Navy nurses attending class, 1940s. Image courtesy US Navy
Credit: US Navy, Bureau of Medicine and Surgery


A legislative committee hears about how pockets of the state struggle to recruit and retain health care workers.

By Rose Hoban

As North Carolina pursues Medicaid reform, and as the health care system continues to evolve, the largest health care profession in the state needs to change with it.

That was the upshot of a presentation given to legislators on the Joint Legislative Workforce Development System Reform Oversight Committee earlier this month.

“We’ve heard for months that we have the worst nursing shortage,” said Sen. Chad Barefoot (R-Raleigh).

But Erin Fraher, who studies health care workforce issues at the Sheps Center for Health Services Research at UNC-Chapel Hill, made it clear to legislators that North Carolina has plenty of nurses.

They’re just not all in the right places.

And Fraher also told committee members that even if North Carolina is flush with nurses, with rapid changes in the health care environment, many nurses need new skills.

Rural shortages

Nurses in North Carolina make up the largest group of health care professionals: about 129,000 registered nurses, licensed practical nurses and advanced practice nurses, like certified nurse-midwives and nurse practitioners (see box). And compared to the nation as a whole, North Carolina has more nurses per capita: 105.5 nurses for every 10,000 residents, compared to a national average of 90 per 10,000.

But those professionals are clustered in urban areas, where there are big hospital systems, leaving rural communities to scramble for talent. Fraher said metropolitan areas have 32 more nurses for every 10,000 people than rural counties.

Nurses_Guide_FinalFraher said she’s regularly asked if the state has a nursing workforce shortage: “And I say that’s the wrong question. We don’t have an overall lack of nurse supply. What we have is nurses who are not in communities where we need them, not in job settings where we need them.”

Increasingly, hospitals are putting emphasis on hiring nurses with bachelor’s degrees, BSNs, who have four years of education that includes instruction in how to conduct research and public health training.

Barefoot talked about a program that helps people transition to BSNs from community colleges, called the RIBN program. It allows for nurses to get a two-year associate’s degree at community colleges and then transfer to the state’s university system to complete a baccalaureate degree.

In 2015, North Carolina’s community college system administrators discussed whether the system should offer four-year nursing programs. They elected not to, but community colleges are now offering more programs that help nurses prepare to transfer to a university.

“We fund [the RIBN program], and apparently it’s very underutilized,” Barefoot said. “Why shouldn’t we look at beefing up that program. and possibly incentivizing RNs to go back to rural communities when they complete the RIBN program so we don’t lose them when they come to the university for a year.”

Up the ladder

Fraher said nurses want to improve their job and earning prospects by moving up the educational ladder. For example, the LPN degree is the entry point for many nurses.

“It’s one year at community college. So if I’m a certified nursing assistant who has a high school education or a medical assistant who has a high school education, often I want to go to work as an LPN, get into the nursing workforce, get a license,” Fraher said.

She said having that ladder to BSN is increasingly important, as even rural hospital systems have put more emphasis on nurses earning a bachelor’s degree. Some hospitals are moving toward only hiring BSNs; they often hire a nurse with an associate’s degree with the proviso he or she finish a bachelor’s degree in a set period of time.

BSN nurses make up about a third of the nursing workforce, and that percentage is growing rapidly. A landmark study by the U.S. Institute of Medicine said that nursing should move within the coming decade toward requiring that all nurses have a bachelor’s degree.

Chart courtesy Erin Fraher, Cecil B. Sheps Center for Health Systems Research at UNC-Chapel Hill

Luckily, Fraher said, many nurses are choosing to work in the rural counties they’re from. She’s found in her research that training nurses from rural counties to become BSNs does not keep them from returning home.

“I lecture around the country, and about 10 years ago I stood up and said, ‘This BSN thing, this is going to be a problem because nurses are going to go to the university, they’re going to stay in the big city and we’re going to lose them to the rural communities,’” Fraher said. “I was wrong.”

She said the UNC system has done a good job of getting BSN education out into rural areas.

In a cohort of associate’s degree nurses Fraher studied, those from rural counties who got BSNs were twice as likely as those from more urban counties to practice in rural areas and three times more likely to practice in the most distressed counties.

“It’s good news,” Fraher told lawmakers. “So any way that you can support continued diffusion of baccalaureate education out into rural communities is really important.”

New skills

But those nurses in rural areas who advanced their education were more likely to change jobs once they got a BSN, Fraher said.

Increasingly, the staffs at nursing homes and assisted-living and long-term care facilities are LPNs and associate’s degree nurses. But once they move up, they move on.

“[They were] much less likely to stay in home care, hospice, geriatric care,” Fraher said, areas where nurses are very much needed.

“We’re all getting older, and we’d like those nurses to be there,” she said.

Fraher also said nursing education needs to change to reflect the new emphasis on “population health” in the health care system. But nurses still tend to train in hospitals and with acutely ill patients; they don’t train as much on keeping people healthy.

For example, Fraher said she recently learned that LPNs get training in obstetrics.

“But most LPNs are working in long-term care and geriatrics, where there really isn’t that much obstetrics happening,” she said. “There needs to be a better alignment between where we know these nursing jobs are going to be in terms of the types of care they’ll be providing in the health care system itself.”

Fraher said nursing educators need to think about more community-based rotations, more mental health training, more public health training, more population health management.

“We need to redirect those resources we would have put into expanding enrollments into redesigning curricula, into finding ways to retool our existing workforce to give them the skills they need,” she said.

“The health care system is changing, right? We know it’s changing. So how do you retool the workforce to get them where they’re needed,” Fraher said after the meeting. “Just because we don’t have a nursing shortage doesn’t mean we can take our foot off the gas.”

[box style=”2″]This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina. [/box]

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Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...