In 2024, along with my colleagues Catherine Sevier, DrPH, MSN; and Hugh Tilson Jr., JD, MPH, I co-chaired the North Carolina Institute of Medicine’s Nursing Workforce Taskforce. This was a follow-up report on the nursing workforce report that was done in 2014. The title of the North Carolina Institute of Medicine’s current report is “Time for Action: Securing a Strong Nursing Workforce for North Carolina.”1 In that report, we examined the current state of the nursing workforce in North Carolina, ways to strengthen pathways toward a nursing career, ways to sustain the nursing workforce, and valuing the work that nurses do. The task force submitted 8 recommendations and 21 strategies aimed at sustaining and retaining North Carolina’s nurses.
This was an exciting opportunity, as it was a chance to look at the nursing workforce for the state of North Carolina post-COVID. We know that COVID took a severe toll on health and health care. During the COVID-19 pandemic, nursing was one of the hardest-hit professions. According to the National Council of State Boards of Nursing data, an estimated 100,000 nurses left the workforce during the pandemic, and by 2027, almost 900,000 nurses—or one fifth of the 4.5 million registered nurses (RNs)—intend to leave the workforce, causing a threat to the national health care system at large if solutions are not enacted.2 In North Carolina, it was estimated that 15.8% of the RNs left the workforce during that time.3
These numbers should be sounding an alarm, because according to a 2026 United States Census Bureau report, North Carolina is ranked as one of the top states for domestic migration and as the third fastest-growing state in the nation.4 It is projected to be the 7th most populated state in the early 2030s.5 As the state’s population grows, so does the need for health care and more nurses. By 2033, hospital RN demand is expected to exceed supply by nearly 10,000 positions, while LPN shortages in hospitals are projected at 31.7%.1 These projections beg the following questions: how do we get nurses to remain in the profession and attract more individuals to become nurses when nurses continue to report acts of incivility, being bullied, violent abuse, burnout, and being undervalued? How are nurses currently valued as professionals?
There are multiple answers to these questions that reflect both positive and negative perspectives. First, nursing is by far the largest member of the health care sector. On a positive note, according to a Gallop poll, nursing has been rated by the public as the most trusted profession over the past 25 years.6 However, despite this outstanding record, nursing is still undervalued. Nurses are frequently viewed as a commodity rather than a value-generating clinical service. Nurses provide care, support, education, leadership, and advocacy across all sectors of health care, such as hospitals, primary care, public health, schools, and long-term care. They are expected to be promoters of health equity, access to care, and adapt and embrace technology. Their service is included in the room and board for inpatient care. Although nurses provide a valuable service (I would argue the most valuable service, since they are there 24/7) and collaborate with members of other health professions, they are not permitted to charge for what they bring to the table like their physician, pharmacist, social workers, physical therapy, or occupational therapy colleagues.
Yet there continues to be an increase in demand for nursing services, both inside and outside of health care facilities. For nursing to recover from the disruptions of the pandemic and to attract and retain nurses, the profession must not only be recognized as caring and trusted, but the service that nurses bring must be included in the revenue-generating column of the health care financial spreadsheet.7 They should not be perceived primarily as a labor cost. The issue of nursing being seen as just cost and no value reflects a system that operates without acknowledging or little appreciation of nursing’s scientific complexity or its central role in protecting the public’s health.
Second, more aggressive steps must be put in place to attract and retain nurses. As previously mentioned, from a positive perspective, nursing already has the trust and respect of the public. However, as nurses are subjected to workplace violence, staffing shortages, and educational debt burdens, it is hard for nurses to want to remain in a profession where they feel undervalued. A 2026 NSI Nursing Solutions, Inc. report, the “National Health Care Retention and RN Staffing Report,” featured input from 527 hospitals in 40 states on RN turnover, retention, vacancy rates, recruitment metrics, and staffing strategies.8 The report covered 965,886 health care workers and 262,405 RNs. The turnover rate for staff RNs grew by 1.2% in 2025, resulting in a national average of 17.6%, reversing the prior year’s decline. RN turnover ranged from 5.6% to 40.0% given hospitals’ varying bed counts. The top reasons cited for leaving the institutions were personal issues, relocation, career advancement, retirement, and education. This report did not draw specific state conclusions, but the Southeast and Western United States reflected figures that were above the national average turnover rate of 17.6%, at 18.7% (+1.4%) and 18.4% (+2.3%) respectively (NSI, 2025).
