For decades, nursing has ridden a roller coaster of volatile supply and demand while continuing to grow in strength and potential, supported by higher education and advances in science and practice. The COVID-19 pandemic, which began in 2020, was an unimaginable hit to a profession already under strain. What first appeared to be a short-term crisis, prompting short-term responses, soon evolved into a prolonged ordeal that placed unprecedented strain on the global health care workforce. North Carolina’s nursing workforce was no exception.
Today, countless stakeholder groups are exploring strategies and solutions to recruit and retain nurses in every workplace. These stakeholders now, rightfully so, extend well beyond the nursing community to include a broad swath of health care leaders, as well as elected officials, business owners, and others who have come to understand the severity of the challenges facing our nursing workforce in North Carolina and beyond.
The COVID-19 pandemic did not create this crisis; rather, it exposed and intensified existing vulnerabilities, leaving the nursing workforce at heightened risk during a period of growing demand.1 To be clear, this is not a nursing crisis. This is a broader crisis affecting patients, communities, and the future of health care delivery. Nurses comprise the largest segment of the health care workforce, protecting patients and delivering compassion, safety, and continuity of care. Strain within the nursing workforce produces cascading effects across health care systems and communities.
Workforce shortages reflect systemic challenges related to policy, regulation, funding, education pipelines, and workplace conditions. Most government officials and employers in North Carolina acknowledge the shortages and express concern, but policy execution lags commitments, pledges, and/or promises. Delayed policy decisions influence the nursing workforce in three key domains: 1) supply and pipeline, 2) distribution and roles, and 3) retention and long-term sustainability.
Nursing Supply and Pipeline
North Carolina is projected to face a shortage of nearly 12,500 registered nurses (RNs) by 2033 according to workforce modeling from the UNC Cecil G. Sheps Center for Health Services Research and the North Carolina Board of Nursing (NCBON).2 At the same time, a 2024 study from the American Association of Colleges of Nursing (AACN) found that nursing schools nationwide turned away more than 80,000 qualified applicants in a single year due to capacity constraints.3
Although limited clinical placements, preceptor shortages, and budget constraints all restrict enrollment capacity, the availability of nursing faculty is a critical bottleneck. North Carolina–specific analyses identify faculty shortages as a key barrier to expanding nursing education programs and meeting workforce demand.4
Nationally, the nurse faculty vacancy rate is estimated at approximately 7%, further limiting program capacity.3 This shortage is driven in part by an aging faculty workforce and impending retirements, but also by compensation disparities. North Carolina mirrors national trends, where nursing faculty often earn significantly less than their clinical counterparts, with reported salary gaps of 20,000–35,000 dollars annually, contributing to turnover and recruitment challenges.5
Addressing this imbalance will require targeted, state-level policy solutions already highlighted by recent North Carolina workforce initiatives, including ongoing investments in faculty compensation, loan forgiveness and financial incentives for graduate nursing education, and expanded partnerships between employers and schools to allow clinicians to continue work while contributing to faculty. Securing and strengthening the faculty pipeline is critical to expanding educational capacity and ensuring North Carolina can meet its future nursing workforce needs.
The North Carolina State budget for the 2023–2024 fiscal year included 10%–15% salary increases for nursing faculty at community colleges and within the University of North Carolina (UNC) System. While this was a meaningful step, ongoing market pressures continue to widen the gap between compensation in nursing education and clinical practice, underscoring the need for further action. Additionally, shortages of clinical training sites and qualified preceptors limit program capacity. Increased competition and rising costs have made it more difficult for schools to secure placements, directly constraining the number of students they can admit.
In 2014, Georgia became the first state to address this issue through a tax incentive for preceptors, which was later expanded to allow eligible participants to claim up to $8,500 annually in state income tax relief in exchange for training students. The success of this model has led to similar efforts in other states. Federal legislation (House Resolution 392, filed in 2025) has also been introduced to implement a comparable program nationwide. Expanding preceptor incentive programs or other compensation methods could help alleviate shortages for RNs and advanced practice registered nurses (APRNs) while creating a more equitable environment for nursing schools, particularly those without the resources to directly compensate preceptors.
The North Carolina General Assembly appropriated $40 million to the UNC System in 2023 in an effort to boost the number of nursing graduates by 50% over the next 10 years. Early returns show measurable results from these short-term investments, but recurring or longer-term appropriations will be necessary to maintain the growth.6
As leaders across the state and nation have actively sought opportunities to expand access to nursing schools, a looming proposal could threaten these efforts. In fall 2025, the US Department of Education proposed a rule that would significantly reduce access for many seeking advanced degrees by capping federal graduate student loans for nurses. These advanced degree nurses are exactly the ones needed for nursing school faculty positions, as well as advanced practice nursing roles designed to maximize efficiencies in the health system.
