Spotlight on the Past and Looking Forward to the Future of in North Dakota

January, 2013

Developed by the North Dakota Center for Nursing Leadership Team

North Dakota Center for Nursing Research Publication #5

Questions regarding this report can be directed to Patricia Moulton, PhD Executive Director at the ND Center for Nursing at [email protected]. This report is available on our website at www.ndcenterfornursing.org TABLE OF CONTENTS

Executive Summary and Policy Recommendations...... 3

Introduction ...... 4

North Dakota Center for Nursing ...... 6

Spotlight on the K-12 Pipeline ...... 8

Spotlight on Higher Education ...... 10

Spotlight on the Nursing Supply ...... 23

Spotlight on the Nursing Demand ...... 30

Spotlight on the Future Supply and Demand ...... 35

References ...... 38

Acknowledgements This report was prepared by the North Dakota Center for Nursing Leadership Team. A special thank you to Erin Follman for her assistance in cleaning data, to Howe Enterprises who assisted in data analysis and report preparation and to Kyle Martin who assisted with graphic layout of the report. We would also like to thank the staff at the North Dakota who tirelessly provided historical copies of reports and answered numerous questions as we prepared this report. The North Dakota Board of Nursing also provided generous funding support for the North Dakota Nursing Needs Study which provides the base for this report. We would also like to extend a special thank you to staff at Job Service North Dakota whom provided data for job openings and assisted with multiple questions regarding demand projections.

2 EXECUTIVE SUMMARY AND POLICY RECOMENDATIONS

Nationally, it is projected that over 4.0 million jobs will be generated in health care by 2018 due to an aging population and advances in medical technology (Woods, 2009). Within North Dakota, health care and social assistance is the largest industry with an estimated 55,598 workers (Job Service North Dakota, 2009). Health care facilities are economic drivers in our communities and are a vital part of North Dakota’s future growth. Ensuring that each North Dakotan has access to high quality care will be even more important as health care reform is implemented. The nursing profession is an important part of all facets of the health care system from prevention through chronic and end-of life care and from prenatal and pediatric to gerontology care. The entire health care system relies on nursing as the backbone, making a healthy supply of nurses a necessity to state policy and planning. This report highlights findings from the ten-year North Dakota Nursing Needs Study as well as initial strategic plans for the North Dakota Center for Nursing. However, the North Dakota Center for Nursing cannot solve all nursing workforce issues and solutions must come from the broader cadre of stakeholders. This report was developed by the ND Center for Nursing Leadership Team which includes 50 different organizations that are working together to provide a unified voice and to work strategically on solutions. Some key findings and strategies from this report include:

K-12 Pipeline

 There are currently many programs and activities that target students in K-12 to increase their awareness of health careers and in nursing in particular and interest in nursing careers has been sustained over a number of years. However, about 1/5 of students are undecided about their future careers. This pool of students would benefit from targeted hands-on activities including high fidelity human patient simulation and activities to bring a greater awareness of the wide scope of the nursing profession. The ND Center for Nursing is working to link targeted partners to provide these opportunities and resources to students.

Higher Education

 North Dakota has a wide cadre of established nursing programs that utilize clinical sites across many areas. However, 17 counties currently have no clinical sites. These are largely rural counties. The ND Center for Nursing is working to determine clinical placement gaps and to work with nursing programs and employers to facilitate additional clinical placements.

 Although LPN programs include about 1/5 minority students, other nursing programs have few minority or male students. Great efforts to increase diversity in nursing education programs are needed. This is also a concern with nursing faculty as there are very few male or minority nursing faculty. The ND Center for Nursing is working to collaborate with several existing grant-funded programs that are targeting increasing diversity. The ND Center for Nursing is also working on developing cultural competence training for faculty.

3  Few current students and nurses are interested in becoming faculty members. In addition, few nurses have climbed the career ladder and obtained further education. Efforts need to be increased to create seamless career ladders amongst North Dakota’s nursing education programs. The ND Center for Nursing is also working to develop faculty recruitment and mentoring programs to help increase the future faculty pool.

Nursing Supply and Demand

 While North Dakota has a good supply of RN/APRNs there is a misdistribution with some rural areas without an adequate supply of RNs. In addition, with the implementation of the Affordable Care Act it is anticipated that RNs will be utilized in greater care coordination roles and APRNs utilized to fill in areas with physicians shortages. The North Dakota Center for Nursing is working to provide a career center along with support to health care facilities to increase retention of new graduates across urban and rural settings.

 North Dakota currently has a good supply of LPNs with some maldistribution. However, projections indicate that the slow growth of LPN supply over the last several years will not be adequate for future projected demand. Efforts to increase the pool of LPNs and to retain current LPNs are needed. The North Dakota Center for Nursing is working to establish regional LPN interest groups in order to establish opportunities for education, networking and support that are currently non-existent.

4 INTRODUCTION The United States is confronting a set of contemporary health and healthcare challenges with numerous and complex elements. Multilayered health professions education and health care delivery systems face an array of demands including expectations for responsiveness in meeting current and emerging health care access and quality needs. For example, demands placed on the nation’s healthcare infrastructure include caring for culturally diverse populations with different language and health care customs and markedly increased numbers of individuals seeking care for chronic conditions (Greer, 2008; Medicare Payment Advisory Commission, 2008). An aging population also adds expectations for training and deploying the health workforce to deliver care specific to this population that is accessible, efficient and of high quality. The current health care system, while reflecting high performing components in both rural and urban areas, overall is underperforming (Cantor, Schoen, Belloff, How, and McCarthy, 2007). Deficiencies in the health care sector Redesigned health workforce result in millions of uninsured, poor care quality, education escalating costs, and inadequate value for the amount of + resources invested. Frequently cited work by McGlynn redesigned health care systems shows that only about half the time, for a set of common = conditions, Americans receive the care that evidence Improved patient outcomes indicates they should. Geographic variation in care + quality also exists. Emerging approaches to solving this improved payment set of thorny challenges, including driving performance improvement through structural changes in payment policy, have major implications for both the delivery of health care services and the preparation of the workforce providing these services (Wakefield & Moulton, 2008). Health personnel shortages can negatively impact health care quality, through reduced health care access, increased stress on providers, and the use of under-qualified personnel. Also, shortages can contribute to higher costs by raising compensation levels to attract and retain personnel and by increasing the use of overtime pay and expensive temporary personnel.