Such drastic turnover not only means that there are less personnel available to provide care but also contributes to the loss of revenue for health care facilities. The average cost of turnover for a staff nurse is $60,090 (down slightly from $61,110 the previous year). Each RN turnover causes the average hospital to lose between $4.2 million and $6.2 million, with total annual losses averaging $5.19 million per hospital (NSI, 2025). It should be noted that the NSI report estimates that each percent change in RN turnover may cost or save the average hospital $295,000 per year. The 1.2% uptick in RN turnover inflated hospital losses by roughly $360,000. Hospitals can mitigate this margin compression by focusing on labor expenses, with reducing dependency on temporary labor as a primary target. Additionally, as stated in recommendation #5 of the taskforce report, the retention of nurses in a practice environment with high rates of turnover or vacancies could be improved by addressing work environment issues such as workloads and offering flexibility in scheduling.
Even if nurses wanted to advance their career, there are stumbling blocks that may hinder that opportunity. This is especially true and challenging given recent moves by the US Department of Education (DOE) to exclude nursing from its revised definition of professional degree programs. Such a decision could hamper or hinder the probability of nurses seeking advanced practice education or wanting to become nurse educators from being able to obtain student loans.
In late February 2026, the DOE proposed new rules for how it defines professional degree programs for Federal student aid purposes that excluded graduate nursing degrees (Master of Science in Nursing, Doctor of Nursing Practice, and PhD) from the definition of “professional degrees.”9 Under the proposed revision, programs such as medicine, law, dentistry, and pharmacy continue to qualify as professional degrees. However, as a result of this proposed change, federal graduate loan programs (including graduate PLUS loans) and the borrowing cap under new repayment structures may affect student eligibility to receive such loans. By limiting access to such loans, nurses (and pre-licensure nursing students) may be unable to finance their education. They may be forced to seek private loans with a higher interest rate. Through the exclusion of nursing from professional degree recognition, federal policy sends a contradictory message: nurses are essential to care delivery, but their education warrants less institutional support. The result of this proposed rule is that there may be fewer advanced practice registered nurses (APRNs) providing care in very heavily rural areas of the state that lack physician providers. This will also affect individuals who are entering pre-licensure nursing programs for the first time, resulting in a continued shrinking nursing workforce for North Carolina and across the country.
Finally, I have always advocated that the nursing profession should be reflective of the people that we serve. The continued growth of the population of North Carolina also reflects evidence of a growing multi-ethnic population. It compounds the need for culturally competent care that is essential for the delivery of safe, effective, and equitable health care. Culturally competent care involves the understanding and respect of a patient’s cultural values, beliefs, language preference, and lived experiences. There needs to be an aggressive campaign that attracts more men and individuals from ethnic minorities into the nursing profession. As health care professionals know, when it comes to providing care, it is important that patients see someone who looks like them and who can advocate on their behalf. Nurses know that when there is diversification within the profession, we are much more likely to see increases in compliance, and through our advocacy efforts, we can make sure that the patient understands and participates in their established care plan. This also translates into better patient outcomes. The more nursing can reflect society, the more success we will have in caring for and healing our patients. Ultimately, this approach also helps to reduce health disparities and ensures that care is patient-centered rather than a one-size-fits-all approach. However, to attract more men and multi-ethnic individuals to the nursing profession, there must be funding opportunities that ease their pathway into the profession.
I firmly believe that nursing still has a pivotal role to play in meeting today’s health care needs and challenges. Nurses must use their advocacy and leadership skills to address those challenges, beginning with educational opportunities. There needs to be greater improvement in opportunities afforded for individuals who desire to become nurses. Whether those opportunities are scholarships or grants from employers to their assistive personnel, state-sponsored grants, or private scholarships, more funds must be appropriated to ease the burden of working and being a student. Additionally, nursing programs must make a concerted effort to attract, train, and graduate qualified candidates to pass the pre-licensure exam. The implementation of holistic admission, supportive environments, and mentorship programs may be a good place to start. Additionally, more funding to support nursing faculty and clinical training sites is also warranted.
Acknowledgments
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Declaration of Interests
The author has no conflicts of interest to declare.