Available online at Nurs Outlook 66 (2018) 46 55

Available online at www.sciencedirect.com Nurs Outlook 66 (2018) 46 55 www.nursingoutlook.org An untapped resource in the nursing workforce: Licensed practical nurses who transition to become registered nurses Cheryl B. Jones, PhD, RN, FAAN*, Mark Toles, PhD, RN, George J. Knafl, PhD, Anna S. Beeber, PhD, RN The University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC ARTICLE INFO ABSTRACT Article history: Received 11 January 2017 Revised 17 April 2017 Accepted 11 July 2017 Available online July 20, 2017. Keywords: LPNs Career development Professional transitions Nursing workforce Background: A more diverse registered nurse (RN) workforce is needed to provide health care in North Carolina (NC) and nationally. Studies describing licensed practical nurse (LPN) career transitions to RNs are lacking. Purpose: To characterize the occurrence of LPN-to-RN professional transitions; compare key characteristics of LPNs who do and do not make such a transition; and compare key characteristics of LPNs who do transition in the years prior to and following their transition. Methods: A retrospective design was conducted using licensure data on LPNs from 2001 to 2013. Cohorts were constructed based on year of graduation. Findings: Of 39,398 LPNs in NC between 2001 and 2013, there were 3,161 LPNs (8.0%) who had a LPN to RN career transition between 2001 and 2013. LPNs were more likely to transition to RN if they were male; from Asian, American Indian, or other racial groups; held an associate or baccalaureate degree in their last year as an LPN (or their last year in the study if they did not transition); worked in a hospital inpatient setting; worked in the medical surgical nursing specialty; and were from a rural area. Discussion: Our findings indicate that the odds of -to-rn transition were greater if LPNs were: male; from all other racial groups except white; of a younger age at their first LPN licensure; working in a hospital setting; working in the specialty of medical-surgical nursing; employed part-time; or working in a rural setting during the last year as. Conclusion: This study fills an important gap in our knowledge of LPN-to-RN transitions. Policy efforts are needed to incentivize: LPNs to make a LPN-to-RN transition; educational entities to create and communicate curricular pathways; and employers to support LPNs in making the transition. Cite this article: Jones, C. B., Toles, M., Knafl, G. J., & Beeber, A. S. (2018, JANUARY-FEBRUARY). An untapped resource in the nursing workforce: Licensed practical nurses who transition to become registered nurses. Nursing Outlook, 66(1), 46 55. https://doi.org/10.1016/j.outlook.2017.07.007. * Corresponding author: Cheryl B. Jones, The University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall, CB #7460, Chapel Hill, NC 27599-7460. E-mail address: cabjones@email.unc.edu (C.B. Jones). 0029-6554/$ see front matter 2017 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.outlook.2017.07.007

Nurs Outlook 66 (2018) 46 55 47 Introduction New approaches are needed to accommodate the emerging and varied roles of registered nurses (RNs), address the need to increase diversity in the RN workforce, and attempt to correct state-level distributional imbalances that exist in the RN workforce (U.S. Department of Health and Human Services, 2014). One largely overlooked sector of the nursing workforce, licensed practical nurses (LPNs), could provide an important source to address these needs if LPNs complete training and licensure to become practicing RNs. Prior studies indicate that LPNs with careers in hospitals and other health care settings develop clinical experience that provides the basis for establishing excellent careers as RNs (Cook, Dover, Dickson, & Engh, 2010). However, unlike RNs, LPNs are usually trained for more task-oriented patient care (e.g., medication administration and completing procedures delegated by RNs and physicians) and lack training to deliver a broader scope of nursing care, such as patient assessment, planning patient care, delegation of work to unlicensed staff, advocacy of patient needs, and collaboration with physicians and other health professionals (Cook et al., 2010; Corazzini, Anderson, Mueller, Thorpe, & McConnell, 2013). In what has been called a win win solution (Porter-Wenzlaff & Froman, 2008; Suttle & McMillan, 2009), increasing LPN to RN professional transitions represent an opportunity to expand the RN workforce and create a meaningful career ladder for LPNs to advance their job prospects, income, and professional ability. Unfortunately, very limited data are available that describe LPN to RN professional transitions defined as LPNs who return to school; study for a variable number of years to acquire an associate, bachelor s, or higher degree in nursing; pass their RN certification examination, and begin new nursing careers as RNs (Brookings Institute, 2014; Fraher, Spetz, & Naylor, 2015; Institute of Medicine, 2010). Innovations in nursing education and community resources are likely