Workforce shortages, while a problem for the entire health care system, are likely to be most severe for rural/frontier regions and medically needy population groups such as the elderly. Ninety-two percent of North Dakota’s 53 counties are health professional shortage areas. North Dakota also has the highest proportion of residents aged 85 and older, the age group with the greatest need for health care services. In North Dakota, this group is predicted to double in size by 2020. Health professional shortages impact all facets of life in North Dakota.

5 Beyond public policymakers, the business community, health care providers, foundations, and others are also advancing solutions with direct and indirect implications for the health care workforce. For example, in their series of reports on quality, the Institute of Medicine (IOM) documented fundamental problems with the U.S. health system. The report Crossing the Quality Chasm, (2001) called for major changes in applying evidence, improving care quality, using technology, and preparing the health care workforce. The report cited the health care workforce as an essential element in needed health system transformation and asserted that meeting six priority national aims (safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity) requires much more of health providers. New demands on workforce education programs include ensuring the acquisition of competencies in the areas of interprofessional teamwork, quality improvement, evidence-based practice, patient-centered care, and informatics (IOM, 2003). As policymakers and others advance new performance expectations for health care delivery systems by requiring expanded public reporting of this performance and titrated associated reimbursement, the competencies the health care workforce acquires are even more important. In 2010, the Institute of Medicine released a report detailing its recommendations for the Future of Nursing. This report’s key messages included:  Nurses should practice to the full extent of their education and training.  Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.  Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States  Effective workplace planning and policy making require better data collection and an improved information infrastructure.

Each section of this report is organized along the health workforce pipeline with available data presented along with concrete strategies by the ND Center for Nursing Leadership team. The workforce pipeline indicates that ensuring an adequate health care workforce for North Dakota citizens requires creating a shared statewide agenda. There are roles for many groups to play including educators, employers, state associations and boards and state and tribal government. Given the demographic trajectory of North Dakota as well as anecdotal and quantifiable information about our health care workforce, the state clearly faces emerging challenges to ensure access to an adequate workforce. Wakefield, Amundson & Moulton, 2006

6 NORTH DAKOTA CENTER FOR NURSING

The Nursing Needs Study was recommended, in 2001, by the North Dakota State Legislature (NDCC Nurse Practices Act 43-12.1-08.2) to address potential shortages in nursing supply. Specifically, the North Dakota Board of Nursing was directed to address issues of supply and demand for nurses, including issues of recruitment, retention, and utilization of nurses. This study, initiated in 2002, was designed to obtain an accurate and complete picture of nurses in rural and urban areas of North Dakota, compare North Dakota’s trends to national trends, and inform institutional and public policy. The study has just completed its tenth year and is funded by the North Dakota Board of Nursing.

Over a number of years, the state’s nursing leadership has worked on various models of collaboration including a Nurse Leadership Council and a Nursing Education Capacity Summit Team. Nursing leadership has also attempted to erect a ND Center for Nursing through legislative bills in 2001 and in 2009. The North Dakota Center for Nursing, a non-profit organization, was officially created in 2011 to provide for a unified voice for nursing excellence. This mission of the North Dakota Center for Nursing is to guide the ongoing development of a well-prepared and diverse nursing workforce to meet the needs of the citizens of North Dakota through research, education, recruitment and retention, advocacy and public policy. The North Dakota Center for Nursing has a governing board of directors that includes representation of 11 organizations:  North Dakota Organization of Nurse Executives  College and University Nursing Education Administrators  ND Chapter of National Association of Directors of Nursing/Long Term Care  North Dakota Board of Nursing  North Dakota Area Health Education Center  North Dakota Nurse Practitioners Association  Nursing Students Association of North Dakota  North Dakota Department of Commerce Workforce Development Division  North Dakota Association of Nurse Anesthetists  North Dakota Nurses Association  Public Member

North Dakota Association of Nurse Anesthetists ANA President Karen Daley, President Wanda Rose with Congressman Rick Berg and President-elect Robert Young at 100th Anniversary Celebration

7 The ND Center for Nursing Leadership Team includes representation from the above organizations along with nursing organizations, nursing education programs, regulatory agencies, philanthropic organizations, state agencies, grant-funded projects that have a focus on statewide nursing workforce development and other interested individuals. The 50+ organizations include:  AARP  Altru Health Foundation  American Association of Nurse Practitioners Regional Representatives  American Indian Community University Partnership  Association of Perioperative Registered Nurses North Dakota State Council  Bismarck State University Nursing Program  Chapters of Sigma Theta Tau  Concordia College Department of Nursing  Critical Access Hospital Quality Network  Dakota College at Bottineau Nursing Program  Dakota Nursing Program  Dickinson State University Department of Nursing  F-M Clinical Sites/Academic Faculties Collaborative  Fort Berthold Community College Nursing Program  Jamestown College Nursing Program  Lake Region State College Nursing Program  Minot State University Nursing Program  Minnesota Nursing Informatics Group Representative  Next Steps: A Career Ladder into the Health Professions in Tribal Communities  North Dakota Association of Home Care  North Dakota Chapters of American Nephrology Nurses’ Association  North Dakota Department of Health  North Dakota Hospice Organization  North Dakota Nurses Association  North Dakota Nursing Education Consortium  North Dakota Public Health Directors of Nursing  North Dakota School Nurses Association  North Dakota State College of Science Nursing Program  North Dakota State Genetics Education  North Dakota State University Nursing Program  North Dakota University System Nursing Articulation Committee  North Dakota Workforce Development Council  Robert Wood Johnson Partners Investing in Nursing’s Future  Rural Nurse Organization North Dakota Representative  Sanford College of Nursing  Sitting Bull College Nursing Program  United Tribes Technical College Nursing Program  University of Mary Nursing Program  University of North Dakota College of Nursing  Williston State College Nursing Program

