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Office of the Secretary

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Portia.wu@maryland.gov | 410-230-6387 | www.labor.maryland.gov

WES MOORE, GOVERNOR | ARUNA MILLER, LT. GOVERNOR │ PORTIA WU, SECRETARY

June 30, 2023

The Honorable Guy Guzzone

Chairman, Senate Budget and Taxation Committee

3 W Miller Senate Office Building

Annapolis, MD 21401

The Honorable Ben Barnes

Chairman, House Appropriations Committee

House Office Building, Room 121

Annapolis, MD 21401

RE: Final Report on Apprenticeships in Healthcare Workgroup – 2022 JCR

Dear Chairmen Guzzone and Barnes,

The Maryland Department of Labor (Labor) is pleased to transmit the enclosed final report on

apprenticeships in healthcare. Pursuant to committee narrative included in the 2022 Joint

Chairmen’s Report, Labor has worked in close collaboration with the Department of Health,

local health departments, and dozens of stakeholders from the workforce system to assess and

better understand the role of apprenticeship in healthcare, direct care, and behavioral health.

This final report summarizes the workgroup process, ongoing efforts to establish or grow

apprenticeships in healthcare and nursing, and cursory recommendations that can help Maryland

build a world-class public-sector healthcare workforce through apprenticeship. We hope that this

report can be a catalyst for continued collaboration and innovative thinking as we consider how

to best support the vital workers in our public sector healthcare agencies.

Sincerely,

Portia Wu

Secretary

Enclosure

cc: Members, Senate Budget and Taxation Committee

Members, House Appropriations Committee

Laura Herrera Scott, M.D., Maryland Secretary of Health

Report Background

During the 2022 session of the Maryland General Assembly, the Chairmen of the Senate Budget

and Taxation Committee and House Appropriations Committee authored the Report on the Fiscal

2023 State Operating Budget (SB 290) and the State Capital Budget (SB 291) and Related

Recommendations. The committee narrative on “Apprenticeship Workgroups for Targeted

Occupations,” outlined the Committees’ concern with workforce shortages among government

employees in the public safety, health, and transportation sectors. The narrative directed the

Maryland Department of Labor to convene workgroups to study and report on the short-term and

long-term needs in each respective sector, as well as efforts to:

• identify the extent of vacancies at the State and local level within each sector, specifically

including, but not limited to, police officers, correctional officers, parole and probation

agents, direct care and public health workers, bus operators, and vehicle maintenance

personnel;

• review existing apprenticeships in the United States and elsewhere specifically for

occupations in these identified sectors;

• design apprenticeships in the occupations within the identified sectors that have the

greatest recruitment challenges and training deficiencies, including estimated costs and

potential funding opportunities;

• identify opportunities to start apprenticeships at the high school level consistent with the

Blueprint for Maryland’s Future;

• identify opportunities, in coordination with the University System of Maryland (USM),

the Maryland Association of Community Colleges (MACC), University of Maryland

Global Campus (UMGC), the Maryland Career and Technical Education (CTE)

Committee, and the Maryland State Department of Education (MSDE), to create degree

apprenticeship programs and other ways to incorporate associate and bachelor’s degrees in

apprenticeships; and

• identify potential apprenticeship sponsors in each occupation.

By request of the Chairmen, the Maryland Department of Labor has authored this final report to

provide updates on the continued activities and final recommendations of the Maryland

Apprenticeship in Healthcare Workgroup.

This final report will focus more narrowly on apprenticeships for nursing and direct care

occupations. As discussed in the Interim Report, these critical roles make up a significant number

of all healthcare professionals in Maryland and have been deeply affected by workforce shortages,

turnover, and attrition. The report will analyze some of the understood constraints on the nursing

workforce and review potential applications and recommendations for apprenticeship.

The State of Apprenticeship Programs in Healthcare,

Direct Care, and Nursing

The largest formal system for apprenticeship in the United States is Registered Apprenticeship, a

long-standing, rigorous, and evidence-backed system of employment and training that remains

highly concentrated in the building trades. Occupations outside of the building trades, such as those

common in the healthcare industry, are considered “non-traditional” for Apprenticeship. While

there are a growing number of Apprenticeship programs in healthcare, nursing, and behavioral

health occupations, their non-traditional status in the organized system of Registered

Apprenticeship means it often takes additional time and work to get employers, sponsors, and

jobseekers acquainted with apprenticeship as a means for training.