necessary to support LPNs as they transition to the RN role, in part, because LPNs who return to school often have limited financial resources. Typically, they work while attending school; have family responsibilities such as supporting young children who conflict with their academic studies; and their academic preparation is more limited in scope than students enrolled in traditional baccalaureate programs in nursing (Suva et al., 2015). More information about LPNs who experience the transitions may be useful as a preparatory step for developing LPN to RN educational supports. Data about the count of nurses who experience LPN to RN professional transitions can also be used to benchmark future performance. Also, although the extent to which the LPN to RN pathway is a viable means to achieve the goal of 80% BSN by 2020 is unclear, a description of the pathways through which LPN to RN transitions occur can help to better understand the unique needs of those who make such a transition, and the timing of these transitions can be useful in targeting future interventions. In addition, a description of the demographic, professional, and geographic histories of LPNs who make the transition to RN can be used to target programs for developing and identifying potential students. New data also may support the development of specialized bridge programs that increase the success of LPNs as they participate in RN coursework (Cook et al., 2010; Doherty, 2011; Goodwin-Esola & Gallagher-Ford, 2009; Miller & Leadingham, 2010; Porter-Wenzlaff & Froman, 2008). One of the challenges in studying the transition of LPNs who become RNs is the lack of national data to conduct such analyses. Fortunately, data on the LPN workforce are contained in the North Carolina (NC) Health Professions Data System (HPDS), and these data represent a potentially important resource for study. Thus, the objectives of this exploratory study were to use the NC HPDS data to a. Describe the occurrence of LPN to RN professional transitions between 2001 and 2013; b. Compare the demographic, professional, and geographic characteristics of LPNs who did and did not have LPN to RN professional transitions between 2001 and 2013; and c. For LPNs who had LPN to RN professional transitions, compare professional and geographical characteristics for LPNs who transitioned to RN in the year before and the year of the transition. Because there are no national data systems that permit the tracking and linking of LPNs who make a professional transition to become RNs, this state-level analysis provides important evidence to guide policymaking and future research. Methods A retrospective design was used to study LPN to RN professional transitions. Data for this study were provided by the NC HPDS, maintained at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. The HPDS contains more than 30 years of data on 19 health professions from 11 different licensure boards. Data on the RN and LPN nursing workforce in NC, derived from annual licensure files from the NC Board of Nursing, are available for the prior year on or about October 31 of each year. The NC Board of Nursing requires that RNs and LPNs register every 2 years for the purposes of licensure registration and renewal, with half of the state s RNs and LPNs registering with the Board of Nursing each year. The HPDS data included only active licensed nurses working in NC. We used data from the years 2000 to 2013 to describe LPN to RN transitions that occurred between 2001 and 2013. A few statistics about NC help to provide context for our study. There were about 105,000 RNs and 17,500 LPNs

48 Nurs Outlook 66 (2018) 46 55 practicing in NC in 2017 (NC Board of Nursing, 2017a). Of these, roughly 18% of RNs and 36% of LPNs were from diverse backgrounds (NC Board of Nursing, 2017b), whereas about 64% of the NC population reported being white in the 2015 census (U.S. Census Bureau, 2017). Also, in the 2014 to 2015 academic year, there were 22 community colleges that offered advanced placement options for LPNs interested in making the transition to become an RN, whereas none of the state-supported BSN programs offered such options (Foundation for Nursing Excellence, 2016). Study Variables The dependent variable was having a LPN to RN professional transition, defined as reporting an advance in the career of that permitted them to work as an RN in NC, vs. not transitioning. LPN to RN professional transitions were described, annually and in aggregate, as the count and percentages of LPNs that reported subsequently being licensed as RNs over the sample of all LPNs. The independent variables included (a) baseline demographic characteristics of LPNs, including gender, race and ethnicity (i.e., white, black, American Indian, Hispanic, Asian, and other), age at first licensure as in NC (i.e., 16 22, 23 27, 28 34, and 34 68), year of first licensure as in NC (i.e., 1938 1981, 1982 1995, 1996 2004, and 2005 2013), LPN degree from a U.S. nursing school (i.e., yes or no), highest nursing degree in the last year as (i.e., diploma, associate degree, baccalaureate