8 SPOTLIGHT ON THE K-12 PIPELINE

An important part of the future health career pipeline is K-12 students and in particular high school students who are in the midst of making decisions about college and career choice. The largest percentage of 2010 North Dakota high school students taking the ACT test indicated an interest in health sciences and allied health fields (21%). Twenty-one percent of North Dakota high school students indicated that they were undecided. Nationally, 20% of high school students indicate an interest in a health science or allied health field and 19% indicate undecided or no response. North Dakota has a significant pool of high school students that have not yet decided on their future career (or may have more than one career in mind) that may be recruited into a health care occupation. (ACT Profile Report, 2010). Over the last five years, interest in health professions has been between 16% and 21% (ACT Profile Reports 2006, 2007, 2008, 2009). 2012 Partners Investing in Nursing Summer Nurse Camp

When asked about the field of their future career plans in 2011, 28% of high schools students indicated an interest in medical/ health care and 25% in engineering or arts, design, entertainment, sports. Of those that chose health care as a field, 34% indicated plans to become a nurse, followed by an interest in becoming a physician, physical therapist or social worker (each 22%). This is similar to 2006 and 2002 in which students interested in health care were most likely to express interest in careers as a doctor, physical therapist, and nurse (Moulton et al., 2011; Hanson et al., 2006, ND Healthcare Association, 2002).

High school students were also asked whether incentive programs would influence their selection Dickinson State University nursing student of careers. Over half of both health care and non- demonstrating a pediatric simulator at a Nurse Camp. health care students agreed or strongly agreed that incentive programs would influence their career choice, especially an incentive program to work in North Dakota. Similar results were found in 2006 and in 2002 (Moulton et al., 2011; Hanson et al., 2006, ND Healthcare Association, 2002)

9 NORTH DAKOTA CENTER FOR NURSING K-12 STRATEGIES

Ensuring a healthy future supply of nurses is an important activity of the North Dakota Center for Nursing. Several partner organizations provide multiple opportunities to encourage K-12 students to pursue nursing careers. These include nursing programs at several colleges/universities that sponsor career days and nursing days. The Partners Investing in Nursing (PIN) project sponsors an annual nursing camp. The North Dakota Area Health Education Center (NDAHEC) continues to work with K-12 schools and with organizations such as Marketplace for Kids to provide health care awareness activities. North Dakota Center for Nursing strategies includes:

 Development of a list of K-12 and other workforce activities including a summary of the activity, contact information and website. This list is available on our website at www.ndcenterfornursing.org

 Following the results of a survey of ND Department of Career and Technical Education health care occupation teachers, we are working on developing linkages between high schools and nursing education programs in order to facilitate the utilization of high- fidelity patient simulators. We are also developing a list of nurses and talking points that are interested in talking to high school students about the nursing career.

 We are also in the process of surveying high school counselors and career advisors to determine needed nursing profession resources.

Minot State University Nursing Faculty and Students promoting Nursing at the Dakota Square Mall

10 SPOTLIGHT ON HIGHER EDUCATION

North Dakota’s Nursing Education Programs

North Dakota currently has eighteen nursing education programs including preparation for LPN, RN, Advanced Practice Nurses and other graduate education programs (NDBON, 2012).

North Dakota nursing education programs utilize many clinical sites in North Dakota. There is significant outreach and rural practice opportunities for nursing students in North Dakota, which supports rural recruitment and employment after students, complete their respective nursing program. However, there are currently 17 counties with no clinical sites (NDBON, 2012).

11 The North Dakota Nursing Education Consortium composed of all of the nursing education programs in North Dakota has over the last four years worked to develop greater opportunities to incorporate high-fidelity human patient simulation.

The use of simulation in the training of future nurses has several benefits including the ability to practice clinical situations in a safe environment, especially when patient census can be a constricting factor in expanding clinical practice sites in some rural areas of the state. There has been a marked increase in the use of high-fidelity human patient simulators from 25% of nursing programs to 87% in 2010. In comparison, only 55% of Florida human patient simulation centers and 66% of “Nursing programs need financial Illinois nursing programs assistance from the legislature to utilize this level of achieve full potential of nursing simulation. In addition, simulation.” most ND programs have University of North Dakota Nursing the ancillary equipment students using simulation North Dakota Nursing Education equipment. Program needed to conduct sessions including video cameras for videotaping sessions for debriefing (Moulton & Johnson, 2012).

Sanford College of Nursing Student with a pediatric simulator.

