Cultivating a Robust Nursing Workforce: The Role of the Public Sector

“Every nurse I know is making a plan to leave the field within the next year—even the new grads.” This comment was made by a friend earlier this year during a small reunion of nursing school classmates. Only one of us still works at the bedside. For the rest of us, our reasons for leaving frontline nursing range from burnout under untenable working conditions to moral distress over providing lower-quality care because of inadequate staff support. Unfortunately, our stories are not unique: According to the 2024 National Nursing Workforce Survey, a staggering 40% of registered nurses (RNs) reported that they planned to retire or leave nursing within five years.¹

The public sector has an essential role to play, both as a regulator and major employer, as the state faces a projected shortage of 12,500 RNs and 5000 licensed practical nurses (LPNs) by 2033.² In 2025, a survey of North Carolina health employers reported an open nursing position rate of 13%, with significantly higher vacancies reported in public facilities (24% for RNs and 41% for LPNs).³

In 2022, leaders at the North Carolina Department of Health and Human Services (NCDHHS), North Carolina Department of Commerce, and North Carolina Area Health Education Centers (NC AHEC) convened a group of state entities to examine the public sector’s role in building a robust health workforce given the state’s significant role in K-12 and post-secondary education, employment of health care workers, and regulation and payment of health services. The North Carolina Caregiving Workforce Strategic Leadership Council (“Caregiving Council”) was charged with identifying challenges across the workforce and recommending public sector policy levers that could mitigate existing and projected workforce crises across key caregiving fields. A culminating report was released in January 2024 and included six overarching recommendations for the nursing workforce:

1. Establish academic coaches for community college nursing students

2. Invest in social resources

3. Enhance and invest in clinical partnerships

4. Readjust nurse faculty salaries and schedules

5. Increase availability of nurse and faculty loan repayment programs

6. Improve employee retention and engagement

While NCDHHS and its state partners have made significant progress in advancing these recommendations, implementation efforts have highlighted areas that demand further investment, coordination, and data.

Caregiving Workforce Strategic Leadership Council Progress

1. Establish Academic Coaches for Community College Nursing Students

A robust nursing workforce relies on a sustainable educational output of licensed nurses equipped to provide high-quality care to North Carolinians. Nursing school admissions are highly competitive, but barriers and bottlenecks remain for admitted students throughout their educational program, clinical training, and transition to practice.

Attrition across pre-licensure nursing programs can reach 20%, with students dropping out due to academic challenges, financial distress, mental health concerns, and lack of support both institutionally and socially.⁴ Addressing attrition was a recommendation of the University of North Carolina (UNC) System and the North Carolina Community College System (NCCCS) in a 2023 report to the North Carolina General Assembly (NCGA), with both systems citing high attrition rates as a barrier to nursing output.⁵

The Community College System recently completed a successful three-year pilot program supported by a $1.8 million investment from the North Carolina GlaxoSmithKline Foundation to test the efficacy of academic success coaches across six partner colleges. With nursing programs as a key focus, the pilot demonstrated measurable gains, including higher completion rates and improved NCLEX (National Council Licensure Examination) pass rates, underscoring the value of dedicated academic coaching in addressing academic-related attrition.

2. Invest in Social Resources

Beyond academic supports, NCCCS and UNC System investments in wraparound services are critical to fulfilling the Caregiving Council’s recommendation to invest in social resources for nursing students. In May, NCCCS announced a $6 million investment from the William R. Kenan Jr. Charitable Trust and AmeriHealth Caritas North Carolina to expand the system’s NC Boost program into health care fields. The NC Boost program, which is modeled after City University of New York’s (CUNY) Accelerated Study in Associate Programs (ASAP), provides dedicated advising, wraparound services, and direct financial support to participating students.⁶ Across the UNC System, many individual colleges offer scholarships that cover tuition as well as ancillary training costs like uniforms, testing fees and prep, parking passes, and more. Building on these existing efforts, the Council has also identified two additional opportunities that could further strengthen social supports for nursing trainees:

Nurse apprentice programs. In 2025, North Carolina Governor Josh Stein set the ambitious goal of doubling the number of registered apprentices across all fields statewide. While work-based learning has long been embedded in many health training programs through clinical rotations, an apprenticeship model in nursing could fulfil the triple aim of decreasing nursing school attrition, providing wraparound supports, and improving employee retention. A tailored earn-while-you-learn model can mitigate financial distress, enable personalized pacing for rigorous academic training, and provide support through mentorship.⁷ According to the US Department of Labor, employers retain 93% of apprentices following program completion—an enormous incentive for employers grappling with high turnover.⁸ North Carolina also provides a tuition waiver for youth in pre-apprenticeship programs who enter a registered apprenticeship within 120 days of graduating high school, providing a tuition-free pathway to community college coursework.⁹

The Rural Health Transformation Program (RHTP). In December, NCDHHS was awarded $213 million from the Centers for Medicare and Medicaid Services (CMS) to improve rural health care, including cultivation of a sustainable rural health workforce.¹⁰ Investments will be driven by locally governed, community-driven hubs that can opt to utilize funding for social supports such as childcare subsidies for rural health providers and trainees.

