North Carolina is facing an estimated shortage of 12,500 registered nurses (RNs) in hospitals by 2033. This major workforce shortage is exacerbated by high rates of nursing turnover, which was 27.1% in 2021.1 Each percent change in nurse turnover costs hospitals $262,500 per year, resulting in US hospitals losing $5.2 million–$9 million a year due to nurse turnover.2 Rural communities are especially vulnerable to the impact of turnover due to less flexibility to react to workforce shortage needs.

Across rural communities, the health care workforce shortage has reached a critical point, straining hospitals, clinics, and the residents who depend on them for timely, quality care. Limited resources, geographic isolation, and an aging workforce have made it increasingly difficult for rural systems to meet growing health needs, underscoring the urgency for innovative, collective solutions. Addressing these challenges will require sustained collaboration among health care organizations, educational institutions, community partners, and policymakers with an emphasis on teamwork and collaboration. No one entity has the answer, and innovative solutions that take a multi-faceted approach are essential.

In 2024, UNC Health launched the Robert A. Ingram Institute for Equitable Healthcare Access (Ingram Institute). The Ingram Institute serves as a collaborating and coordinating partner within UNC Health, connecting with academic and community partners to develop, pilot, and evaluate models to address health care needs, especially in rural communities. As part of Amplified Academics in UNC Health’s Forward Together 2030 Strategic Plan, the Ingram Institute works with partners such as the NC Center on the Workforce for Health, North Carolina Area Health Education Centers (NC AHEC), North Carolina Department of Public Instruction (NC DPI) Career Technical Education (CTE), and the North Carolina Community College System to build and sustain educational pathways for health care careers, from high school to returning to the workforce. Using guidance outlined in the North Carolina Institute of Medicine’s (NCIOM) Future of Nursing Task Force report, “Time for Action: Securing a Strong Nursing Workforce for North Carolina,” Ingram’s approach is intentionally interprofessional, with engagement across professions and a focus on the essential skills needed for collaborative practice.3 This article highlights three programs in our model focused on Explore (designing pre-health exploration programs); Employ (making connections for individuals to enter the workforce pathway seamlessly); and Empower (building opportunities for long term growth and retention).

Explore: Experiencing Health Professions

Students from rural communities often have limited opportunities for shadowing a diverse range of health care professionals, which can delay their career selection or provide missed opportunities for exposure to a health career. Expanding access to shadowing experiences with a diverse range of professionals can help students make informed academic choices and more seamlessly pursue health care pathways. In 2019, The University of North Carolina at Chapel Hill launched BIOL 117 (Considering Health Professions), a one-credit-hour elective offering focused on health care careers and interprofessional education. BIOL 118 (Pursuing Health Professions), also one credit hour, was established in 2020 and focused on application readiness, shadowing, and internship opportunities.

In a needs assessment completed in 2023, students expressed a greater desire for opportunities to work within health systems. This request, in alignment with Strategy 2 of the NCIOM Future of Nursing Task Force, was the catalyst for launching BIOL 119 (Experiencing Health Professions). This three-credit-hour course is an academic-practice partnership between UNC Health and UNC Chapel Hill where students work in patient-facing roles to gain experience in the health system. A unique outcome of this course is that students are eligible for per diem jobs at completion of the course and can work throughout the UNC Health System. In August 2024, the course was piloted with 30 students who completed 96 hours each as patient sitters. The course has now expanded to 80 students each semester (fall and spring) who work in high-need roles such as phlebotomy, paraprofessional roles, pathology lab, and patient sitters. Students learn essential communication skills such as TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) and hear from a variety of guest speakers across the health system who share their professional journey.4

The goal of the Ingram Institute is to expand this course across the UNC System and to support health systems wishing to expand this model in their own practice. This course is taught by two nursing faculty members and is cross listed within the UNC School of Nursing (SON), meeting the requirements for elective credit for pre-nursing students. Since its creation, about 15% of the students each semester in the course have been hired in per diem roles, and student evaluations reflect a deep commitment to pursuing a health career at course completion.

Employ: The Rural PrOMISE program

Strategy 17 in the NCIOM nursing taskforce report states the importance of retaining and incentivizing nurses in needed roles and rural areas.3 The World Health Organization’s policy on increasing the rural workforce recommends education as the foundation for producing competent health workers.5 It concludes that programs designed to identify students from rural areas, train them in rural locations, and use methods and curricula tailored to address rural health are more likely to influence their future practice location. Programs that incorporate scholarship, education, recruitment, and placement of students demonstrated success and increased self-efficacy across disciplines.

In response, Ingram Institute launched the Rural PrOMISE (Providing Opportunities and Mentorship in Scholarship and Education) program, a three-year initiative funded by The Duke Endowment. This program has created a recruitment and retention model that equips students and preceptors with the skills needed for mentorship, simulation, clinical training, and support for nursing care in rural communities. UNC School of Nursing undergraduate students interested in practicing in rural communities will receive innovative clinical training opportunities and guided preceptorships within UNC Health entities to maximize engagement during rural and academic hospital rotations. These opportunities will be paired with scholarship support for a commitment to practice in a rural community of their choice for three years following graduation.

