Thank you for inviting me to speak today. I appreciate the opportunity to serve on the North Carolina Institute of Medicine Task Force for identifying collaborative solutions to address shortages in the nursing workforce. This is of major concern to the North Carolina Community College System.

Health programs make up one of the largest, fastest growing and most important areas of study in our community colleges.  Our colleges educate the majority of health assistants, technicians and nurses working in our state's hospitals, nursing homes, public health clinics and doctors offices.

The North Carolina Community College System is committed to meeting the workforce demands of our health care facilities. We want to continue to provide the state with a qualified workforce to meet the increasing demand for healthcare professionals. The number of learners requesting to enter our programs has increased, and where we have the resources, we have increased enrollment.

Particularly in the area of nursing, however, we are very aware that the rate of growth simply is not keeping up with demand.

Recently, members of the Joint Commission on Accreditation of Healthcare Organizations stated, "while we have had crises in availability and distribution of nurses before, this shortage is unprecedented in its complexity and future implications." I believe that it is essential that educators understand the significance of the present healthcare provider shortage.

We are working hard to expand capacity in our associate degree programs for preparing students to sit for their RN licenses. Currently, 51 of our 58 comprehensive community colleges have associate degree, programs with enrollment of approximately 5,000 students. A new program at Bladen Community College has been approved for implementation in the fall of 2004. Two more colleges, Brunswick and Carteret, have submitted letters of intent for establishing programs. Five of the Associate Degree Nursing programs either have, or will be, requesting expansion of their programs. This will increase our capacity for enrollment in the Associate Degree Nursing program by 159.

We work with baccalaureate institutions on two programs for registered nurses. A number of our community colleges work with institutions within the University of North Carolina to provide degree-completion programs for nurses (RN to BSN) who have earned associate degrees in nursing and wish to complete the BSN. While the bachelor's degree comes from the university, many of these programs are physically located on community colleges campuses. Locating these programs on our campuses increases enrollment of students, and greatly strengthens the likelihood that underserved rural areas will have graduates who will remain in that location.

We also offer a pre-major within our college transfer program for students who want to transfer into a nursing program at a University. Part of the Comprehensive Articulation Agreement with the University of North Carolina. This college transfer track averages about 700 enrollees a year; however, we find that students who are enrolled are not finishing their degrees. We are told that the program is not working, and we need a comprehensive evaluation of the Comprehensive Articulation Agreement to evaluate the program and determine why students are leaving early and where they are going.

Our practical nursing programs have also grown in recent years. Five additional programs (Nash, Edgecombe, Wilson, Halifax and Southwestern) were approved over the past 12 months, bringing the total number of colleges approved to offer Practical Nursing Education to 34. For the year 2002, we had more than 1,000 students enrolled in our Practical Nursing Education program. Two additional colleges, Guilford and Haywood, plan to seek approval for the program this year. The addition of these seven programs will provide a projected increase in enrollment of over 200 students.

The North Carolina Division of Facility Services estimates that the nation will need approximately 758,000 more aide/direct care workers before the year 2008. North Carolina alone will need approximately 31,000.

With the support of the health care industry, we have put significant effort into establishing and expanding programs for nursing assistants. Last year, the Community College System graduated more than 11,000 nursing assistants from our degree and continuing education programs. Statistics for this program over the past three years show an increase of approximately 1,000 students.

We currently have 32 nursing assistant curriculum programs. One additional college, Forsyth Technical Community College, has received approval to begin offering the curriculum program in the fall of 2003. All 58 of our campuses can offer this program under continuing education. The program under continuing education is designed so that students may complete Nurse Aide Level I and go directly to work and return later to take Nurse Aide Level II. Therefore an emerging trend is that of terminating curriculum programs and increasing enrollment under continuing education because of this flexibility. Terminations of that sort should not be interpreted as lack of support for the training. Rather, they reflect positive response to the industry's needs, which are telling us that we need to provide the essential skills quickly and flexibly.

We are also involved in early recruitment of talented young people who should consider health as a career.

A number of community colleges participated in the establishment of Allied Health Science Academies, a program at local high schools, which provides courses in the health sciences areas to high school students. These academies assist in identifying freshman students who have an interest in the health care field. These students can enroll in the academy and take courses provided by the community college in medical ethics, nursing assisting and medical terminology. The students are also provided opportunities to "shadow" a health care provider and complete civic projects that are related to health care. More than half of the System’s colleges (under the Huskins program) are administering placement tests to approximately 8,000 students still enrolled in high school to determine the student’s readiness for college level work.