3. Enhance and Invest in Clinical Partnerships

Data from the North Carolina Board of Nursing (NCBON) found that one in three qualified applicants was denied admission to pre-licensure nursing programs each year—equivalent to about 4000 students in 2021.¹¹ Persistent faculty shortages are one of the most significant factors limiting nursing school enrollment. In addition to not having enough nurses pursuing the graduate education necessary to become faculty, schools of nursing also face challenges retaining existing faculty, largely because academic salaries are comparatively lower than clinical nursing roles.¹²

Recruiting faculty from the bedside can also exacerbate understaffing across the workforce. NC AHEC is addressing this problem through its innovative Clinical Instructor Partnership (CIP) program, a model that allows nurses to split their time between patient care and a clinical faculty position within their own institution. Costs are shared between the clinical and academic institutions so that the nurse in the CIP role can maintain their clinical income and practice while working as faculty. The program expanded to 37 partnerships^[1] between 2023 and 2025 across 32 nursing schools, with program evaluation responses indicating increased capacity to expand enrollment.¹³ The CIP program also plays a pivotal role in workforce recruitment for the employer; a similar program in Arizona reported that more than half (53%) of students participating in a program using a clinical instructor partner were recruited into employment with that practice partner following graduation.¹⁴ In April, Governor Stein proposed a comprehensive budget that included a $1 million investment to expand AHEC’s Clinical Partnership program with the goal of increasing qualified training sites and faculty.¹⁵

4. Readjust Nurse Faculty Salaries and Schedules

In 2023, the NCGA made a significant investment in recruitment and retention of nursing faculty when they passed a state budget, increasing faculty salaries in the UNC System and NCCCS by 10% (starting faculty), with a 15% cap (all faculty). More analysis is needed to examine whether the salary increases altered retention and recruitment and led to increased training capacity. Investments in faculty training are now more critical than ever given the U.S. Department of Education’s April final rule excluding nursing from the list of professions eligible for certain graduate level loans.¹⁶

5. Increase Availability of Nurse and Faculty Loan Repayment Programs

Decreasing the financial strain of undergraduate and graduate nursing programs is critical for recruiting nurses, especially in rural, public, or underserved settings. Scholarships and loan repayment programs can also make entry to the nursing workforce possible for underrepresented populations who otherwise face insurmountable financial barriers to the field. In 2023, the NCGA allocated $2 million to NCDHHS to expand the state’s existing loan repayment program to include RNs for the first time. In October, NCDHHS’s Office of Rural Health launched the North Carolina Nurse Initiative, offering loan repayment to RNs practicing in outpatient primary care in rural, medically underserved parts of the state, as well as those working in the 13 state-operated health facilities. In a report to the NCGA, NCDHHS reported that a significant number of inquiries into the program were made by nurses working in acute care hospitals and specialty offices—settings that are not eligible under the current statute.¹⁷ Given the high level of interest from RNs practicing across all setting types, expanding eligibility criteria for loan repayment to additional high-need settings could extend the program’s impact across North Carolina’s broader nursing workforce.

6. Improve Employee Retention and Engagement

Nurse turnover is costly to employers and threatens access to high-quality care for North Carolinians. Competitive wages and retention incentives are crucial to addressing staffing needs in public-sector settings like state-operated health facilities, county health departments, local schools, and correctional settings. While detailed data sources are limited, as many as 5%–15%^[2] of the 110,956 licensed RNs currently working in North Carolina are employed in the public sector, including federal, state, school district, or county employees.¹⁸ The largest public employers of nurses in North Carolina have staggering vacancy rates. At state-operated health facilities, the vacancy rate for nursing positions is 40%; at the Department of Corrections, it is 44%.¹⁹ More data are needed to analyze employment rates and vacancies across public sector nursing positions as well as the salary adjustments necessary to compete with private sector employers.

Governor Stein and his administration have also identified salary adjustments as a key strategy. In Executive Order 33, signed in February 2026, the Governor directed the state’s human resources office to analyze salaries required to attract talent for relevant positions at NCDHHS and other public agencies. As North Carolina’s executive and legislative branches continue negotiations this summer, the Governor’s proposed budget released in April 2026 included pay increases for nurses employed by the state, citing retention and recruitment needs and projected nurse shortages.¹⁵ As a leading employer of nurses, state agencies play a critical role in improving statewide recruitment and retention by embracing evidence-based measures to promote retention such as flexible scheduling, competitive salaries, student loan incentives, transition to practice programs, and professional advancement opportunities.²⁰

Future of Public Nursing Workforce Development

State government’s role in addressing North Carolina’s nursing workforce crisis requires a dual focus on expanding the educational pipeline and improving retention. While expanded clinical partnerships and faculty investment will help address the state’s educational capacity needs, public employers of nurses—including state hospitals, correctional facilities, schools, and local health departments—have tremendous influence over environmental and financial factors that can improve retention across critical safety-net settings. State and local employers of nurses should align strategies to ensure that the state has a sustained and well-supported nursing workforce that can provide high-quality care for the more than 11 million people who call North Carolina home.²¹

While writing this commentary, yet another one of my nursing school classmates switched employers in search of a role that provides a more sustainable, supportive staffing environment. My hope is that the next time we gather as classmates and colleagues, our conversations will center on the progress we’ve made—supported educational pathways, sufficient and well-equipped faculty, more coordinated state policies, and a shared confidence that we, as proud North Carolina nurses, can continue caring for the people of our beloved home state.

Disclosure of Interests

The author has no conflict of interest disclosures to share.

Correspondence

Address correspondence to Sarah Kaminer Bourland (sarah.bourland@dhhs.nc.gov).