12 North Dakota’s Nursing Students

Most nursing students are below age 24 with about ¼ between 25-30 years of age (2011-2012 NDBON Nursing Education Annual Report)

2012 ND LPN Nursing Student Age 2012 ND RN Nursing Student Age Distribution Distribution

8% 6% 14% 19% 49% 53%

27% 24%

<24 25-30 31-40 >40 <24 25-30 31-40 >40

Bismarck State College Harvey LPN Student Pinning Ceremony 2012

Nursing Student Association of North Dakota Board 2012-2013

13 LPN programs have 2012 ND Nursing Student Male and Minority the greatest percentage Percentages of enrolled minority students and RN 9% programs have the Minority 9% 22% greatest percentage of male students (2011- 8% 2012 NDBON Male 12% Nursing Education 5% Annual Report)

0% 5% 10% 15% 20% 25% APRN students RN students LPN students

2009 Lifestyle Characteristics of ND Nursing Many nursing students are Students married, have children and are currently employed in a 87% Employed in Nursing Related Job 57% nursing related job. This is 55% especially the case for 72% Have children 25% APRN students (Lang & 49% Moulton, 2009). 79% Married/Committed Relationship 37% 49%

0% 20% 40% 60% 80% 100%

APRN students RN students LPN students

The number of LPN Graduates 2004-2012 LPN graduates has 300 150 varied throughout 250 the last eight years. 200 99 72 87 95 166 86 87 In 2005-2006, 150 100 95 certificate degree 100 73 78 86 86 50 LPN graduates 0 0 started to emerge (NDBON Nursing

Education Annual

2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 Reports 2004- Certificate LPN Associate LPN 2012).

14 The number of BSRN graduates has risen over the last eight years including the addition of graduates from RN Graduates 2004-2012 Associate degree 462 600 414 445 395 408 415 programs 500 406 365 starting in 400 2005-2006 300 (NDBON 200 96 99 112 100 57 90 91 86 Nursing 0 Education 0

Annual

2011-12 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 Reports 2004-05 2004-2012). Associate RN BSN RN

One of the most significant trends identified in nursing practice in North Dakota is the continuing increase in advanced practice nursing including both masters prepared and doctorate levels (NDBON Annual Nursing Education Reports 2001-2012).

15 In 2009, more LPN (78%) and RN (58%) students plan to work in North Dakota following graduation as compared to 2004. The top reasons Percentage of ND Nursing Students Planning to Work in ND included family living in North Dakota, North 100 78 Dakota is a safe place to 80 live and to raise a 65 55 58 59 family, the low cost of 60 48 living and that the 40 spouse or significant other has a job in North 20 Dakota (Lang & 0 Moulton, 2009). 2004 2009

LPN RN APRN

Most LPN students (66%) anticipate practicing in a hospital setting. The remaining LPN students plan to go into other health related fields such as long term care, ambulatory care, , and public/community health. It should be noted, while the majority of the LPN students expect to be employed in hospital settings, LPNs are utilized predominately in long term care/nursing homes or clinic settings (Lang & Moulton, 2009). Most RN students (83%) also plan to work in a hospital setting. The remaining locations of employment are long-term care/nursing homes (7%) with others as public health, clinic, and school nursing and nursing education.

Of currently licensed LPNs, 59% graduated from a North Dakota nursing education program. The greatest number of Number of Current LPNs that Attended In-state Nursing Programs graduates (30% of total population) 0 200 400 600 800 1000 1200 attended North North Dakota State College of Science 1184 Dakota State Lake Region State College 331 Williston State College College of 298 Dickinson State University 162 Science (NDBON United Tribes Technical College 105 2012 Licensure Dakota College at Bottineau 79 Database). Bismarck State College 59 Fort Berthold Community College 45 Former Hospital-based Nursing… 91 Turtle Mountain Community College 9 Sitting Bull Community College 4

16 Of currently Number of Current RNs that Attended In-state Nursing Programs licensed RNs, 64% graduated 0 200 400 600 800 1000 1200 1400 1600 from a North University of North Dakota 1585 Dakota education Former Hospital Based Programs 1268 University of Mary 1260 program. The Sanford College of Nursing/MedCenter… 703 greatest number North Dakota State University 701 attended the Minot State University 616 University of Jamestown College 580 Dickinson State University 510 North Dakota Tri-College University 276 (about 13% of Williston State College 105 total population), North Dakota State College of Science 101 followed by Lake Region State College 84 Dakota College at Bottineau 70 former Hospital- Bismarck State College 68 Based Programs Fort Berthold Community College 10 (i.e. Saint Luke’s Hospital School of Nursing, Trinity Hospital School of Nursing) which accounts for about 10% of the total population. University of Mary was the third highest accounting for about 10% of the total RN population (NDBON 2012 Licensure Database).

North Dakota’s Nursing Faculty

Despite recent increases in masters and doctoral program graduates, there has been little movement up a career ladder among the ND nursing population. Most currently licensed LPNs remained with their initial degree (95% of those with an Associate’s Degree and 77% with a Vocational Certificate). Most currently licensed RNs have also remained with their initial degree (93% with a Bachelor’s Degree and 84% with an Associate’s degree). This extends to a lack of interest in faculty positions. In 2009, 54% of LPN students, 60% of RN students and 28% of APN students indicated they have no intention of pursuing a nursing faculty role sometime in the future. The most frequent reason was that they didn’t want to obtain the additional education required (Lang & Moulton, 2009).

17 The total number Full and Part-time Faculty Trend of faculty has 350 313 varied over the 300 past seven years 250 207 193 with faculty 200 172 176 165 148 153 numbers with a 150 163 153 peak of 476 faculty 129 133 143 100 122 128 111 members in 2009- 50 2010. In recent 0 years, there has

been a noticeable

2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2004-05 drop in part- time Full-time faculty Part time faculty staff and an increase in full- time nursing faculty. (NDBON Annual Education Reports 2004-2012). (Note: faculty numbers include nurse faculty interns and assistants as reported in annual reports)

The number of faculty position openings has varied greatly over the last eight years from a low of 6 to 32 faculty Total Nursing Faculty Openings position vacancies (NDBON Annual 35 32 31 Education Reports 30 2004-2012) (Note: 25 27 Part time openings 20 were counted as .25 18 20 15 full-time opening and 15 10 openings were 10 rounded to the nearest 5 6 whole number). 0

2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12

18 There is very little diversity within the nursing faculty population with 98% Caucasian and 98% female (2011-2012 NDBON Nursing Education Annual Report)