For the purposes of this Workgroup, Nursing, including Certified Nursing Assistant (CNA/GNAs),

Licensed Practical Nurses (LPNs), Registered Nurses (RNs), and Advanced Practice Nurses,

served as useful model occupations to understand the opportunities and limitations for

Apprenticeship in healthcare. Specifically, because Nursing occupations, similar to behavioral

health professionals and other medical professionals, are generally educated and trained through

higher education-based programs with strict legal frameworks. This presents unique challenges

not found in the building trades or other sectors where Apprenticeship is a more common system

of employment and training.

Successful models for nursing Apprenticeships may be replicable for behavioral health

occupations and other direct care medical occupations of interest to the workgroup.

Maryland’s Current Nursing Apprenticeship Programs

As of this report, Maryland has two approved Registered Apprenticeship programs for the

occupation of LPN, sponsored by Baltimore Alliance for Careers in Healthcare (BACH), a non-

profit organization, and Howard Community College (HCC), one of Maryland’s 16 community

colleges. These two programs represent the highest level of direct care professionals that can be

trained through Apprenticeship programs in Maryland. Though several sponsors are approved to

operate CNA Registered Apprenticeship programs, no CNA Apprentices were active in Maryland

at the time of this report.

Both BACH and HCC operate programs with direct connections to existing healthcare and long-

term care employers in Maryland. Both entities also use a Maryland Board of Nursing-approved

Community College-based Nursing program to offer Related Instruction that would qualify an

apprentice for LPN licensure by examination. Where the programs differ is in their employer

engagement and instruction delivery.

In May of 2023, BACH reported to the Workgroup that, under its LPN Apprenticeship program,

Apprentices must already hold a CNA qualification. The prerequisite allows the Apprentices to

function at the competency level of a CNA for the employment portion of the Apprenticeship - a

crucial component of the program. Apprentices then must be accepted to the LPN course of study

offered by the program’s Related Instruction provider (Community College of Baltimore County)

and complete any requisite coursework. BACH reports that the program’s largest employers are

nursing homes and assisted living facilities who are using the program to upskill existing

CNA/GNA staff.

HCC’s program, conversely, has its largest employer relationship with two hospitals, Ascension

St. Agnes and Howard County General Hospital, and HCC offers its program’s Related

Instruction coursework in house. In order to meet scope of practice for employment, Apprentices

function as Patient Care Technicians (PCTs) or CNAs - a similar delineation of roles to BACH’s

program. HCC additionally offers some coursework onsite at the employer (St. Agnes) and

assists participants with transportation to campus for other Related Instruction Coursework.

As of this report, HCC reported 35 total program participants across both hospital sites with 13

currently registered with the State as Apprentices. As of December 2022, BACH had 8 active

LPN Apprentices registered with the Maryland Department of Labor.

BACH and HCC’s LPN programs are model programs for Nursing Apprenticeship in Maryland

and by extension, models for how Apprenticeship might fit with Maryland’s health occupations

regulatory and legal framework. Each program requires Apprentices to possess or acquire

another credential or level of competency for Apprentices to function in the workplace as a direct

care professional. Similarly, each program delineates time spent working and participating in On

the Job Learning from the clinical components of education.

Alabama and the Apprentice Nursing Permit

Discussed at length in the Interim Report, Alabama takes a novel approach to Nursing

Apprenticeship enabled by a legislatively created Apprentice Nurse Permit under the Alabama

Board of Nursing. The Permit creates a legal role for Registered Nurses to be trained under

Registered Apprenticeship, without eliminating the degree and licensure requirements associated

with the RN qualification. In contrast with the LPN programs organized under Maryland law,

Alabama’s permit gives Registered Apprenticeship sponsors and employers the ability to employ

Nurse Apprentices without requiring that the Apprentice first possess or earn another credential

prior. The Permit helps scope of practice limitations better fit Registered Apprenticeship,

reducing a major barrier for nursing occupations.

The Apprentice Nurse Permit has helped enable the Alabama Office of Apprenticeship,

institutions of higher education, and Alabama’s healthcare employers to rapidly scale Nursing

Registered Apprenticeship Programs since the permit's creation. As of this report, the Alabama

Office of Apprenticeship reports 70 active LPN Apprentices, 339 active RN Apprentices, 59

employers, and 16 sponsors, all of which are community colleges and universities.

As with Maryland’s programs, Alabama’s Apprentice Nurses are completing Nursing

coursework through colleges and universities that meet both the State and national accreditation

body standards for quality. Apprentices Nurses in Alabama, despite being granted the special

permit to allow training, must be qualified by examination, be accepted by their nursing

program, and comply with the requirements set out by the Board of Nursing.

