Framing the Challenge

As we seek to grow North Carolina’s nursing workforce, it is important first to zoom out and acknowledge that shortages are not new. In 1989, the North Carolina General Assembly passed the Nursing Shortage Alleviation Act (Sess. Law 1989-560), recommending a series of actions across state entities to boost talent supply, strengthen retention of new nurses, and give state agencies more flexible tools to recruit and retain nurses in public health and public safety settings. Sounds familiar. Even with its enactment and promising vision, Sess. Law 1989-560 lacked one critical element needed to drive and monitor progress: a defined goal.

Today, North Carolina benefits from more robust data systems. The Cecil G. Sheps Center for Health Services Research released NC NurseCast—widely regarded as a national leader among nursing workforce forecasting tools—and projected that the state’s nursing shortage will reach 12,500 registered nurses (RNs) and 5000 licensed practical nurses (LPNs) by 2033.1 While these projections help us understand the scale of the challenge, we operate in a dynamic environment and must actively engage decision makers across a large and multifaceted health workforce ecosystem.

Tracking Progress Toward Closing the Gap

The NC Health Talent Alliance (NC HTA)—a project of the NC Center on the Workforce for Health launched in partnership with the NC Chamber Foundation and the North Carolina Area Health Education Centers (NC AHEC) in 2023—uses a straightforward proxy to track progress toward closing the nursing workforce gap: the annual talent deficit. Because sustained annual deficits drive long-term shortages, a metric that reflects both retention and educational output provides a useful way to measure progress.

Using annual supply data from the North Carolina Board of Nursing (NCBON) and demand estimates derived from Lightcast labor market analysis, North Carolina’s 2025 demand for RNs exceeded supply by 2710 nurses. Eliminating this annual deficit—reaching a net zero gap—requires a combination of strategies to reduce demand and increase supply. This approach goes beyond simply producing “more” nurses and instead reflects the cumulative impact of initiatives underway across the state.

While a metric based solely on employer demand is inherently limited—workforce capacity ultimately exists to improve population health—it remains a strong indicator of labor market imbalance. When paired with other data sources, it also provides a framework for sub-state analysis.

In addition to the annual deficit metric, the NC HTA assesses employer demand through an annual survey tracking open position rates and churn across multiple employer types and care settings. Collectively, NC Health Talent Alliance (NC HTA) analyses use both primary and secondary data to deliver statewide and regional diagnostics of nursing workforce stability,2 including:

  • An annual deficit of 2710 registered nurses: the gap between annual demand and annual supply.

  • A 13% open position rate: the proportion of authorized positions that are unfilled.

  • A 43% churn rate: the annual movement of professionals into and out of organizations, including separations for any reason.

  • A 72% program completion rate: the cohort-level completion rate across public Associates Degree in Nursing (ADN) and Bachelor of Science in Nursing (BSN) programs.

Further analyses are underway to develop additional metrics related to regional retention (e.g., the proportion of graduates who remain in their local communities) and pathway utilization (e.g., routes students take to enter the nursing profession).

These data help NC HTA regional collaboratives—made up of employers, educators, and workforce partners—define local challenges and prioritize targeted interventions. They also provide state and local partners with insight into year-to-year trends that help contextualize complementary resources such as NC NurseCast. Ultimately, progress toward eliminating annual talent deficits will signal whether North Carolina is meeting short-term workforce needs while preparing for rapid growth in nursing demand. The North Carolina Department of Commerce projects nursing jobs will grow by 10% between 2024 and 2034, driven by population growth and aging.3 Workforce diagnostics help describe the challenge; existing research helps identify opportunities for solutions.

Assessing Current Priorities

North Carolina benefits from an exceptionally strong community of organizations and leaders dedicated to supporting the nursing workforce. One of the most important opportunities ahead is to maximize the shared impact of this community by aligning around common priorities.

Over the past three years, partners representing employers, educators, and state agencies have produced nearly 300 pages of recommendations across five major reports focused heavily on the nursing workforce:

  • “Time for Action: Securing a Strong Nursing Workforce for North Carolina” (North Carolina Institute of Medicine Task Force on the Future of the Nursing Workforce).4

  • “Investing in North Carolina’s Caregiving Workforce” (Caregiving Workforce Strategic Leadership Council, co-led by the North Carolina Department of Health and Human Services [NCDHHS] and the North Carolina Department of Commerce).5

  • “Recommendations on Increasing Nursing Graduates: In Response to SL 2022-74 (HB 103), Section 8.3” (the University of North Carolina [UNC] System and the North Carolina Community Colleges System [NCCCS]).6

  • “North Carolina Healthcare Association Critical Workforce Needs Assessment” (RTI International).7

  • “2025 NC Health Talent Alliance Annual Survey & Workforce Trends” (NC Center on the Workforce for Health and NC Chamber Foundation).2

These reports collectively reveal consistent themes and clear opportunities for coordinated action. All five emphasize strategies to increase the supply of nurses by:

  1. Expanding academic and success-coaching supports.

  2. Scaling and modernizing clinical training capacity.

  3. Strengthening faculty supply through improved compensation and flexibility.

  4. Expanding physical classroom capacity.

  5. Strengthening recruitment and entry pathways.

Boosting New Supply

North Carolina is steadily increasing its production of new nurses. Over the past three years, NCBON data show nearly a 15% increase in new ADN and BSN graduates who pass the NCLEX (National Council Licensure Examination), resulting in more than 4500 new nurses last year alone. This progress reflects significant statewide efforts, supported by approximately $95 million in state investments targeted at health sciences and nursing education, with more than $42.1 million directly supporting 44 public nursing programs.8,9

If this growth trajectory continues and ADN and BSN program output rises by an additional 15% over the next three years, the annual deficit would narrow to approximately 2070 nurses. While achieving this growth will be challenging, opportunities exist, particularly through targeted efforts to maximize existing program capacity.