2012 Nursing Faculty Diversity 2012 Nursing Faculty Gender

2% 2%

98% 98%

Caucasian Native American Male Female

2012 Nursing Faculty Age Distribution The greatest percentage (42%) of nursing faculty are age 51 0.40% and above. However, almost 7% 5% 1/3 are between 25 and 40 years of age (2011-2012 NDBON 24% Nursing Education Annual 36% Report). 27%

< 24 25-30 31-40 41-50 51-60 >60

Barbara Diederick, Associate Professor and Chair, North Dakota State College of Science Nursing Program

19 2008 Faculty Workload Weekly Hours by Rank Full-time faculty average 53 hours 36 All Faculty 53 each week for their 47 faculty position. Associate Professor/Professor 50 41 Part-time faculty Assistant Professor 53 35 average 36 hours Instructor 58 per week (Lang & 34 Clinical Faculty 49 Moulton, 2008).

0 20 Hours 40 60

Part-Time Full-time

Average nursing faculty salary has increased over the last four years with the greatest increase for those faculty with Professor rank (Note: Average ND Nursing Faculty Academic Year Salary All salaries are 2008 and 2012 converted to reflect $86,213 average nine-month Professor $61,034 academic year salaries) $77,439 (2012 ND Center for Associate Professor $58,881 Nursing Education Assistant Professor $60,783 Program Survey; Lang $50,863

& Moulton, 2008). Instructor $49,715 $42,575 Average 2012 nursing $0 $20,000 $40,000 $60,000 $80,000 $100,000 program administrator 2012 2008 salary varies greatly between programs. For those programs with 12-month contracted administrators the average salary is $127,607. For 9 month contracted administrators the average salary is $65,586 (2012 ND Center for Nursing Education Program Survey; Lang & Moulton, 2008).

Carla Gross, North Dakota State University Nursing Program Chair at Wharton Executive Leadership Program

20 U.S. Bureau of Labor 2011 ND Postsecondary Faculty Average Annual Statistics data (2011) Salaries comparing professions that require graduate History 62,600 education for faculty English and Literature 50,980 positions indicate that Art, Drama, Music 52,870 Criminal Justice/Law Enforcement 62,760 ND nursing faculty Nursing 66,110 salaries are less than Area, Ethnic, Cultural Studies 60,160 biological science, Atmospheric, Earth, Marine, Space 69,680 agricultural science and Biological Science 76,030 Agricultural Sciences 75,430 business faculty. Mathematical Science 52,110 Business 67,700

0 20,000 40,000 60,000 80,000

In 2008, 52% of faculty indicated they had been contacted by a recruiter with information about a faculty position at another program out of state. Faculty indicated that offers ($75,000 - $100,000) generally were significantly higher than the current salaries they were receiving. Other benefits, in addition to the higher salary, included housing allowances between $50,000 and $300,000 and full benefits including health, dental, vision and retirement (Lang & Moulton, 2008).

American Indian Community University Partnership Conference at Standing Rock Reservation and Sitting Bull College

21 NORTH DAKOTA CENTER FOR HIGHER EDUCATION STRATEGIC PLANS

Working with North Dakota’s nursing education programs is a key function of the ND Center for Nursing. All of the nursing education programs are represented on the ND Center for Nursing Leadership Team and are active members in many ongoing activities.

 We are working to help ensure continued success of the North Dakota Nursing Education Consortium which has received legislative and state-appropriated funding to provide for increased availability of high-fidelity simulation and electronic health record technology for all nursing education programs. The consortium is led by the University of North Dakota College of Nursing and Professional Disciplines.

 We are working with several grant-funded initiatives to help leverage and coordinate activities and resources related to increasing diversity. The Next Steps Program is led by Candeska Cikana Community College and funded by the federal Administration for Children and Families. This program was designed to provide support for American Indian people to attend health care career educational programs including mentoring support. The American Indian Community University Partnerships program, led by North Dakota State University is funded through a federal Administration for Children and Families grant to enhance future nursing employment options and sustainability of employment for American Indians in North Dakota.

 We are tracking the number of minority and English as Second Language students in order to determine future programmatic needs. We are also working on designing cultural competence training for faculty.

 We are in the in the process of examining the clinical placement location of in-state and out-of-state nursing students in order to determine where gaps exist and to determine future clinical placement coordination needs. Information about the location of nursing student clinical placements is also useful for the North Dakota Area Health Education Center as they continue to build inter-professional opportunities.

Minot State University Nursing Students at Graduation

22  We are designing a faculty recruitment program including a brochure and poster with talking points to distribute to nursing students and nurses in the field to encourage them to consider a faculty career. A video is also in development which will feature faculty from different nursing education programs talking about the benefits of a nursing career. Different options to provide legislative support for nursing faculty including salary differentials, faculty tax credits, and support for joint appointments are being explored. A mentoring program for new faculty will also be developed in the next few years.

 We are exploring innovative teaching techniques for increasing awareness and skills for the gerontology population and for utilizing distance education technologies.

 We are the co-lead for the North Dakota Action Coalition which is working with the Robert Wood Johnson Foundation and the Campaign for Action to implement leadership development programs for faculty/nursing researchers and students in response to the Institute of Medicine Future of Nursing report.

Jamestown College student doing a health screening at a primary school in Nha Trang, VietNam

23 SPOTLIGHT ON NURSING SUPPLY

Number and Distribution of Nurses

There are currently 12,219 RN/APRN Licensure Supply Projections RNs including 898 Advanced 18000 Practice RNs 16000 14000 (NDBON 12000 Annual Report 10000 2011-202). There 8000 has been a 6000

marked increase

1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 in the number of 1990 RNs and APRNs Projection using 22 year average net gain(246) licensed in North Projection using 10 year average net gain(383) Dakota in the last five years which Projection using 5 year average net gain(619) far exceeds increases over the last 10 or 22 years. If growth continues at the same rate, the state will have over 18,000 RNs and APRNs by 2021 (NDBON Annual Reports 1990-2011)

North Dakota School Nurse Organization exhibit at North Dakota Education Association Conference

Governor Dalrymple signing Senate Bill #2148 providing prescriptive practice privileges to APRNS.