Rural PrOMISE funds a cohort of 8 undergraduate nursing (BSN) students a year and works alongside the UNC Health system to identify, train, and support up to 30 preceptors practicing in rural communities, allowing for professional development of practicing nurses. Providing high-quality clinical opportunities for nursing students in rural areas can facilitate recruitment for permanent positions. Ultimately, these experiences add enculturation within the organization, which has been shown to increase a student’s beliefs and expectations that they can be successful (self-efficacy) in a rural community, making them more likely to transition to and remain in a rural setting. This approach reduces turnover costs and helps address nursing shortages in these rural entities.6 Scholarships to reduce debt burden will incentivize rural and underserved practice areas and ensure training is accessible to students regardless of economic background. In the long term, decreased staffing shortages will reduce strain on the entire care team and increase access and quality of care for patients.

Students complete rotations as a cohort in three rural health systems, as well as one rotation in a major academic medical center, with a final capstone experience at a rural location of the student’s choice, ideally their desired place of employment. Additionally, students participate in monthly networking sessions with faculty, rural leaders and advocates, and community partners. Topics include understanding North Carolina’s rural communities, end-of-life care, patient and self-advocacy, and educational advancement opportunities beyond graduation. These sessions are intentionally designed to expose students to the full continuum of care and the interprofessional teams that support it. Sessions are also designed to encourage students to expand their networks and help them navigate their pathways to success. Students in the cohort are excited for their roles in improving health outcomes in rural communities.

Empower: The RN Refresher Program

For registered nurses who have left the workplace, returning to active nursing can feel daunting. Established in the 1990s and updated in 2024, the RN Refresher program by NC AHEC provides updated educational content and clinical experiences for nurses who wish to return to active practice. The program is open to RNs who have an expired or inactive license (especially those inactive for over five years), or those wishing to have a knowledge update.7

While NC AHEC aims to keep program costs reasonable, costs can be a detriment to enrolling in this program. Therefore, the Ingram Institute partnered with NC AHEC to offer scholarships for nurses from rural communities who wish to return to practice in their home communities. Launched in February 2026, 12 scholarships are available through the Ingram Institute, with three nurses currently enrolled in the program. Following completion of the 24 self-paced modules, participants are placed on the unit that they wish to work on and complete 140 hours on the unit. Following completion, nurses are connected with the HR team for employment opportunities.

Making the Case for Investment

Investing in rural nursing is a strategic and necessary response to persistent health inequities, workforce shortages, and an aging population in rural communities. Rural residents experience higher rates of chronic disease, limited access to primary and specialty care, and longer travel times for essential health services. Nurses are often the backbone of care delivery in these settings, serving not only as clinicians, but also as care coordinators, educators, and trusted community resources. Strengthening the rural nursing workforce improves access to care, enhances continuity, and supports the sustainability of local health systems, ultimately contributing to better health outcomes and economic stability in rural regions.

Early and intentional pre-health exposure is a proven pathway to building that workforce. When rural students are introduced to nursing and health careers through pre-health experiences such as the BIOL 119 and Rural PrOMISE program, they are more likely to pursue health professions and return to serve their home communities. These experiences demystify the profession, build confidence and academic readiness, and expand the pipeline of diverse, locally rooted future nurses. Investing at this stage helps address long-term workforce needs while creating upward mobility opportunities for rural students who may not otherwise see nursing as an attainable career.

Students often face unique barriers, including financial strain, limited access to clinical placements close to home, and fewer academic support resources. Targeted investments such as rural clinical rotations, housing and travel support, stipends, and strong academic-practice partnerships increase retention and successful program completion. Evidence consistently shows that nurses are more likely to practice in rural areas when they train there, making this investment both efficient and impactful for workforce stabilization.

Finally, nurses wishing to return to the bedside represent a high-value, experienced talent pool that rural communities cannot afford to overlook. Many licensed nurses have stepped away from direct care due to burnout, family responsibilities, or lack of flexible opportunities. Re-entry programs, refresher courses, supportive onboarding, and flexible scheduling can successfully bring these nurses back into practice. For rural health systems, investing in return-to-practice pathways restores critical expertise, reduces staffing shortages, and strengthens care teams while offering nurses a supported, sustainable path back to meaningful clinical work.

Declaration of Interests

The authors have no conflicts of interest to declare.

Correspondence

Address correspondence to Meg Zomorodi, UNC School of Medicine – Dean’s Office, Ingram Institute, Campus Box 7000, 150 Medical Drive, 7000 Roper Hall, Chapel Hill, NC 27599 (meg_zomorodi@unc.edu).