In addition to these external partnerships, our community colleges also work together to meet the needs of our students and the health care industry. These efforts involve collaborative agreements between our colleges. There are over fifty health-related collaborative agreements between our colleges. These agreements assist in providing educational resources to as many students as possible by:

1. Providing classroom instruction in remote areas of the state
2. Pooling available resources to provide cost efficient training
3. Providing arrangements for joint utilization of clinical allotments; and
4. Facilitating the transfer of credits for our students

We have three consortia for nursing education: Nash-Edgecombe-Wilson-Halifax (NEWH), Cleveland-Isothermal-McDowell (Foothills) and Haywood-Southwestern-Tri-County (Region A). These were established by three to four colleges who do not have sufficient need to warrant a program in any one of the college communities. By establishing one infrastructure, we find sufficient clinicals, students, and continuous jobs. A review of the shared infrastructure costs revealed that it is costly to offer a program this way because of the tremendous amount of coordination that is required by a master’s prepared nurse and travel costs.

Colleges are working with local health care providers to assess their needs for employees and to provide educational programs to meet the identified needs. Of the North Carolina Community College System graduates, approximately 49% are employed in hospitals, 18% are employed in doctors offices, 15% are employed in nursing homes, 8% are employed in dentist offices, 3% are employed in home health, 3% are employed in rehabilitation facilities, 2% are employed in laboratories, and about 2% are employed outside of health fields.

Although the Practical Nursing and Associate Degree Nursing programs offered by the North Carolina Community College System have aggregate board passing rates higher than the national passing rates, we continue to monitor these programs and provide assistance for improvement. We find employment of our graduates to be consistently good. All who become licensed or listed on the Nurse Aide registry are employed. The small percentage of graduates, who do not pass boards after repeating, often times will take the necessary steps to become listed as aides or go into another health field. Of concern to us is the need to increase our retention rates. While nationally and statewide we find our retention rates to be similar, we would like to have an aggregate retention rate greater than 50 percent.

The System Office has partnered with other state agencies including the Department of Public Instruction and the University of North Carolina for recruitment, retention and articulation efforts to meet additional and continuing educational needs of the learners. These collaborative efforts must be maintained, and in some instances expanded.

The North Carolina Community College System will continue to develop and strengthen collaborative efforts in resource development through internal and external partnerships. To the extent possible, the System will continue to conduct feasibility studies to determine the needs of industry. We will continue to work with Area Health Education Centers, and the Sheps Center for Health Sciences at The University of North Carolina-Chapel Hill. We will continue to seek funding from outside sources such as Reynolds, The Duke Foundation and other partners on the implementation and expansion of new programs at local colleges.

The goals for the future are:

1. Collaborate with the University of North Carolina system and others to increase the number of master’s prepared nurses as instructors
2. Start new programs in underserved areas of the state; and, expand existing programs where needed or deliver existing programs by distance
3. Increase student enrollment and retention in the health sciences programs
4. Recruit and retain an increasing number of students who are representative of the diverse population of our state
5. Increase collaboration with the health care industry and agencies for development of clinical sites and clinical preceptors; and
6. Increase the offering of workforce continuing education health occupation courses for reeducation and continued certification.

A number of challenges currently exist that prevent the implementation of the System's future plans for graduating more students from health programs. There is a limited number of qualified faculty members, compounded by a lack of funding in our system to hire qualified faculty members. There is insufficient funding for current faculty members to earn required degrees and maintain certifications. Current salary levels make it easy for business and industry to recruit faculty from our System.

We have very positive experience working with hospitals and grant agencies such as the Duke Endowment for providing funds to help increase faculty/student ratio and allow for more individualized instruction. The instructors would also serve as tutors and mentors so that the graduates will be better prepared for the world of work. The ultimate goal would be to increase retention. Although we might be able to identify the funds, we are not able to find a qualified instructor.

We have a 10-20% employee turnover rate each year. A report from the American Nurses Association titled the "Aging of America: Implications for Health Workforce" addresses the impact of an aging population on various health professions. Supply and demand become a major issue as the demand increases and the supply decreases. We are seeing this in our colleges as health science educators’ "age" out. The average age of health science educators at our colleges is 48. Considering the current trend of retiring at an early age, this presents a major problem when we look at the future of our programs and availability of faculty. The addition of system-level resource support for faculty recruitment and retention activities will enable colleges to evaluate working conditions with the possibility of causing mediocrity and showcase positive programs of career benefits and long-term service.