of science in nursing, master of science in nursing, doctorate in nursing); (b) the professional characteristics of LPNs, including work setting in the last year as (i.e., hospital inpatient, longterm care, solo/group practice or hospital outpatient, other), specialty in the last year as (i.e., community-based practice, geriatrics, medical surgical, pediatrics, other), employed full time in the last year as (i.e., no and yes); and (c) the geographic characteristics of LPNs, including work in rural area in the last year as (i.e., no and yes), and location in Area Health Education Center (AHEC) in NC in the last year of employment as (i.e., Area L, South East, Greensboro, Mountain, Southern Regional, Eastern, Charlotte, Wake, Northwest; ordered by increasing size). It should be noted that AHEC regions were included in our analysis because they provide the most comprehensive description of NC geographically, including areas where LPN transition programs might be located. AHEC regions encompass all 100 counties in NC, and the regions include all types of locations rural, urban, and suburban. Approximate quartile splits were used to set the categories for year of first licensure and age at first licensure. Data Analysis Analyses were conducted using SAS, version 9.4 (SAS Institute, Inc., Cary, NC). To carry out this study, we first concatenated individual years of data into one data set and then created the variables needed to address the other study objectives. For the first objective, we computed frequencies and percentages of LPN to RN transitions for each year 2001 to 2013 and totals for all those years. For the second objective, we computed logistic regression models of the occurrence of a transition from LPN to RN in terms of the demographic, professional, and geographic characteristics, first one characteristic at a time and then all characteristics in combination. To more accurately isolate transitions, data for licensed LPNs who were also RNs in all the years were excluded from these analyses because they had transitioned before the study start point. For the third objective, we computed contingency tables comparing selected professional and geographic characteristics for LPNs who transitioned to RN in the year before the transition and the year of the transition. Only data for LPNs who had transitioned to RN were included in these analyses. Findings Among personal variables in the HPDS (Table 1), at least 99% of the data were complete for gender, race and ethnicity, age at first licensure as, year of first licensure as, and degree at first licensure as an LPN from a school in the United States. Approximately, 22% of data were missing for the highest nursing degree in the last year as. Among professional characteristic variables, about 18% of data were missing for work setting in the last year as, specialty in the last year as, and employed full time in the last year as. Among geographic characteristic variables, no data were missing for both rural vs. urban Table 1 Occurrence of Missing Data for LPNs in NC Who Transitioned to Become RNs* Variable n (%)* Gender 2 (0.01) Race and ethnicity 312 (0.8) Age at first licensure as 299 (0.8) Year of first licensure as 297 (0.8) Degree at first licensure as from 224 (0.6) U.S. school Highest nursing degree in the last year 8,343 (22.1) as Work setting in the last year as 6,953 (18.4) Specialty in the last year as 7,041 (18.6) Employed full time in the last year as 6,828 (18.1) Located in rural area in the last year as 0 (0.0) Located in NC AHEC in the last year as 0 (0.0) Note. AHEC, Area Health Education Center; LPN, licensed practical nurse; NC, North Carolina; RNs, registered nurses. * Of 37,781 nurses who were licensed in NC only as at some time during 2000 to 2013.

Nurs Outlook 66 (2018) 46 55 49 setting in the last year as and AHEC region in the last year as. The first objective of the study was to describe the occurrence of LPN to RN professional transitions between 2001 and 2013. Of a total of 39,398 LPNs in NC between 2001 and 2013, there were 3,161 LPNs (8.0%) who had a professional transition to become an RN during the period. There were also data for 1,617 (4.1%) nurses who reported being licensed as RNs for all the years of the study period. Observations for these LPNs were excluded in subsequent analyses. Table 2 provides the occurrence of LPN to RN professional transitions in each year between 2001 and 2013 for the remaining 37,781 LPNs. In Figure 1, the frequencies of these transitions are plotted in a bar graph. As indicated in Figure 1 and Table 2, the number of LPN to RN professional transitions ranged from 190 to 336 on average, approximately 1.4% of licensed LPNs per year during the study period. As shown in Table 3, LPNs who transitioned to become RNs were primarily female (92.5%), white (67.0%), or black (25.2%), educated in the United States (98.4%), licensed as between 1996 and 2013 (78.2%), and between the ages of 16 and 34 years at the time of LPN licensure (80.4%). Moreover, in the last year before LPN to RN transitions, most LPNs who