LVN TO RN APPRENTICESHIP PROGRAM
Chief nurse executive Barbara Barney-Knox and deputy director of the Nursing Program Jane Robinson presented on the topic of the LVN to RN Apprenticeship Program in place at California Correctional Health Care Services (CCHCS). Barney-Knox led off by describing the well-established career tracks for employees within CCHCS, except for those employees who were licensed vocational nurses (LVNs). The LVN to RN Apprenticeship Program was developed in order to fill this gap and is a collaboration among six groups: CCHCS, the Division of Apprenticeship Standards, Service Employees International Union Local 1000, San Joaquin Delta College, the California Community Colleges Chancellor’s Office, and the Board of Registered Nurses. The program, said Robinson, offers LVNs a career ladder, a boost in salary, incentives to continue as state employees, and greater job satisfaction.
Barney-Knox underscored that it is not one of California’s 20/20 education programs, in which an employer pays an employee up to 20 hours of wages to go to school. Rather, this program not only pays the equivalent of up to 20 hours of work to attend school but also provides numerous types of support for the student, including a “success coordinator” who is available to provide academic resources, professional support, and help navigating school and work issues. It also offers other essential services that resolve issues around childcare, transportation, and other challenges to make it possible for students to participate and succeed in the program.
Robinson went on to describe the goals of the apprenticeship program within three main areas: students, community, and workforce. For students, the program seeks to prepare graduates who will be eligible for licensure to practice as registered nurses (RNs), who have a solid foundation in providing competent care, and who are able to function within legal and ethical boundaries. For communities, the program opens job opportunities to people who are traditionally overlooked for careers within the health workforce as it provides much needed clinical sites for overburdened community colleges. The third area, focusing on the workforce, helps reduce the cost of new hires by developing an RN workforce from existing employees. Reduced turnover and low vacancy rates then lead professionals to view CCHCS as an “employer of choice.” In addition to these goals, said Robinson, the program will aim to improve patient outcomes. Eighty percent of new RNs who completed the apprenticeship program have reported increased confidence in their work, and a better understanding of their role within patient care and the health care community as a whole.
With permission, Robinson and Barney-Knox shared the stories of some of the participants in the program. One such participant was Alexis
Barba, a second-generation U.S. immigrant and first-generation college graduate who has been working on her nursing prerequisites for the past 7 years. Having recently graduated from the CCHCS LVN to RN Apprenticeship Program, said Robinson, Barba’s compensation (with benefits) will double from about $6,400 per month to $12,900 per month. Upon being accepted into the program, Barba commented “I’m shaking in my skin because I’m so excited. I just saw no opportunity for doing this because of my work schedule.” She recently started preparations to begin work on her bachelor’s degree. Another of their program participants was Juanita Esquer. Esquer is a first-generation immigrant mother who shared Barba’s enthusiasm: “I’m so excited. I feel blessed to be chosen. I’ve always dreamed of getting my nursing degree while I work. This is going to be life changing because I can better provide for my family.”
The big task now, said Robinson, is to articulate the value for government agencies, employers, students, and higher education—and to mitigate any of the challenges the program encounters. For example, employers participating in the program will have to backfill LVNs as they attend school and when they become RNs. In addition, managing the apprenticeship program places additional workloads on existing administrative and executive staff. As for students’ challenges, Robinson listed English as a second language; balancing work, school, and family obligations; and dealing with the challenges of not having attended school in years. In order to move this program forward and scale it up across the state, said Robinson, there is a need to prove the value for all stakeholders involved.
Following Barney-Knox and Robinson’s presentation, Kennita Carter with the Health Resources and Services Administration asked workshop participants to brainstorm at their tables about how to “package this program for success” so that they could then share their ideas with the group.
Erin Fraher from the University of North Carolina at Chapel Hill opened the discussion by reporting that her group approached the issue in terms of return on investment (ROI)—quantifying the cost of the program and comparing it to the costs saved. The potential savings from this program, said Fraher, could include less money spent on recruiting and retaining staff, as well as money saved from fewer hospitalizations because of improved patient care. Barney-Knox responded that staff turnover is a very large expense and that, with the cost of replacing an employee somewhere between $35,000 and $58,000, savings in this area could help justify the costs of the program. Julie Pavlin, who directs the Board on Global Health at the National Academies of Sciences, Engineering, and Medicine, remarked that while helping nurses advance in their training could lead to better retention, it could also result in nurses being “snatched up by competitors in the community.”