24

LPN Licensure Supply Projections There are currently 3,694 4500 LPNs (NDBON 4000 Annual Report 2011-2012). In 3500 contrast to the RN 3000 trend, the last five 2500 years has featured

a slowing in

2012 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2014 2016 2018 2020 1990 growth of LPNs in Projection using 20 year average (34) the state as compared to 10 Projection using 10 year average (52) and 22 year Projection using 5 year average (20) averages. This will result in a statewide supply of LPNs in 2021 between 3,900- 4,200 (NDBON Annual Reports 1990-2011).

In 2012, North Dakota has 13.73 RNs per 1,000 people which is greater than the national average of 8.79/1,000 people (U.S. Bureau of Labor Statistics, 2012; U.S. Census Bureau, 2011). However, 13 counties have less than the national average which is more than the 9 counties with less than the national average in 2010 (Moulton, Johnson & Lang, 2010). It is important to note that national averages do not take into account differences in health care delivery systems in states with large rural and elderly populations like North Dakota.

25 In 2012, North Dakota has 4.61 LPNs per 1,000 people which is greater than the national average of 2.41/1,000 people (U.S. Bureau of Labor Statistics, 2012; U.S. Census Bureau, 2011). However, four counties have less than the national average which is more than the two counties with less than the national average in 2010 (Moulton, Johnson & Lang, 2010). It is important to note that national averages do not take into account differences in health care delivery systems in states with large rural and elderly populations like North Dakota.

In 2012, North Dakota has a total of 509 Nurse Practitioners as compared to 407 in 2010 (NDBON Annual Report 2011- 2012). In 2012, 10 counties have 0 Nurse Practitioners compared to 11 counties in 2010 (Moulton, Johnson & Lang, 2010). (Note. This map includes NP primary work county. Additional counties where NPs work are not reflected in this map).

26 In 2012, there are 323 Certified Registered Nurse Anesthetists as compared to 286 in 2012 (2011-2012 Board Report). Thirty-five counties currently have 0 CRNAs as compared to 32 counties in 2010 (Moulton, Johnson & Lang, 2010). (Note. This map includes CRNA primary work county. Additional counties where CRNAs work are not reflected in this map).

Nurse Demographics

Average age has Average Age 2003-2012 remained relatively constant across the 60 last eight years for 55 LPNs, RNs and 50 49 APRNs (Moulton, 50 48 48 47 46 47 47 2012, NDBON 46 45 46 45 44 Nurse Licensure 45 46 44 44 44 45 44 44 Database 2012). 40 42 42 44 Nationally, the 41 median age for RNs 35 is 46 (HRSA, 2010). 30

2003 2004 2005 2006 2007 2009 2011 2012

LPN RN APRN

27 Projecting retirement at age 60, it is estimated that 20% of current LPNs will have retired by 2013 and 50% by 2026. Projected LPN Retirement at Age 60 and 67 Projecting retirement at 100 age 67, it is 80 estimated that 60 20% of current 40 20 LPNs will have 0

retired by 2020

2011

2013 2015

and 50% by 2017

2019

2021

2023

2025

2027

2029

2031 2033

2032 (Moulton, 2035

2037

2039

2041

2043

2045

2047 2049

2012). North 2051

2053

2055 2057 Dakota Nursing Age 67 Age 60 2059 Survey results indicate that LPNs would consider delaying retirement if they were able to increase pay, have flexible scheduling and retain benefits while working part-time (Lang & Moulton, 2009)

Projecting retirement at age 60, it is estimated that 20% of current RNs will have retired by 2014 and 50% by Projected RN Retirement at Age 60 and 67 2027. Projecting 100 retirement at 80 age 67, it is 60 estimated that 40 20% of current RNs will have 20 retired by 2021 0 and 50% by

2011 2034

2013

2015

2017

2019

2021

2023

2025 2027

2029 (Moulton,

2031

2033

2035

2037

2039

2041 2043

2045 2012). North

2047

2049

2051

2053 2055 2057 Dakota Nursing Age 67 Age 60 Survey results indicate that RNs would consider delaying retirement if they were able to increase pay, have flexible scheduling and retain benefits while working part-time (Lang & Moulton, 2009)

28 Projecting retirement at age 60, it is estimated that 20% of current APRNs will have retired by 2013 and 50% by Projected APRN Retirement at Age 60 and 67 2023. Projecting 100 retirement at 80 age 67, it is 60 40 estimated 20 that 20% of 0

current

2011 2013

APNs will 2015

2017

2019

2021

2023

2025

2027 2029

have retired 2031

2033

2035

2037

2039

2041 2043

by 2020 and 2045

2047 2049 50% by 2030 2051 (Moulton, Age 67 Age 60 2012).

Percentage of Male Nurses 1998-2011 The percentage of male nurses has 10% changed very little 8% over the last 14 years 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 6% 7% 6% 6% 6% (NDBON Annual Report 1998-2012). 4% 3% 3% 3% 3% 3% Nationally, between 2% 3% 3% 3% 3% 3% 3% 3% 3% 2% 6.2% and 9.6% of 0% RNs are male

(HRSA, 2010).