had professional transitions primarily held a nursing diploma as the highest nursing degree (81.8%), worked in long-term care (40.9%), specialized in geriatrics (36.2%), worked full time (73.6%), worked in urban (vs. rural) settings (68.1%), and worked in the Mountain, Southern Regional, Eastern, Charlotte, Wake, and Northwest AHEC regions (79.1%). The second objective of the study was to compare LPNs who did and did not have LPN to RN professional transition between 2001 and 2013 (Table 4). Comparison of the individual demographic characteristics of LPNs who Table 2 Occurrence of LPN to RN Transitions, 2001 to 2013 Year Number of LPNs* LPN to RN Transitions During Study Period, n (%) 2001 17,275 336 (1.9) 2002 16,624 246 (1.5) 2003 16,723 278 (1.7) 2004 16,725 221 (1.3) 2005 16,829 190 (1.1) 2006 17,172 216 (1.3) 2007 17,444 237 (1.4) 2008 17,831 256 (1.4) 2009 17,958 284 (1.6) 2010 17,885 273 (1.5) 2011 17,900 219 (1.2) 2012 18,023 213 (1.2) 2013 18,098 193 (1.1) Average during study period 17,422 243 (1.4) Note. LPN, licensed practical nurse; RN, registered nurse. * Excluding LPNs who were RNs for all their years of North Carolina licensure. Figure 1 The occurrence of LPN to RN professional transitions over time. Note. LPN, licensed practical nurse; RN, registered nurse. transitioned to become RNs, vs. those who did not, shows that (a) the odds of male LPNs transitioning to become an RN were 1.20 times greater than the odds of female LPNs transitioning; (b) the odds of transitioning from LPN to RN were greater for LPNs who were Asian (2.18), American Indian (1.49), or black (1.09 times) than for LPNs who were white; and (c) the odds of transitioning from LPN to RN were greater if LPNs were first licensed in NC between the ages of 23 and 27 (1.72 times), 28 and 34 (1.36 times), and at the youngest ages of 16 and 22 (1.19 times), than were those who were first licensed between the ages of 34 and 68. Comparison of the professional characteristics of LPNs who transitioned to become RNs, vs. those who did not, shows that the odds of transitioning from LPN to RN were much greater if LPNs held baccalaureate (1.62 times) or associate (1.19 times) degrees in nursing during their last year as, relative to those with a nursing diploma. Moreover, LPNs working in the hospital inpatient setting during their last year as were more likely to transition to become an RN than those employed in all other settings. In fact, those working in the hospital inpatient setting were 2.67 times more likely to transition ths working in long-term care. Similar to the transition behavior noted for setting, LPNs working in the medical surgical specialty area during their last year as were more likely ths working in all other specialties, including communitybased practice and geriatrics, to transition to become RNs. The odds of LPNs working in the medical surgical specialty during their last year transitioning to become RNs were 3.14 times greater than those working in the geriatrics specialty, although LPNs in the geriatric specialty accounted for the greatest number of LPN to RN transitions. Comparison of the geographic characteristics of LPNs who transitioned to become RNs, vs. those who did not, shows that LPNs working in a rural area were 1.29 times more likely to transition to become an RN than those not working in a rural area. Finally, we compared the composite (Table 5) effects of characteristics for LPNs who did and did not transition to become RNs. We found similar results with two

50 Nurs Outlook 66 (2018) 46 55 Table 3 LPNs in NC Who Transitioned to Become RNs, 2001 to 2013 Variable n Values n (%) Gender 3,161 Female 2,924 (92.5) Male 237 (7.5) Race and ethnicity 3,154 White 2,112 (67.0) Black 796 (25.2) American Indian 61 (1.9) Hispanic 42 (1.3) Asian 58 (1.8) Other 85 (2.7) Age at first licensure as 3,133 16 22 702 (22.4) 23 27 990 (31.6) 28 34 828 (26.4) 34 68 613 (19.6) Year of first licensure as 3,133 1938 1981 97 (3.1) 1982 1995 585 (18.7) 1996 2004 1,554 (49.6) 2005 2013 897 (28.6) Degree at first licensure as from U.S. school 3,126 No 49 (1.6) Yes 3,077 (98.4) Highest nursing degree in the last year as 2,229 Diploma 1,823 (81.8) Associate degree 317 (14.2) Baccalaureate of Science in Nursing 63 (2.8) Master of Science in Nursing 23 (1.0) Doctorate in Nursing 3 (0.01) Work setting in the last year as 2,346 Hospital inpatient 662 (28.2) Long-term care 960 (40.9) Solo/group practice or hospital outpatient 285 (12.2) Other 439 (18.7) Specialty in the last year as 2,373 Community-based practice 173 (7.3) Geriatrics 860 (36.2) Medical surgical 389 (16.4) Pediatrics 156 (6.6) Other 795 (33.5) Employed full time in the last year as 2,377 No 628 (26.4) Yes 1,749 (73.6) Located in rural area in the last year as 3,162 No 2,154 (68.1) Yes 1,008 (31.9) Located in NC AHEC in the last year as 3,162 Area L 179 (5.7) South East 205 (6.5) Greensboro 278 (8.8) Mountain 422 (13.3) Southern Regional 421 (13.3) Eastern 404 (12.8) Charlotte 338 (10.7) Wake 454 (14.4) Northwest 461 (14.6) Note. AHEC, Area Health Education Center; LPN, licensed practical