Pavlin encouraged the speakers to collect data in order to know the real impact of the program. One workshop participant suggested that the program could result in lower recidivism rates, thus lowering costs for the state since patients would receive better mental and physical health care while incarcerated. Fraher also mentioned the possibility of measuring nurse satisfaction, and then using this measure to demonstrate the value of the program. On this point, Mary Dickow of the Organization for Associate Degree Nursing said that many students want to remain and work in their own communities. This is another potential benefit of the program, she said, if the program were viewed as a way to improve the health and sustainability of the entire community, not just the prison population.
Malcolm Cox, a former co-chair of the forum, noted that some of these cost savings will take several years to become apparent. He then asked if the current grant funding will last long enough to demonstrate the ROI. Barney-Knox responded that the initial grant period was 3 years and that the current grant period is another 5 years, so this longer timeframe should allow them to measure changes in outcomes.
In the future, said Barney-Knox, CCHCS is hoping students will be placed in practicum sites at the correctional facilities; however, based on laws, regulations, and Board of Nursing requirements, it has not yet been possible. She added that one of the overarching goals of the program is to have CCHCS viewed as a viable health care organization, noting that the prison population mimics the demographics and health status of other communities. Barney-Knox closed her presentation saying: “By partnering with the community colleges, we can start to build a pipeline for future hires through clinical rotations that come through our prison system.”
PATIENT-CENTERED CARE IN PUBLIC HOUSING
The Pine Ridge Family Health Center is a unique health care system where the primary care center is owned and operated by a public housing authority, said Shirley Dinkel of Washburn University in Topeka, Kansas. The health center offers primary and urgent care services, has a nurse practitioner-led health care center, and is a dedicated training site for Doctor of Nursing Practice students. In its 1 year of existence, said Dinkel, it has had 777 unique encounters with 359 new patients. It was originally designed to offer services only to those living in Pine Ridge Manor, the largest and oldest public housing neighborhood in Topeka. Soon it became clear that people from across Topeka were in need of these services. Topeka has a relatively high rate of poverty, said Dinkel, and more than one-quarter of its children live in poverty. The Pine Ridge Family Health Center is designed to provide health care services to those who face challenges in accessing care through other means. The center is embedded in the community, which is
absolutely key for access among people who lack transportation options. Dinkel said that the model of the center is to address multiple social determinants of health, in particular, transportation, access, and cost.
The center got its start because of “harmonic convergence at its finest,” commented Dinkel. There was an opportunity for an interprofessional practice and education (IPE) grant from the Accelerating Interprofessional Community-Based Education and Practice initiative out of the National Center for Interprofessional Practice and Education (the National Center) (2018). Dinkel wanted to use it to develop an IPE curriculum in order to teach students how to create sustainable innovation within their own communities. At the same time, Dinkel said, she was “dragged” into a conversation about a local preschool that needed nurse practitioner volunteers to provide free health care services. This conversation took place between Dinkel, Jane Brown—who was then a faculty member at Washburn and is now the head nurse practitioner at the center—and Mallory Keeffe, who is a community social worker. Their conversation centered around the fact that children in the community had high ACE (adverse childhood experience) scores, which can translate into greater health risks later in life.
At some point in the conversation, Dinkel’s “head popped off” and the idea of building a community health center from the ground up was born. A team of faculty at Washburn was assembled to develop the Classroom to Community IPE curriculum. The team included faculty and staff from the School of Nursing, School of Business, Department of Communication Studies, Small Business Development Center, and Office of Sponsored Projects. Dinkel said that the team created a curriculum that included instruction in social justice, motivational interviewing, business ethics, leadership of self, crisis communication, and trauma-informed care. Students from these varied departments and schools helped to plan and organize the creation of the clinic. Business students helped create business plans, communication students set up health literacy opportunities for patients, etc.