Factors Constraining the Nursing

Workforce in Maryland

In the interest of using Nursing as a model profession to understand vacancies, workforce

outcomes, and applications for Apprenticeship, the Workgroup spent considerable time discussing

factors which may be limiting the supply of nurses in the workforce. In this section, several of

these factors are discussed in relation to how they impact the supply of “new nurses” and how they

may impact experienced professionals in the field.

Many of these factors are structural factors stemming from the legal, regulatory, and institutional

standards that govern training institutions and the profession. Identification of these factors as

“constraints” on the workforce is intended only to drive discussion and analysis and does not

represent a recommendation for policy change without further review.

New Nurses

Nursing Education

All levels of nursing licensure require some level of education, all levels above CNA/GNA require

a post-secondary credential or degree. Several components of education limit the total number of

nurses that can enter the profession each year. Many of these factors are practical or financial

constraints associated with the capacity of approved education providers.

Competitive Admission & Performance: Nursing programs are competitive admission

programs, applicants must meet institutional admission requirements, prerequisites, and

adhere to attendance and performance standards to continue in a program. Not all

prospective nursing students will gain admission to their program of choice and not all

admitted students will persist to clinicals or completion.

While many Maryland high schools offer CNA/GNA training and biomedical concentrator

programs designed to get students connected to careers in healthcare, these resources are

not necessarily distributed across the state based on workforce demand.

Program Capacity: Competitive admission is based on the fixed constraints of the

institution such as physical facilities, instructor capacity, lab capacity, etc. There are a

limited number of accredited programs and the number of students enrolled is constrained

by approved program capacity.

Clinical Site Capacity: Clinical education is a foundational component of nursing

education. Clinical education requires facility space and staff resources that allow student

nurses to be placed. Clinical capacity is limited by healthcare facilities’ staffing capacity,

the supply of nurse preceptors, clinical faculty, and the number of healthcare facilities with

appropriate resources in a given area. Clinical capacity further constrains program capacity

and limits the number of student nurses trained in a given year and geographic area.

Financial and Opportunity Cost: Nursing programs charge tuition and fees in

conjunction with coursework and credit bearing clinical experience. Clinical education is

generally unpaid, and the demanding hours may limit a student’s ability to work a paying

job outside of classes and clinicals. Tuition costs, student debt, family obligations,

childcare, cost of living, and many other social and economic factors limit participation in

education, deterring some prospective students from entering nursing programs.

Licensure & Examination

Nursing students who complete a nursing program must sit for examination and complete all the

required steps for State licensure. Several steps in the examination and licensure process may limit

the supply of new qualified nurses entering the workforce.

Examination Process: Prospective nurses must sit for an examination associated with their

level of education and licensure. Individual factors such as test anxiety may persistently

impact performance and passage rates for certain test-takers, but practical constraints such

as the availability of testing dates and seats constrain the overall number of new nurses that

can be examined in a given period.

Licensure Process: The State licensure process requires the submission and verification

of numerous documents, test scores, and other components. Technological system

limitations, data security issues, staffing, and regulator complexity can all impact the rate

at which licensure materials are received, processed and approved, limiting the supply of

new nurses or prolonging qualified nurses’ entry into the workforce.

Financial Costs: There are costs associated with sitting for examination and completing

State licensure. While assistance programs exist, some applicants may struggle to afford

associated costs, particularly for repeated examination attempts.

Existing Nurses

Attrition from the Field: Nursing is a challenging and demanding profession and external shocks

such as the global pandemic of COVID-19 have pushed healthcare systems and frontline workers

to new limits. New and existing nurses alike choose to exit the profession every year, whether for

concerns over safety, pay, work life balance, or job satisfaction.

Turnover and Churn: As skilled workers with generally portable certifications, nurses may move

between employers seeking better pay, more favorable working conditions, or career advancement.

Some nurses may also choose temporary or travel-based assignments that offer higher pay over

local employment.

Career Advancement:

Advanced nursing practices, specialized roles, and nursing education all require career

advancement milestones and often additional education. The constraining factors of education

discussed above may continue to impact practicing nurses, limiting their ability to advance their

careers and access higher paying positions or more favorable working conditions.

Can Apprenticeship Address Workforce Issues for

Nurses and Nursing Employers?

Building upon the previous section, this section further analyzes each potential workforce

constraint against some of the central principles and documented benefits of Apprenticeship. The

table highlights potential applications where Apprenticeship may prove effective for resolving

workforce issues in the nursing field, and areas where Apprenticeship is expected to have little or

no impact without additional investment and direction.

Potential Application for

Apprenticeship

Limitations of

Apprenticeship

Competitive

Admission &

Performance

States with higher education

sponsored nursing apprenticeship

programs report improved academic

outcomes for apprentice nurses.