nurse; NC, North Carolina; RN, registered nurse. notable exceptions; male gender and certain racial characteristics (Asian, American Indian, or other) were no longer significant predictors of LPN to RN transitions. To assess possible collinearity for the composite model, we computed R 2 values for models of each of the indicator variables underlying this model in terms of the other indicator variables. The largest R 2 value was 0.57, indicating that the model does not have collinearity problems. The third objective of the study was to compare characteristics of LPNs who transitioned to RN in the year before and the year of the transition. As described in Table 6, the professional characteristics of LPNs that were most likely to change in the first year of RN licensure included working in solo/group or hospital outpatient work settings, the specialty of community-based practice, and working full time. The geographic characteristics of LPNs that were most likely to change in the first year of RN licensure included work in a rural setting or in the Area L, Southern Regional, Northwest, Mountain, or South East AHEC regions. Discussion Despite the growing size of the RN workforce nationally and in NC, changes in the health care system have

Nurs Outlook 66 (2018) 46 55 51 Table 4 Individual Effects of Characteristics for LPNs in NC Who Did and Did Not Transition to Become RNs, 2001 to 2013 Variable n* Values All LPNs, n (%) LPN Only, n (%) Became RN, n (%) OR 95% CI p Gender 37,779 Female 35,356 (93.6) 32,432 (91.7) 2,924 (8.3) Male 2,423 (6.4) 2,186 (90.2) 237 (9.8) 1.20 1.05 1.38.009 Race and ethnicity 37,469 White 26,230 (70.0) 24,118 (91.9) 2,112 (8.1) Black 9,153 (24.4) 8,357 (91.3) 796 (8.7) 1.09 1.01 1.20.033 American Indian 532 (1.4) 471 (88.5) 61 (11.5) 1.49 1.14 1.96.004 Hispanic 538 (1.4) 496 (92.2) 42 (7.8) 0.98 0.71 1.34.878 Asian 365 (1.0) 307 (84.1) 58 (15.9) 2.18 1.64 2.89 <.001 Other 651 (1.7) 566 (86.9) 85 (13.1) 1.73 1.37 2.18 <.001 Age at first licensure as Year of first licensure as Degree at first licensure as from U.S. school Highest nursing degree in the last year as Work setting in the last year as Specialty in the last year as Employed full time in the last year as Located in rural area in the last year as Located in NC AHEC in the last year as 37,482 16 22 9,182 (24.5) 8,480 (92.4) 702 (7.6) 1.19 1.06 1.33.003 23 27 9,227 (24.6) 8,237 (89.3) 990 (10.7) 1.72 1.55 1.91 <.001 28 34 9,527 (25.4) 8,699 (91.3) 828 (8.7) 1.36 1.23 1.52 <.001 35 68 9,546 (25.5) 8,933 (93.6) 613 (6.4) 37,484 1938 1981 8,515 (22.7) 8,418 (98.9) 97 (1.1) 0.12 0.10 0.14 <.001 1982 1995 9,923 (26.5) 9,338 (94.1) 585 (5.9) 0.64 0.57 0.71 <.001 1996 2004 9,017 (24.1) 7,463 (82.8) 1,554 (17.2) 2.11 1.94 2.31 <.001 2005 2013 10,029 (26.8) 9,132 (91.1) 897 (8.9) 37,557 No 1,609 (4.3) 1,560 (97.0) 49 (3.0) 0.33 0.25 0.44 <.001 Yes 35,948 (95.7) 32,871 (91.4) 3,077 (8.6) 29,438 Diploma 24,889 (84.5) 23,066 (92.7) 1,823 (7.3) Associate degree 3,688 (12.5) 3,371 (91.4) 317 (8.6) 1.19 1.05 1.35.006 Baccalaureate of 555 (1.9) 492 (88.6) 63 (11.4) 1.62 1.24 2.12 <.001 Science in Nursing Master of Science 281 (1.0) 258 (91.8) 23 (8.2) 1.13 0.73 1.73.582 in Nursing Doctorate in Nursing 25 (0.1) 22 (88.0) 3 (12.0) 1.73 0.52 5.77.376 30,828 Hospital inpatient 3,748 (12.2) 3,086 (82.3) 662 (17.7) 2.67 2.40 2.97 <.001 Long-term care 12,911 (41.9) 11,951 (92.6) 960 (7.4) Solo/group practice 5,711 (18.5) 5,426 (95.0) 285 (5.0) 0.65 0.57 0.75 <.001 or hospital outpatient Other 8,458 (27.4) 8,019 (94.8) 439 (5.2) 0.68 0.61 0.77 <.001 30,740 Community-based 3,412 (11.1) 3,234 (94.9) 173 (5.1) 0.68 0.58 0.81 <.001 practice Geriatrics 11,848 (38.5) 10,988 (92.7) 860 (7.3) Medical surgical 1,970 (6.4) 1,581 (80.3) 389 (19.7) 3.14 2.76 3.58 <.001 Pediatrics 2,175 (7.1) 2,019 (92.8) 156 (7.2) 0.99 0.83 1.18.887 Other 11,335 (36.9) 10,540 (93.0) 795 (7.0) 0.96 0.87 1.07.469 30,953 No 6,777 (21.9) 6,149 (90.7) 628 (9.3) 1.31 1.19 1.44 <.001 Yes 24,176 (78.1) 22,427 (92.8) 1,749 (7.2) 37,781 No 27,579 (73.0) 25,425 (92.2) 2,154 (7.8) Yes 10,202 (27.0) 9,194 (90.1) 1,008 (9.9) 1.29 1.20 1.40 <.001 37,781 Area L 1,398 (3.7) 1,219 (87.2) 179 (12.8) 1.70 1.42 2.05 <.001 South East 2,302 (6.1) 2,097 (91.1) 205 (8.9) 1.14 0.96 1.35.150 Greensboro 3,497 (9.3) 3,219 (92.1) 278 (7.9) 1.00 0.86 1.17.974 Mountain 4,120 (10.9) 3,698 (89.8) 422 (10.2) 1.33 1.15 1.52 <.001 Southern Regional 4,744 (12.6) 4,323 (91.1) 421 (8.8) 1.13 0.99 1.30.018 Eastern 4,819 (12.8) 4,415 (91.6) 404 (8.4) 1.06 0.92 1.22.395 Charlotte 5,533 (14.6) 5,195 (93.9) 338 (6.1) 0.76 0.65 0.87 <.001 Wake 5,555 (14.7) 5,101 (91.8) 454 (8.2) 1.03 0.90 1.18.635 Northwest 5,813 (15.4) 5,352 (92.1) 461 (8.0) Note. AHEC, Area Health Education Center; CI, confidence interval; LPN, licensed practical nurse; NC, North Carolina; OR, odds ratio; RNs, registered nurses. * Of 37,781 nurses who were licensed in NC only as at some time during 2000 to 2013. Relative to the most populous category indicated by. ORs, CIs, and p values for the occurrence of to RN transition computed for each variable separately.