In 2024, nursing programs responding to the NC HTA survey reported operating at only 72% of maximum enrollment capacity. Closing this gap could yield as many as 2800 additional graduates. Across the 2024 and 2025 surveys, program leaders identified two primary constraints: limited faculty availability and insufficient clinical placement capacity. Collaboration with employers is already demonstrating progress through initiatives such as the Clinical Instructor Partnership and through regional NC HTA collaboratives addressing both barriers. Efforts to expand capacity must be matched with initiatives to improve student completion. Among 2025 HTA participants, attrition rates were substantially higher in ADN programs (37%) than in BSN programs (17%), likely reflecting differences in student supports and institutional resources.

Promising initiatives are underway statewide to address faculty supply, clinical partnerships, and student success. In the Southeast AHEC region, for example, a $22.3 million New Hanover Endowment grant supports expanded capacity, enrollment, and completion at Cape Fear Community College and University of North Carolina Wilmington’s School of Nursing. Early outcomes are encouraging and exemplify collaboration occurring across the ten NC HTA regional collaboratives.

Boosting Already-Trained Supply

In addition to expanding new supply, North Carolina can draw on pools of already-trained RNs to meet current demand. While out-of-state recruitment remains important, many nurses who have left active practice or have disengaged from nursing altogether may be positioned to re-enter in clinical or educational roles.

Internal analysis of NCBON licensure and employment data conducted by the NC Center on the Workforce for Health and NC AHEC shows that RN disengagement varies significantly by region and occurs at multiple points along the participation continuum. Across NC AHEC regions, nurses differ not only in employment status but also in license status. Examining these indicators together provides a more complete understanding of workforce attrition.

For example, Mountain AHEC and Southeast AHEC emerge as regions with consistently elevated disengagement. In both regions, inactive licenses exceed expected levels, and among nurses holding active licenses, the proportion not employed in nursing is among the highest statewide (15% in Mountain AHEC and 17% in Southeast AHEC). This layered pattern suggests both partial and complete disengagement from the workforce.

These findings underscore the importance of region-specific re-engagement strategies. While initiatives such as RN Refresher programs and NC HTA partnerships can support reentry, sustained retention of re-engaged nurses requires coordinated efforts across education, employers, and support systems.

Improving Retention

The reviewed workforce reports consistently highlight retention strategies aligned with established job-quality frameworks from the US Chamber Foundation, the US Surgeon General, and PHI International. Three major retention themes emerge:

Compensation and financial supports: Adjusting public-sector wages to keep pace with inflation, expanding loan repayment and scholarship programs tied to service commitments, offering retention incentives, and addressing non-wage pressures such as childcare and transportation costs.

Work environment and burnout: Addressing heavy workloads, safety concerns, and inflexible scheduling through safer staffing models, increased support staff, flexible scheduling, mental health supports, and reduced administrative burden via team-based care and technology.

Career pathways and professional development: Expanding mentorship, nurse residency, transition-to-practice programs, and leadership development to improve job satisfaction and long-term retention.

Scaling Coordinated Action

Because these priorities span the full continuum of nursing education and practice, durable progress requires coordination.

Across reports from the North Carolina Institute of Medicine (NCIOM),4 the Caregiving Workforce Strategic Leadership Council,5 and NC Health Talent Alliance,2 three needs appear repeatedly: (1) Strengthening social and institutional supports for nurses, (2) implementing targeted retention strategies, and (3) addressing faculty capacity constraints. While these issues are longstanding, what has been missing is an accountability mechanism to align action across organizations.

Introducing the Nursing Workforce Coordinating Council

In late 2025, the NC Center on the Workforce for Health announced the formation of the Nursing Workforce Coordinating Council (NWCC), a nurse-led, statewide body composed of nursing leaders, educators, employers, health care executives, researchers, and representatives from key state agencies.

Building on North Carolina’s strong history of nursing workforce leadership, the NWCC is designed to be nurse-centric, community-informed, and action-oriented. Its purpose is to guide strategy, inform policy, and advance collaborative solutions to strengthen the nursing workforce.

Strategically, the NWCC will:

  • Advance Strategy 18.1 of the May 2024 NCIOM Task Force report, which calls for convening a nurse-led advisory group.4

  • Ensure nurse leadership guides the Center’s participation in the National Forum of State Nursing Workforce Centers.

  • Provide a structured vehicle to prioritize, align, and implement existing recommendations.

The NWCC builds on existing leadership infrastructure, strengthens alignment across organizations, and elevates research, data analysis, policy coordination, and emerging innovations.

During its initial meetings, the NWCC prioritized nursing retention and cross-sector coordination, aligning with themes raised across major workforce reports. Action teams are now inventorying current initiatives, identifying gaps, and coordinating implementation. The NWCC will provide the shared infrastructure needed to ensure that the impact of our shared efforts is greater than a collection of fragmented initiatives.

Acknowledgments

The author would like to thank Dr. Jill Forcina and Lara Gastelumendi-Franco for their contributions to this analysis. NCIOM provides the Center on the Workforce for Health contracted project management support for the Nursing Workforce Coordinating Council.

Correspondence

Address correspondence to Andy MacCracken (andy_maccracken@ncahec.net).