By the year 2033, it is estimated that there will be a shortage of 12,500 nurses in North Carolina.1 While North Carolina’s vacancy rate has improved since 2024, it is currently at 13%, which is still higher than the national average of 10%.2 In the next decade, NC Nursecast predicts that North Carolina will need an additional 17,500 nurses, primarily due to the rate at which our population is aging. We anticipate that North Carolina residents over the age of 65 will grow by 1 million from 2022 to 2042. By 2035, the percentage of North Carolinians over age 65 will be 20%, compared to only 12% in the year 2000.2 It is also important to note that 40% of these older adults will live in rural areas where access is often limited.3
Shortages are not new to the nursing profession. At various times, we have faced periods when shortages were worse than others. The current nursing shortage is different because there is both a shortage of nurses and an increase in demand for nurses. The shortage, combined with an increase in demand, leads to an even wider gap. Although we anticipate the supply of nurses to grow year over year, it will not be enough to meet the demand for the expected growth in hospital admissions by 40%.4
While many experts are concerned with registered nurse workforce trends, special attention should also be given to the licensed practical nurse (LPN) workforce. By the year 2030, we can expect the supply and demand gap to be up to 20% for LPNs.3 With North Carolina’s population aging quickly, long-term care facilities, which are the primary employers of LPNs, are facing their own challenges. Urban health care organizations are also recruiting LPNs to fill their vacancies, which further impacts long-term care facilities’ ability to recruit and retain LPNs. In 2023, the Centers for Medicare & Medicaid Services proposed an adjustment in staffing standards for long-term care facilities that receive federal funding. If passed, the new requirements would have increased hours per resident per day (HPRPD) for both registered nurses (RNs) and LPNs.3 While the intent was to improve quality and safety in long-term care facilities, the proposed rule would have further limited the ability of these facilities to care for residents. In 2025, the proposed rule was repealed by the U.S. Department of Health and Human Services. The repeal was based on the premise that the rule would place additional strain on facilities and impede access to care for patients.5
To make matters more concerning, we must consider the faculty shortage and its impact on the supply of nurses. According to a report conducted by the American Association of Colleges of Nursing, the average age of nursing faculty is increasing. The average age of doctorally prepared nursing faculty is 61.2 years.6 Despite the demand for the role of nursing faculty, salaries for these individuals typically fall within the lower range of the profession. This equates to a salary of approximately $12,000 less than the lowest-paid practicing RNs.3 As the cost of living increases, the willingness to accept the lower pay associated with being a nursing faculty member is impacted. In addition to financial challenges, nursing faculty are facing a significant amount of burnout. In a national survey of 3556 nursing faculty, where the mean age was 55 years old, 85.2% reported a moderate or high level of burnout.7 All these factors lead to a vicious cycle. Short staffing leads to increased workload demands, which leads to job dissatisfaction and burnout, which then leads to turnover and increased costs.4
Strategies for Academia
During the planning of the 2022–2023 North Carolina state budget, legislators called on UNC system institutions and the State Board of Community Colleges with nursing programs to partner with the goal of increasing the number of LPNs and RNs by 50% annually. This ambitious increase would add approximately 63,000 nurses annually. As a result, several initiatives have been implemented with the goal of decreasing attrition and increasing enrollment.3
To increase enrollment, there has been recognition that institutions must increase faculty salaries and create avenues for nontraditional entry into nursing faculty positions. In the 2023–2024 North Carolina state budget, the General Assembly approved a 10% salary increase for nursing faculty who are state employees.8 This was a significant step forward; however, some argue that this increase only scratches the surface of what is needed to keep up with the demands of everyday living in North Carolina. In addition to improvements for faculty, this collaboration resulted in strategies designed to reduce attrition among nursing students. Students were provided with direct financial assistance, child care vouchers, and professional coaching opportunities.3
Health care organizations must collaborate with academic institutions to expand access to clinical placements and nursing faculty. For instance, in the early 2000s, while serving as a clinical nurse specialist (CNS), I also had the opportunity to function as nursing faculty for a local university as part of my role. During that time, a group of CNSs guided a cohort of nursing students through the full range of clinical rotations required for their BSN program. Participation in the cohort required students to commit to employment with the organization that provided their clinical training.