To the extent that Youth

Apprenticeship and School to

Apprenticeship programs can be

successfully integrated with high

quality science and math education,

healthcare focused apprenticeship

programs for younger job seekers can

reinforce classroom learning with on

the job skills.

Apprenticeship cannot reduce the

admissions standards for other

training programs or increase the seat

capacity of a program.

Registered Apprenticeship programs

in building trades are also

competitive and apprentices

experience barriers to entry requiring

remediation and additional support.

Program

Capacity

Apprenticeship cannot increase the

capacity of a training program.

Clinical Site

Capacity

Apprenticeship is a potential means

to educate and train nurse preceptors.

Apprenticeship cannot increase

clinical site capacity.

The required one to one ratio for

supervision under Apprenticeship

generally exceeds what is offered in

nursing clinicals.

Clinical sites that struggle to secure

preceptors may similarly struggle to

accommodate apprentice nurses.

Financial and

Opportunity

Cost

Apprentices are employees and are

paid progressively increasing wages.

Apprenticeships on their own do not

provide resources to pay an

Restructuring some nursing programs

as Apprenticeships would ensure

nursing students are compensated for

their labor.

Costs of Related Instruction, such as

tuition and fees, are generally

covered or supported by employers,

sponsors, or other sources under

Apprenticeship.

Nursing Apprenticeships are a proven

strategy to reduce the cost of nursing

education and student debt.

Earlier connection to wages would

reduce or eliminate the opportunity

cost associated with choosing to enter

training.

Apprentice’s wages or Related

Instruction costs.

Employers must be willing and able

to invest in the cost of training and

employing Apprentices.

Examination

Process

Other states and jurisdictions with

Nursing Apprenticeship Programs

have reported promising examination

outcomes for Nursing Apprentices.

Apprentices generally have a longer

period of clinical/practical education

than traditional higher education-

based programs, which may benefit

some learners and improve outcomes.

Apprentice wages may offset the

costs of examination fees and

employers, sponsors, and unions may

cover or assist with fees.

Apprenticeship cannot replace or

eliminate examination processes that

are required by statute, regulation, or

employer policy.

Most examination processes and

standards in nursing and other

healthcare occupations are based on

national standards set by

accreditation bodies.

Licensure

Process

Apprentice wages may offset the

costs of licensure and employer,

sponsors, and unions may cover or

assist with fees.

Apprenticeship cannot replace or

eliminate licensure requirements and

scope of practice restrictions for

healthcare and behavioral health

professionals.

Most licensure standards in nursing

and other healthcare occupations are

based on national standards set by

accreditation bodies.

Scope of practice limitations may

restrict the functions an Apprentice

can perform on the job, with or

without supervision.

Attrition

from the

Field

Registered Apprenticeship programs

have strong connections to collective

bargaining. To the extent that

bargaining units may impact worker

retention, Apprenticeship may be a

tool to increase worker voice and

labor-management partnership.

Apprenticeships have a demonstrated

positive impact on employee

retention in other industries,

Apprenticeship may potentially slow

attrition in healthcare and behavioral

health.

Apprenticeship is unlikely to address

some of the most pressing challenges

for healthcare workers such as

worker pay, working conditions, or

safety.

Turnover and

Churn

Apprenticeships have a demonstrated

positive impact on employee

retention in other industries,

Apprenticeship may potentially slow

attrition in healthcare and behavioral

health.

Apprenticeships and direct

mentorship have been demonstrated

to build positive workplace

professional relationships.

Apprenticeship is unlikely to address

some of the most pressing challenges

for healthcare workers, such as

worker pay, working conditions, or

safety.

Career

Advancement

Apprenticeships present opportunities

for clear career advancement, regular

pay increases, and low or no cost

training.

Apprenticeships can be developed at

all career stages to create ladders of

progression that help workers

advance, access training, and remain

in the field.

Apprenticeship does not guarantee an

apprentice higher paid positions or

better assignments.

Recommendations for Apprenticeships in Healthcare

and Direct Care in Maryland

1. Support and Expand the Existing Nursing Apprenticeship Programs in Maryland

Focus should be placed on supporting and studying Maryland’s small number of approved

Nursing Apprenticeships (CNA/GNA and LPN). These programs could serve as important

models of how the profession can benefit from Registered Apprenticeship, but more data

and larger enrollments are needed. In order to achieve larger enrollments more employer

engagement and, support for apprentices is needed, and a coordinated effort to expand the

programs should be undertaken.

2. Conduct a Systematic Survey on Nursing Education

The Workgroup was able to identify some constraining factors that may impact the supply

of new nurses and the retention and advancement of existing nurses. Registered

Apprenticeship is likely to be more effective at removing some barriers than others.