2009 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2010 2011

LPN RN

North Dakota Hospice Association Members

29

LPN Diversity Distribution 1998-2011 The LPN population has 100% become slightly more 98% diverse over the last 14 96% years with increases in Native American and other 94% ethnic groups (NDBON 92% Annual Report 1998-2012). 90%

2007 1998 1999 2000 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011

White Native American Other

The RN population is less RN Diversity Distribution 1998-2011 diverse than the LPN 100% population, but has also shown a slight increase over 98% the last 14 years (NDBON 96% Annual Report 1998-2012). 94% Nationally, 83.2% of RNs are white (HRSA, 2010). 92%

90%

2001 2008 1999 2000 2002 2003 2004 2005 2006 2007 2009 2010 2011 1998 White Native American Other

ANNA Red River Nephrology Association Chapter #341 Officers: Cray Eppler, Amy Lamb, Angela McCarvel and Sandy Kantola

30 SPOTLIGHT ON NURSING DEMAND

The percentage of nurses working full-time has increased over the last 14 years (NDBON Annual Report Percentage of Nurses Working Full-time 1998-2012). 1998-2011 Nationally, 63.2% 75% 70% 71% of RNs are 67% 69% 71% 70% 66% employed full-time 65% 65% 62% (HRSA, 2010). 60% 62% 62% 62% 59% 61% 63% 62% 55% 52% 52% 53% 55% 51% 51% 50% 52% 53% 45% 49% 46% 47% 48% 47% 40%

1999 2000 1998 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 LPN RN

A greater percentage of LPNS Nurses Unemployed 1998-2011 are unemployed (NDBON 14% Annual Report 1998-2012). 12% 12% 11% 11% 10% 10% 11% This has increased in the last 10% 9% 8% six years. 8% 8% 8% 6% 6% 6% 5% 5% 7% 7% 7% 7% 6% 5% 6% 6% 4% 5% 5% 4% 4% 4% 4% 2% 0%

2005 1998 1999 2000 2001 2002 2003 2004 2006 2007 2008 2009 2010 2011

LPN RN

31 The majority of LPNs are LPN Employment Setting 1998-2011 employed in long term care, 100% hospitals, and Clinics/Physician Offices. 80% There has been a slight 60% decline in the percentage of 40% LPNs in the hospital setting 20% and an increase in other

settings over the last four 0%

2000 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 years (NDBON Annual 1998 Report 1998-2012). Hospital Long Term Care Clinics/Physician Office Other

The greatest percentage of RNs RN Employment Setting 1998-2011 work in the hospital and other 100% settings (NDBON Annual Report 80% 1998-2012). Nationally, 62.2% of 60% RNs work in hospitals and 10.5% 40% in ambulatory care (HRSA, 2010). 20%

0%

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 1998

Hospital Long Term Care Clinics/Physicians Offices Other

32 According to Job LPN and RN/APRN Wages Service North Dakota, RN/APRN wages have $70,000 $56,113 $57,600 risen slightly in the past $60,000 $53,610 $45,631 10 years. LPN wages $50,000 $40,760 $42,479 have experienced $40,000 $36,830 smaller increases $30,000 $33,865 $34,813 $27,793 $30,617 (North Dakota $20,000 $25,770 Employment $10,000 Projections Reports $- 2002-2011). 2002 2004 2006 2008 2010 2011 LPN RN/APRN

The 2010 statewide vacancy rate for LPNs was seven percent, which is a decrease from the 2007 vacancy rate of nine percent. The RN statewide vacancy rate of four percent was an increase from the 2007 rate of three percent (Johnson & Moulton, 2010). Nationally, RN vacancy rates in hospitals are about 8% (AHCA, 2008). According to economists, a full workforce in most industries exists when Statewide Vacancy Rates 2003-2010 vacancy 12% 11% 10% rates do not 7% 9% 8% 9% exceed five 7% 6% 5% to six 4% 5% 4% 5% 3% percent 2% (Prescott, 0% 2000). A 2003 2004 2005 2006 2007 2010 shortage is Year considered to LPN RN be present at a sustained vacancy rate above this level.

33 The statewide turnover rate for LPNs was 22 percent in 2010 which is lower than the statewide turnover rate Statewide Turnover Rates 2003-2010 in 2007. The 50% statewide turnover rate 40% for RNs was 31% 30% 30% 30 percent, 20% 21% which was 20% 15% 17% 22% 18% 20% 19% higher than 14% 12% previous 10% years 0% (Johnson & 2003 2004 2005 2006 2007 2010 Moulton, Year 2010). LPN RN

According to the most current Employment Projections by Job Service of North Dakota (2010- 2020 Edition) using a federal demand projection model, RNs are projected to have the 10th and LPNs have the 42nd greatest growth over the next 10 years. They also ranked for the number of projected replacement openings (openings due to retirement/death etc.) with RNs ranked at 12th and LPNs at 21st. RNs and LPNs RN/APRN and LPN Demand Historical Estimates are both and Projection characterized as 9000 “Bright Outlook” 8000 occupations based on growth 7000 openings and 6000 growth rate. Looking back 5000 before 2010, 4000 RNs experienced 3000 smaller annual increases through 2000 2006 with a one 2000 2002 2004 2006 2008 2010 2015 2020 year decline in LPN RN 2008 and more marked increases from 2010 through 2020 in demand. LPNs have experienced a smaller, but steady increase over the last twelve years.

34

Data from Jobsnd.com (2012), the state’s job posting system that pulls job postings from the majority of job postings by employers can be utilized to roughly estimate demand. There was an average of 139 jobs/month for LPNs during 2012. Eight counties averaged between 5 and 50 LPN job postings over the twelve months of 2012. Twenty counties had no job postings for LPNs. (Note: Jobsnd data includes flex time, traveling and other positions).

There was a monthly average of 441 job openings for RN/APRN jobs using Jobsnd.com data (2012). Three counties averaged over 50 job postings for RN/APRN positions over the twelve months of 2012. 12 counties averaged between 5 and 50 RN/APRN job postings. Nine counties had no job postings for RN/APRNs. (Note: Jobsnd data includes flex time, traveling and other positions).