52 Nurs Outlook 66 (2018) 46 55 Table 5 Composite Effects of Characteristics for LPNs in NC Who Did and Did Not Transition to Become RNs, 2001 to 2013 Variable* Values OR 95% CI p Gender Female Male 0.87 0.71 1.07.177 Race and ethnicity White Black 1.24 1.10 1.39 <.001 American Indian 1.38 0.96 1.99.082 Hispanic 0.99 0.65 1.51.958 Asian 1.44 0.92 2.27.113 Other 1.15 0.79 1.68.467 Age at first licensure as 16 22 2.89 2.49 3.37 <.001 23 27 2.45 2.13 2.82 <.001 28 34 1.81 1.57 2.10 <.001 35 68 Year of first licensure as 1938 1981 0.06 0.05 0.08 <.001 1982 1995 0.48 0.42 0.55 <.001 1996 2004 1.13 1.00 1.28.043 2005 2013 Degree at first licensure as from U.S. school No 0.12 0.07 0.21 <.001 Yes Highest nursing degree in the last year as Diploma Associate degree 0.92 0.79 1.06.240 Baccalaureate of Science in Nursing 1.49 1.09 2.04.013 Master of Science in Nursing 1.64 1.03 2.61.038 Doctorate in Nursing 1.56 0.20 12.3.673 Work setting in the last year as Hospital inpatient 242 1.98 2.96 <.001 Long-term care Solo/group practice or hospital 0.73 0.59 0.90.004 outpatient Other 0.74 0.62 0.90.002 Specialty in the last year as Community-based practice 0.97 0.76 1.22.781 Geriatrics Medical surgical 1.80 1.43 2.27 <.001 Pediatrics 1.14 0.89 1.48.306 Other 1.12 0.94 1.33.217 Employed full time in the last year as No 1.79 1.60 2.00 <.001 Yes Located in rural area in the last year as No Yes 1.15 1.02 1.28.019 Located in NC AHEC in the last year as Area L 0.92 0.70 1.19.517 South East 0.95 0.77 1.19.670 Greensboro 0.79 0.64 0.97.023 Mountain 1.03 0.86 1.24.741 Southern Regional 0.73 0.61 0.88.001 Eastern 0.78 0.65 0.93.007 Charlotte 0.72 0.60 0.86 <.001 Wake 0.74 0.62 0.88.001 Northwest Note. AHEC, Area Health Education Center; CI, confidence interval; LPN, licensed practical nurse; NC, North Carolina; OR, odds ratio; RNs, registered nurses. * For 26,829 or 71.0% of the 37,781 nurses who were licensed in NC only as at some time during 2000 to 2013. Relative to the most populous category indicated by. ORs, CIs, and p values for the occurrence of to RN transition computed for all variables in combination. prompted calls to increase the educational capacity of RNs and encourage their practice at the highest levels of licensure (Cook et al., 2010; Institute of Medicine, 2010), given the potential growth in demand for RNs in emerging models of care, including preventive care and care coordination (Brookings Institute, 2014; Porter-Wenzlaff & Froman, 2008). A viable career ladder to expand the educational capacity of nurses, in general, and RNs, in particular, is to encourage LPNs to make professional transitions to become RNs. It also is plausible that such transitions may contribute to increased satisfaction and retention of some LPNs in the nursing workforce who might otherwise leave nursing altogether. This study was conducted to characterize the occurrence of LPN to RN professional transitions. Findings indicate that (a) 8.0% of the 39,398 LPNs licensed in NC between 2001

Nurs Outlook 66 (2018) 46 55 53 Table 6 Changes in the Professional and Geographic Characteristics of Nurses with LPN to RN Professional Transitions Nurse Characteristic Nurse N Values In the First Year as an RN Unchanged Changed Work setting 2,329 Hospital inpatient 629 (95.4) 30 (4.6) Long-term care 903 (94.8) 50 (5.2) Solo/group practice or hospital outpatient 245 (87.5) 35 (12.5) Other 397 (90.8) 40 (9.2) Specialty 2,354 Community-based practice 145 (85.8) 24 (14.2) Geriatrics 812 (95.1) 42 (4.9) Medical surgical 370 (95.1) 19 (4.9) Pediatrics 143 (93.5) 10 (6.5) Other 744 (94.3) 45 (5.7) Employed full time 2,359 No 601 (96.2) 24 (3.8) Yes 1,566 (90.3) 168 (9.7) Located in rural area 3,122 No 2,009 (94.2) 124 (5.8) Yes 839 (84.8) 150 (15.2) Located in NC AHEC Region 3,122 Area L 144 (80.9) 34 (19.1) South East 170 (85.0) 30 (15.0) Greensboro 230 (88.0) 47 (12.0) Mountain 348 (84.1) 66 (15.9) Southern Regional 341 (82.8) 71 (17.2) Eastern 347 (87.8) 48 (12.2) Charlotte 298 (88.2) 40 (11.8) Wake 387 (86.0) 63 (14.0) Northwest 383 (83.6) 75 (16.4) Note. AHEC, Area Health Education Center; LPN, licensed practical nurse; NC, North Carolina; RN, registered nurse. and 2013 had LPN to RN professional transitions at some point before or during the study period and (b) LPNs that made an RN transition were primarily female, white, and from nonrural areas. To our knowledge, prior studies have not described the occurrence of LPN to RN professional transitions, making it difficult to compare the occurrence of transitions observed in our study with those from other state or national studies. However, findings from this study indicate that on the average during this 20-year period, 1.4% of the LPN population (234 of 17,422) had to RN transition. Although these LPN to RN transitions are made by a small fraction of the total population of LPNs, the number of transitions remained relatively stable during the 13-year period (ranging from 1.1% to 1.9%). After excluding LPNs who were licensed as RNs (n = 1,617 or 4.1%) before the study period (2001 2013), and comparing those who did and did not