Barbara Brandt, who leads the National Center, underscored the importance of Dinkel’s work by emphasizing that this type of collaboration within academic institutions can greatly benefit the institution itself and participating departments as individuals work together and learn from each other. The best part about this clinic, she said, is the substantial community support and collaborations between providers and organizations.
Dinkel acknowledged Brandt’s comments, added that Washburn University and Topeka Housing Authority (THA) are the two founding partners of the health center, and noted that it is sustained through the work of local physicians, nurse practitioners, and medical institutions. Local residents have also been big supporters of the clinic, said Dinkel, and are co-creators of the effort. Residents participated in focus groups, helped to refine and administer a community assessment survey, volunteer at the
clinic, and help to get the word out about the clinic and its services. Dinkel added that, while there is a high rate of turnover in public housing, there are “resident champions” who have charged themselves with making sure that new residents know about the clinic.
The use of a community-based participatory research framework, said Dinkel, helped to focus the center on the specific, identified needs of the community residents (e.g., primary care, dental health, mental health) and to engage community members at every step of the process. In addition to outlining the community and resident support, Dinkel described the people involved—including the clinic’s paid staff and people from THA—as “fearless” and “optimistic.” THA has a “yes” approach to everything, she said, which has been critical to the success of the project. Trey George, chief executive officer of the nonprofit side of THA, has been known to say he does not know how they are going to make it happen, but the answer is yes. This optimistic spirit has helped in countless ways, including building the clinic itself and finding the resources to pay staff. In Dinkel’s opinion, a key to the center’s success has been everyone’s ability to “embrace chaos” and to adapt and move forward when things go wrong.
The presentation then shifted to the center’s future goals and the next steps for the IPE curriculum. First, said Dinkel, the center plans to hire an RN to serve as a preceptor for RN students moving into ambulatory care. Second, they and the center plan to expand the clinic and offer more services, such as optometry. Third, they are seeking increased resident participation on the Advisory Council. Fourth, she said, there is a need to develop outcomes measures in order to really capture the value of the clinic. Fifth, the center is looking at strategies for making the financing of the clinic more sustainable, including billing insurance companies and using payment plans. Finally, the IPE curriculum is being expanded and improved in order to give students rotations in the center and to encourage them, as Dinkel said, to “really think about social determinants of health.”
Dinkel closed her presentation with a quote from a patient of the Pine Ridge Family Health Center, who said:
I want to give a shout out to all of the staff at Pine Ridge and to THA as a whole for one of the very best experiences I’ve had accessing and receiving health care in my entire adult life. Leaving the office, all I could think about was the quality of my experience and care from start to finish. I knew at that moment that this would be my new primary medical care clinic. Your collective attentiveness and direct action are definitely making a difference to the underprivileged you serve in public housing in Topeka.
Anthony Breitbach with the Association of Schools of Allied Health Professions shared his concern that programs or initiatives such as the
Pine Ridge Family Health Center are potentially exacerbating the divide between health care for low-income people and health care for high-income people. He feared this type of system would send a message to students that “there are two health systems” rather than treat everyone the same. Dinkel responded by saying that she and her colleagues also address this type of attitude with their IPE curriculum, adding that her group does not “support academic tourism.” She agreed with Breitbach about the dichotomy in health care and said that, while perhaps regrettable, it already exists and they are “not going to pretend like it doesn’t.” Dinkel then relayed a story about a friend of hers who was hiking through the woods with a heavy load and came to a downed tree that lay across the trail.
The friend took off her backpacks, threw them over the tree, climbed over the tree, put the packs back on, and continued to hike on. She later asked her friends and fellow hikers if they were also exhausted from climbing over the tree with all of their things. The friends responded, “No. We just walked around it.” Dinkel analogized the current health care system to the downed tree: The system is “really hard for many, many people so let’s just walk around it.” The center is her way of helping people “walk around” the health care challenges, rather than work within a broken system.
National Center for Interprofessional Practice and Education. 2018. Accelerating interprofessional community-based education and practice. https://nexusipe.org/advancing/ accelerating (accessed February 21, 2019).
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