A recurring budget issue over the past decade has been the level of faculty salaries in our colleges. Periodic data from the Southern Regional Education Board suggest that North Carolina typically ranks relatively low among the 15 participating states in the average salary of its community college faculty.

During the 1999 North Carolina General Assembly session, state lawmakers considered issues related to "the employment of community college faculty." The Faculty Salary Study was conducted in 2001 at the express request of the General Assembly. Several reports over the past few years have found faculty salaries to be unacceptably low and have recommended increases.

In the 2001-2003 strategic plan one of our primary goals is the promotion of recruitment, retention and development of high quality faculty necessary to achieve the educational training and objectives of the System. During this year, the System will develop a strategy to increase by five percent the year-to-year retention of full-time faculty. In addition to improving faculty salaries, the System is identifying strategies for aggressively recruiting highly qualified individuals for faculty positions.

There is a lack of sufficient funding for the start-up of new programs and the expansion of current programs. Health sciences programs are expensive to operate. The current funding formula does not take into account the additional costs of implementing and operating health sciences programs. The System's funding is based on the number of students enrolled, not the cost of operating the programs. Additional costs for most healthcare programs include accreditation by outside agencies, low ratio of students to instructor, use of expensive disposable health care supplies, expensive state of the art equipment, and direct supervision of learners in multiple clinical settings. There are not a sufficient number of counselors and student services personnel to provide the support needed when increasing enrollment. These personnel are essential for recruitment and retention of students.

Community colleges suffer from a limited number of equipped classrooms and laboratories, making support of increased enrollment difficult, and sometimes impossible. Colleges must often seek grants to procure the necessary equipment and faculty to start-up new programs in allied health and nursing. After initial implementation, however, the replacement of equipment is extremely difficult. One community college president was recently asked to expand his nursing program. The response was negative due to insufficient funding. The requesting entity provided the start-up funding for program expansion. Once funding was identified, the task of recruiting faculty became a challenge. Feasibility studies conducted by System Office staff have validated that more than 1800 students across the system were interested in entering one of our health programs, but not admitted due to limitations in equipped classrooms, laboratories and clinical instructors.

While we are experiencing high student interest in health programs, many of these learners lack the prerequisite skills to be successful in the program. With an average age of 35, our learners typically did not take college preparation courses in high school. Therefore, they need to extend their reading and writing skills to college level. Learners also need additional math and science instruction to prepare them for the heavy emphasis placed on these subjects in health sciences programs. These adult learners often have other responsibilities that make it difficult for them to find sufficient time for classes and study. Without adequate support services, these learners often change to less academically challenging programs, citing the difficulty of raising a family while enrolled in a rigorous degree program as their reason for the change.

The State of North Carolina is currently experiencing one of the worst revenue shortfalls in recent memory. As such, community colleges join other state agencies and institutions in reverting budgeted funds. While the North Carolina Community College System has been spared the depth of budget cuts that other agencies have received and have pledged to curtail impacts upon instruction, these actions come at a time when enrollments are at an all-time high. Our overall enrollment has increased by 14,000 additional full-time equivalent students for 2002-2003. Enrollment in nursing programs is limited by lack of qualified faculty, approval requirements, clinical rotation space availability, and college fiscal capacity. Therefore, further temporary or permanent budget reductions in health areas severely limit colleges' ability to meet student and industry demand.

Given the temporary budget reversions for 2002-03 and the prospect of permanent budget reductions for 2003-04, the picture becomes cloudier. There is no feasible way, from a budget perspective, that the North Carolina Community College System can supply additional highly educated and qualified health care professionals to the marketplace with the current funding stream. It is probable that North Carolina Community College System will be faced with enrollment caps, especially in all nursing and Allied Health programs should funding be diminished.

We would not be able to provide the quality or number of educational opportunities for our citizens if it was not for collaborative efforts with our local high schools, universities, local Area Health Education Centers, the North Carolina Board of Nursing, the North Carolina Center for Nursing. Financial support from hospitals and foundations and other state and private agencies, like those represented here today, is critical for implementing and expanding programs. There is a compelling need to continue to develop a coordinated, comprehensive and systemic resource development framework statewide to capture resources needed to provide educational opportunities. North Carolina Community Colleges must acquire additional resources to provide assistance in supporting health professional programs. With our continued efforts and commitment to meeting the needs of our citizens, we will strive to reduce the shortage of health care professionals.