Without a comprehensive and first-hand understanding of how barriers and constraints

really affect prospective students, students in training, preceptors, faculty, employers, and

licensing/regulatory bodies, it will be difficult to prioritize resources and identify areas

where Registered Apprenticeship may be a workforce solution.

- Survey students on their admission and application experience

- Survey students on their prior work or education experience

- Survey new nurses on their impressions of the field and experience with

examination and licensure

- Survey nursing faculty on their perceptions of student attrition

- Survey nursing administrators on their perceptions of new nurse readiness,

retention, and attrition

- Survey existing nurses on their career goals, long term outlook, and likelihood of

serving as an educator.

3. Invest in the Capacity of Nursing Programs and Clinical Sites

In recent years several pieces of legislation have created new programs to address critical

shortages of frontline healthcare workers, including nurses and nursing assistants.

However, a proportional share of resources has not been directed to expanding the capacity

of nursing programs and creating new nursing faculty and preceptors to staff clinical sites.

4. Work to Improve Academic Readiness among Prospective Students

Nursing is a competitive and rigorous academic disciple. Admitting a greater number of

students without compromising qualifications and standards will mean ensuring students

are better prepared with educational foundations, prerequisites, and career expectations that

match program requirements. This may include a stronger focus on STEM education for

students interested in nursing or more accessible prerequisite coursework pathways for

adult learners.

State and Federal Resources and Initiatives to Support

the Expansion of Apprenticeship Programs

As Apprenticeship grows as a means of training diverse pools of workers for the modern

workforce, local, state, and federal entities have increasingly made more and more resources

available to expand Apprenticeship programs. The following new resources or initiatives are

expected to begin in 2023 and should be considered tools for implementing the strategies identified

in this report:

State Apprenticeship Expansion Formula Grant Funds (US Department of Labor)

In the spring of 2023, the US Department of Labor (USDOL) Employment and Training

Administration released an invitation to apply for federal funds to support the expansion of state

Apprenticeship programs. This included a portion of formula funds to support operations and

modernization, and a competitive fund to support innovative ideas for expansion. MD Labor

applied on behalf of the State of Maryland seeking funds for a range of State apprenticeship

activities.

MD Labor sought $3 million from this opportunity to establish a Public Sector Registered

Apprenticeship Innovation Fund. The Fund would provide apprentice Related Instruction

reimbursements, on the job learning assistance funds, and apprentice supportive service alliances

for public sector employers, including healthcare agencies. USDOL is expected to make an award

announcement in June 2023.

Blueprint for Maryland’s Future Investments in College and Career Readiness

The Blueprint, Maryland’s sweeping education reform legislation, sets new standards and goals

for nearly all dimensions of education in Maryland. One of the Blueprint’s College and Career

Readiness goals specifies that 45 percent of Maryland high school graduates will complete the

high school equivalent of Registered Apprenticeship or another industry recognized credential by

the end of the 2030-2031 school year. This ambitious goal has created a mandate for Maryland’s

Local Education Agencies to invest in and partner with apprenticeship programs.

The career counseling services arrangement with Local Workforce Development Boards is another

significant component of the Blueprint reforms affecting the public workforce system. This new

program will allocate formula-based funding to Local Workforce Development Boards to cover

the cost of career counseling services for students from Local Education Agencies (school

districts). As discussed elsewhere in this report, LWDBs are crucial connection points for

employers, job seekers, training providers, and Registered Apprenticeship sponsors. The

counseling program, paired with other Blueprint investments, could be a significant tool for

advancing Youth Apprenticeship and School to Apprenticeship programs.

The Apprenticeship 2030 Commission (Senate Bill 104)

On April 24, 2023, Governor Wes Moore signed SB104 into law, providing for the establishment

of the Apprenticeship 2030 Commission. According to statute, the purpose of the Commission is

to examine and make recommendations to reduce skill shortages in high–demand occupations and

provide affordable training for career pathways for young people by expanding Registered

Apprenticeships in industry sectors with skill shortages, growing the number of Registered

Apprenticeships to at least 60,000 by 2030, and reaching the Blueprint goal for 45% of high school

graduates completing the high school level of a Registered Apprenticeship.

The Commission, which is expected to begin meeting in July 2023, will play an important role in

helping Maryland’s policy makers and workforce system stakeholders understand the

opportunities associated with apprenticeship programs, particularly in regard to the Blueprint for

Maryland’s Future and the State’s youth employment goals. The Commission is positioned to play

a significant role in advancing the recommendations and findings of this workgroup for

apprenticeships in healthcare.