have LPN to RN professional transitions (Table 5), those who transitioned were more likely to be black; prepared with an associate or a baccalaureate degree in nursing during the last year as ; employed in a hospital inpatient setting; and from a rural area in NC. Not surprisingly, the odds of transitioning from LPN to RN were much greater if LPNs were first licensed at a younger age, which suggests that nurses who attained LPN licensure later in life may have viewed that as their final nursing career transition and terminal nursing license. Among LPNs who reported transitions to advanced degrees, we observed that some LPNs transitioned to MSN and doctoral degrees without obtaining an RN license. Two factors likely explain this occurrence: (a) LPNs who obtained an MSN degree may not have reported their RN licensure in the survey and (b) LPNs who achieved a doctorate degree either did not report RN licensure or transitioned to other professions for which a registered nursing license was not required. The data neither in our study nor prior studies permit us to answer this question definitively. Also, among LPNs who became RNs between 2001 and 2013, the professional characteristics that were most likely to change in the first year of RN licensure were their work setting (i.e., solo/group or hospital outpatient work settings) and specialty (community-based nursing). The geographic characteristics that were most likely to change in the first year of RN licensure were working in a rural setting or in certain regions of NC (i.e., Area L, Southern Regional, Northwest, Mountain, or South East AHEC regions). A more comprehensive assessment of LPN transitions to the RN workforce is needed to determine whether the LPN to RN pathway can be a source for increasing the numbers of RNs in the future. For example, it is unclear whether certain groups (e.g., individuals from under-represented racial groups) in the nursing workforce initially enrolled in LPN training when they were better suited for RN training (and thereby might have avoided the need to transition to the RN role later in their careers). It will be an important step to develop

54 Nurs Outlook 66 (2018) 46 55 procedures to identify nurses with a desire and aptitude for initial training at the bachelors level and avoid LPN training and subsequent RN transitions. Also, among rural and under-represented racial/ethnic groups in the nursing workforce, LPN to RN transitions represent a potentially meaningful clinical ladder for becoming an RN, enriching local communities, and building social capital. Moreover, our finding in the composite predictor model (Table 5), that the likelihood of LPN to RN transitions was greater for black than white LPNs, warrants careful follow-up study. For example, it is not known why this difference in race impacts professional transitions or how to incentivize those with proportionately larger group of LPNs with white race to advance their nursing licensure. Finally, the finding that LPN to RN professional transitions were more likely to occur in a subset of the AHEC geographic regions suggests that (a) LPNs with similar demographic and professional characteristics associated with making the transition are clustered in a subset of the AHEC regions, which could explain regional variation and (b) educational opportunities for LPNs to successfully train and become licensed as RNs is greater in some AHEC region than others. Our findings suggest several implications for research. Our study of LPN to RN professional transitions was conducted using data from one state and should be expanded in a study using a national sample and should include a parsimonious multivariable model to ascertain an appropriate combination of predictors of LPN to RN transitions. In addition, our study used secondary data, which did not include many factors that likely influence the rate of LPN to RN professional transitions; thus, future studies should identify and describe the drivers of LPN to RN professional transitions, including describing the nursing programs where LPNs train to become RNs; identifying community and financial supports for LPNs who become RNs; conducting surveys and interview studies of LPNs and LPNs who become RNs to develop a qualitative description of nurses and the barriers and facilitators of LPN to RN transitions. Our exploratory findings also suggest implications for nursing leaders and policymakers. Between 1994 and 2009 (Fraher et al., 2015), LPNs represented the second largest sector of the NC health workforce with the greatest increase in diversity. First, it will be important to build capacity among educators to skillfully counsel nursing students to make informed choices about pursuing careers as LPNs vs. RNs from the outset. Second, we found that LPNs with black race, compared with other racial groups, were more likely to make to RN career transition. This finding suggests that policies are needed to target the acceleration of LPN to RN transitions for existing LPNs from racial groups that are underrepresented in the RN nursing workforce to enrich