35 SPOTLIGHT ON FUTURE SUPPLY AND DEMAND

Over the next 10 years it is projected that statewide RN/APRN supply will continue to meet demand (Moulton & Howe, 2013). The figure also includes estimates of high and low demand in order to emphasize that many factors may influence demand including population shifts, aging and economics RN/APRN Supply and Demand Projections which may 10000 not be captured in 9000 the demand projections. 8000 Factors 7000 such as implementa 6000

tion of the

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 ACA will 2010 also Supply Demand High Demand Low Demand increase demand.

As of 2010 and for the next years, it is projected that there will be a striking statewide shortage of LPNs when LPN Supply and Demand Projections compared 4500 to demand 4000 including 3500 high and low 3000 demand 2500 estimates 2000

of demand

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 (Moulton 2010 & Howe, Supply Demand High Demand Low Demand 2013).

36 NORTH DAKOTA CENTER FOR NURSING SUPPLY/DEMAND STRATEGIC PLANS

The ND Center for Nursing is engaged in a variety of activities with partnering organizations to provide for recruitment and retention of nurses.

 We are in the process of developing a career center which will be connected nationally with other state-based nursing career centers. The career center will provide a resource for nurses in-state and out-of-state to locate job openings and for employers to post job openings.

 We are examining strategies for bringing nurses back that have left the field including providing re-entry information and determining demographic profiles of nurses that have left.

 We are working with the ND Department of Commerce Workforce Development division to determine mechanisms for attracting nurses from other states.

 We are the co-lead for the North Dakota Action Coalition which is working with the Robert Wood Johnson Foundation and the Campaign for Action to implement leadership development programs for front-line nurses, community nurses and advanced practice nurses in response to the Institute of Medicine Future of Nursing report.

 We are examining the movement of nurses between different occupations and health care facilities in order to better determine nurse movement in ND.

 We are examining models for transition to practice programs that are designed to provide on-the-job mentoring and training to new graduates in order to ensure a smooth transition.

 We are developing a research study to determine the prevalence of key national nursing environment indicators in North Dakota’s hospitals.

37  We are exploring mechanisms for providing clinical scholars at the point of care with evidence-based resources in order to improve patient care quality. A research mentoring program for nurses in clinical practice will also be developed in the next few years.

 We are developing advocacy resources for all nurses and nursing organizations in order to increase engagement in the legislative process. An infrastructure for the identification of practice and policy issues has also been developed and will provide a mechanism for providing united policy platforms.

 We are developing an online resource for best practices including a mechanism for sharing evidence based practice documents across health care facilities and education institutions.

 We are working with LPNs across the state to develop regional interest groups to provide networking and support.

 We will continue to track key nursing education, supply and demand workforce indicators in order to better inform future activities and state policy.

38 REFERENCES

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Cantor, J.C., Schoen, C., Belloff, D., How, S.K.H., and McCarthy, D. (June 2007). Aiming Higher: Results from a State Scorecard on Health System Performance, New York, NY: The Commonwealth Fund Commission on a High Performance Health System. http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2007/Jun/Aiming-Higher-- Results-from-a-State-Scorecard-on-Health-System-Performance.aspx (last access 8/6/10)

Greer, A. (2008, June). Embracing accountability: Physician leadership, public reporting, and teamwork in the Wisconsin Collaborative for Healthcare Quality. Commonwealth Fund, Pub.1142. New York, NY: www.commonwealthfund.org

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HRSA (2010). The Registered Nurse Population: Initial Findings from the 2008 National Sample Survey of Registered Nurses. U.S. Department of Health and Human Service, Health Resources and Services Administration. http://bhpr.hrsa.gov/healthworkforce/rnsurvey/initialfindings2008.pdf (last access 8/9/10)

Institute of Medicine Committee on Quality of Healthcare in America. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press.http://iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality- Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf (last access 8/9/10)

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Lang, T. & Moulton, P. (2008). North Dakota Nursing Faculty Survey Results. Report to the North Dakota Board of Nursing.

39 Medicare Payment Advisory Commission. (June 2008). Report to the Congress: Reforming the delivery system. Washington, DC. http://www.medpac.gov/documents/Jun08_EntireReport.pdf (last access 8/10/10)

Moulton, P. (2012). North Dakota Nursing Needs Study: 2011 Licensed Nurse Supply Analysis. North Dakota Center for Nursing Research Publication #3.

Moulton, P. & Howe, M. (2013). North Dakota Nursing Needs Study: Direct Care Supply and Demand Projections Technical Report. North Dakota Center for Nursing Research Publication #4.

Moulton, P. & Johnson, S. (2012). North Dakota Nursing Education Consortium: Impact of Legislative Support for High-Fidelity Simulation. North Dakota Center for Nursing Research Publication #1.

Moulton, P., Johnson, S. & Amundson, M. (2011). North Dakota High School Student Survey Results. North Dakota Center for Nursing Research Publication #2.

Moulton, P., Johnson, S., & Lang, T. (2010) Snapshot of North Dakota’s health care workforce. Report developed for the UND School of Medicine and Health Sciences.

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Prescott. P. (2000). The Enigmatic Nursing Workforce. Journal of Nursing Administration. Volume 30, No. 2.

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Wakefield, M. & Moulton, P. (2008). Enhancing Health Care for Rural Populations through Interdisciplinary Training and Quality Improvement. Report submitted to The Advisory Committee on Interdisciplinary Community-Based Linkages. Division of Diversity and Interdisciplinary Education, Bureau of Health Professions, Health Resources and Services Administration.

Woods, R. (2009). Industry Output and Employment Projections to 2018. Monthly Labor Review, Nov. 52-81. http://www.bls.gov/opub/mlr/2009/11/art4full.pdf (last access 8/10/10)

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