This strategy resulted in several benefits for students, academic institutions, and health care organizations. Students had the opportunity to be taught by advanced practice registered nurses who were considered experts in their fields. For example, labor and delivery experiences were taught by a certified labor and delivery CNS. Students became very familiar with the culture and practices of the organization and were ready to transition into practice upon graduation. The academic institution gained adjunct faculty and was able to increase enrollment by approximately 10 students year-over-year for this program. The organization benefited by developing a cohort of students trained by experienced team members who were committed to joining the workforce upon graduation.
Organizational Strategies
In addition to partnering with schools of nursing, organizations have an obligation to ensure that the nursing profession remains attractive by increasing pay, considering employee needs based on generational differences, and implementing alternative models of care and technological advances. To support the increased demand for nurses, organizations have increased RN salaries, further widening the gap between nurse and faculty salaries. Between 2019 and 2022, RN salaries in North Carolina increased by an average of 18%, while LPN salaries rose by 12%.3
Unfortunately, these averages do not accurately represent disparities in pay based on location. Rural hospitals are often unable to pay as much as urban organizations, leading to a greater dependence on staffing agencies. In some cases, nurses leave their organization to work for a staffing agency for higher pay, only to be assigned back to the organization they left. This cycle continues.3
In addition to addressing pay gaps, organizations must consider the generational needs of the workforce. As nursing education becomes more accessible, Generation Z nurses are becoming more prevalent in the workforce. These nurses are accustomed to technology, value quick access to information, and prioritize flexibility and collaboration.9 Organizations should review their policies and scheduling practices to ensure they are employee friendly. Nurses should not have to wait extended periods to learn whether their vacation requests are approved. Scheduling processes should be more responsive and adaptable. Some nurses may prefer traditional schedules, while others may prefer clustered shifts that allow for extended time off to pursue personal or professional interests.9
Organizations must also explore alternative models of care where nurses function at the top of their license. Nurses must see themselves as leaders in health care. Historically, nursing has been perceived as quiet, humble, and deferential to physicians. However, nursing is grounded in science, problem-solving, and leadership. Nurses demonstrate leadership through confidence, assertiveness in patient advocacy, and contributions to policy and decision-making.10
In recent years, virtual nursing has become increasingly popular. This model provides experienced nurses with the opportunity to deliver education, improve patient flow by reducing discharge workload, and it allows bedside nurses more time to provide direct clinical care.11 In one model based in Houston, the integration of a virtual intensive care unit (ICU), virtual nursing, and traditional bedside care created more efficient workflows while offering experienced nurses meaningful opportunities to remain engaged in patient care in less physically demanding roles.4
Virtual nursing represents both an alternative model of care and a technology-driven solution to workforce challenges. Organizations must continue to explore advancements in artificial intelligence and digital tools, such as wearable devices that integrate with the medical record, to reduce documentation burden and increase time spent providing patient care.11
Conclusion
As health care organizations and academic institutions strive to create solutions that attract and retain nurses and faculty, we must begin to see things from the perspective of what nurses and faculty need and want. We must develop creative practice environments that embrace fair pay practices, digital technology, and a strong emphasis on safety and professionalism in nursing.
We must also ensure opportunities for creativity and an appreciation for problem-solving and new ideas. We can no longer rely solely on traditional or even team-based models of care. We must leverage technology to lessen the workload for nurses and improve the work environment. We must learn to see beyond the initial cost of implementing technological advances and recognize the long-term benefits of reducing length of stay, improving patient flow, and decreasing nurse turnover.
Acknowledgments
I would like to acknowledge the dedication and resilience of the North Carolina nursing workforce, whose unwavering commitment continues to sustain our health care system in the face of ongoing challenges.
Disclosure of Interests
The author has no conflicts of interest to declare
Financial Support
The author reports no financial support for the development of this commentary.
Correspondence
Address correspondence to Dr. Waqiah Ellis, 3000 New Bern Avenue, Raleigh, NC 27610