nursing workforce diversity. Third, our finding that, after LPN to RN transitions, new RNs tend to move to careers in hospitals, suggests that incentives are likely needed to fill gaps in community-based, ambulatory, and primary care, and along the full continuum of care that extends from home to long-term care services. Finally, as the nursing workforce in rural hospitals continues to shift from to RN workforce, policies and procedures for incentivizing and supporting rural LPNs to transition to a career as an RN in rural hospitals may also be warranted. Taking these steps will generate greater understanding and viability of the LPN to RN career ladder. Finally, our findings suggest implications for nursing educators. First, the possibility that some LPNs might eventually transition to the RN role because they were not well informed when deciding to become LPNs suggests the need to carefully advise students about career options in nursing and the long-term employment advantages of a career as an RN. Second, the low frequency of LPN to RN transitions suggests the need for strong peer and academic support for LPNs when they consider professional transitions and participate in coursework and study for the licensure examination. Supports might include group activities for students and more accomplished peers to share experiences about their growth as professionals; coping with the stress related to the professional transition; and resources or strategies for successfully completing nursing programs. Third, our finding that LPN to RN transitions occurred more frequently in a subset of regions of NC suggests the need to identify and replicate effective LPN to RN educational programs.this work might be started with an evaluation of program characteristics in regions with the highest and lowest rates of LPN to RN transitions; the goal of this evaluation would be (a) to identify recruitment strategies, financial and academic supports, and incentives for students in higher performing regions as well as (b) to identify opportunities and resources for replicating these services for students in lower performing regions. Finally, as educators look for opportunities to increase LPN to RN transitions, it will be important to teach LPN students about the nursing career ladder and opportunities for advancing their careers. Limitations This study was limited, as with any study using secondary data, by restrictions imposed by the data. Because of the nature of secondary data and the lag between the collection and availability of data, real-time data were unavailable for our analyses. This analysis included the most currently available data at the outset of our study. Another important limitation is that our analyses used only LPN data from NC. Although the LPN workforce NC is similar to the national workforce in terms of age, gender, and work setting, there may be important differences in the regulation and employment of LPNs that affect LPN transitions. However, because no national data systems currently exist that permit the tracking and linking of LPNs who make an employment transition, this state-level analysis provides important evidence to guide policymaking, identify needs for developing or enhancing future workforce data sets, and guidance on

Nurs Outlook 66 (2018) 46 55 55 modeling employment transitions and mobility in the health workforce. Also, because studies of LPN to RN transitions are lacking, this study represents an important step in examining this potentially important group in the nursing workforce. However, it was only possible to determine LPN to RN transitions that were reported. The fact that low percentages of LPNs with an MSN or a doctoral degree transitioned to RN suggests that transitions in these groups were underreported. Finally, our findings are primarily descriptive in nature, reflecting only characterizations of LPN characteristics and their professional transitions. Future research is needed to examine the more likely pathway of LPN to RN career transitions (i.e., ADN or BSN), and the causal mechanisms of LPN to RN transitions. Conclusions This study fills an important gap in our knowledge of LPN to RN transitions. Our findings indicate that the odds of to RN transition occurring were greater if LPNs were male; from all other racial groups than white; of a younger age at first LPN licensure; worked in a hospital setting or in the specialty of medical surgical nursing; and were employed part time or worked in a rural setting during the last year as. Policies are needed to provide better career counseling for nurses who enter LPN programs and to incentivize LPNs to become RNs to bring diversity to the RN workforce, build local communities, and to become prepared to help fill gaps in community-based, ambulatory, and primary care, and along the full continuum of care that extends from home to long-term care services. Further research is recommended to determine the viability of the LPN to RN pathway as a source for increasing the numbers of RNs in the future. 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