beg

un. T

his

low

num

ber i

s an

arti

fact

for 2

003

only.

** T

he a

ttriti

on ra

te is

the

perc

ent o

f stu

dent

s th

at d

id n

ot p

rogr

ess

on ti

me

with

thei

r ent

ry c

ohor

t acc

ordi

ng to

the

curri

culu

m p

lan

for f

ull-t

ime

stud

ents

. It i

s no

t nec

essa

rily

an in

dica

tion

of th

e pe

rcen

tof

stu

dent

s w

ho h

ave

left

the

prog

ram

, but

als

o in

clud

es s

tude

nts

who

are

atte

ndin

g pa

rt-tim

e, o

r who

may

hav

e go

tten

off-p

rogr

ess

due

to a

cade

mic

wea

knes

ses.

It is

als

o im

porta

nt to

real

ize th

at th

em

ajor

ity o

f RN-

BSN

stud

ents

are

par

t-tim

e st

uden

ts a

nd s

o th

is s

trict

def

initi

on o

f attr

ition

may

giv

e a

dist

orte

d vi

ew o

f the

act

ual n

umbe

r of R

N-BS

N st

uden

ts w

ho u

ltim

atel

y co

mpl

ete

thei

r pro

gram

.

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A p p e n d i x 3 . 3

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Appendix 3.3 Recent Trends in the Capacity and Production of New Nurses by Program Type, 2002-2004

2000 2001 2002 2003 1/1/2004

PNE PROGRAMSApproved Capacity 905 934 944 1082 1102

Prelicense Graduates 454 484 522 636 N/A

Total NCLEX Passers 487 508 515 672 N/A

ADN Programs

Approved Capacity 5425 5585 5654 6090 6250

Prelicense Graduates 1522 1524 1530 1799 N/A

Total NCLEX Passers 1455 1508 1497 1740 N/A

Diploma Programs

Approved Capacity 600 600 600 615 615

Prelicense Graduates 121 119 148 135 N/A

Total NCLEX Passers 119 120 144 138 N/A

BSN Programs

Approved Capacity 2549 2549 2549 2684 2704

Prelicense Graduates 775 720 789 682 N/A

Total NCLEX Passers 749 723 766 719 N/A

Sources: Approved capacity is from the records of the North Carolina Board of Nursing. Years 2000 - 2003 report capacity at year’s end. 2004 capacity figures are as of January 1, 2004. It is important to remember that approved capacity refers tothe total number of prelicensure students enrolled in a program. Graduate numbers are from the annual school report to the NC BON, and include only prelicensure students. The time frame for counting graduates is not a calendar year—it is: October 1to September 30. The number of students passing the NCLEX contains both first-time test takers in a calendar year and thenumber of repeat takers. The number is the total number of students who passed the exam that year and were educated in that program at some point in time—not necessarily that calendar year.

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