After this change takes effect on July 1, 2026, graduate nursing programs will not be classified as “professional degrees,” making them subject to lower borrowing limits than previously available to nurses. The American Nurses Association and its partner organizations posit that this restricts access to essential, high-level nursing education, exacerbating the current workforce shortage,7–9 and are pushing back on the rule through lawsuits and legislative channels. Excluding nursing degrees from “professional” eligibility jeopardizes workforce sustainability, limits access to care and directly contradicts the Trump Administration’s stated investments in strengthening the nursing pipeline and recognizing the indispensable role nurses play in the nation’s health care system.8
Initiated as perhaps a well-intended attempt to reduce the cost of higher education across the spectrum of degrees and professions, the new rules are expected to be released in time to take effect July 1, 2026. After a significant public comment response, there is hope that the final rule will include nursing on the list of professions eligible for the higher loan cap.
Nursing Distribution and Roles
Boosting supply through expanded access to nursing schools is not enough to provide balance with demand. North Carolina must maximize the value of the existing nursing workforce by utilizing nurses to the full extent of their education and training, while also paving the way for them to practice in underserved areas. A part of the current shortage is really a distribution problem.2
Rural areas of the state have larger nursing shortages, but nurses educated there are more likely to practice close to home. Expanding access to community colleges in rural parts of the state is critical to both addressing the immediate shortage and planning for future workforce expansion with a “grow your own” mentality supported by evidence and strengthened through resource infusion. Programs like the recently announced North Carolina Nurse Initiative through the North Carolina Department of Health and Human Services (NCDHHS) are important milestones in this area. This example is a state-funded loan repayment program managed by the NCDHHS Office of Rural Health, helping qualifying registered nurses and clinical nurse specialists pay off educational student loans in exchange for committing to work in underserved, rural areas.10
North Carolina must also seize the opportunity to better leverage its current nursing workforce, especially some of its most highly qualified nurses. APRNs should have maximum flexibility to meet patients where they are, but antiquated regulatory barriers in our state limit the ability of some master’s- and doctorally prepared nurses to choose when and where they provide patient care. Over half of the states in the nation have already modernized laws governing advanced practice nurses, and the research overwhelmingly supports these reforms.11 Within five years of implementing full practice authority in Arizona, the number of nurse practitioners providing care to rural communities jumped by 73%.12
Executive order waivers during COVID-19 and in the aftermath of Hurricane Helene provided temporary removal of the administrative barriers limiting advanced practice nurses; the COVID-19 waivers were in place for more than two years, and the waivers due to Hurricane Helene are still active. The NCBON did not see an uptick in complaints during either period and has not issued any disciplinary action against APRNs from either group. Meanwhile, certified nurse midwives (CNMs) have enjoyed increased flexibility in North Carolina since 2023 without incident, during which there has been a 54% increase in licensed CNMs. Nurse practitioners have also practiced with full practice authority in our state through the Veterans Administration since 2017, and the military has a long history of utilizing advanced practice registered nurses.13
In addition to obvious workforce benefits, APRN reforms could save nearly one billion dollars a year, according to research from Duke health care economist Chris Conover.14 These savings are increasingly important as discussions continue about escalating budget needs related to Medicaid expenses in North Carolina and threats to hospitals as health care costs swell.
Until North Carolina lawmakers address policy changes necessary to enable APRNs to practice to the full extent of their education, the state is forfeiting a proven strategy that can simultaneously increase access to care and lower costs. Exacerbating the situation, many of these nurses will choose to practice in states that have more modernized regulatory systems in place. For the APRNs educated in the University of North Carolina System, the state is using tax dollars to subsidize advanced degrees with an educational curriculum that supports certification and full practice authority, but it is then immediately limiting the practice of these nurses within the borders of the state.
Nursing Retention and Sustainability
All expansion and distribution efforts must work in tandem with nursing retention and sustainability strategies. At a time when burnout and turnover are plaguing many nursing workplaces, this is even more critical.15,16
Often employer policies, benefits, and culture are the first line of defense against nursing turnover and burnout, but public policy can also play a role. As recently as 2024, the North Carolina General Assembly implemented new laws in response to increasing violence in the hospital setting, now requiring the presence of law enforcement, combined with required assessments and preparation strategies. And multiple times over the past two decades, North Carolina has increased the criminal penalty for violence against nurses and other health care professions. Unfortunately, the incidents of workplace violence toward nurses continue to climb.9
Adequate staffing is also a key concern during a workforce shortage, such as the one currently underway, and a significant contributor to burnout. Nurse leaders and bedside clinicians should be heavily involved in staffing decisions as they relate to nursing. Administrations should acknowledge that understaffing related to lack of available personnel and/or budget concerns will ultimately result in higher costs through burnout and turnover.17
While the nursing profession in North Carolina lacks consensus about whether or not government policymakers should play a role in safe staffing, decisions should be made with frequent consideration of the acuity level of the patient load and the experience of the nurses assigned at the moment. Funding threats, both real and potential, to the hospital and health system environment may deplete resources necessary for nurses to do their work. Even if the funding cuts do not directly eliminate nursing FTEs, depletion of resources, ancillary personnel and other important components hinder the nurse and will increase risk of turnover, burnout, and moral injury.18
There are approximately 166,000 RNs licensed in North Carolina, but data from the NCBON show that only about 126,000 are currently employed. Both state government and employers should actively seek out budgetary and policy incentives that would activate a higher number of nurses across the state.4
Conclusion
North Carolina stands at a pivotal moment. Without alignment between policy, education, and practice, the state will continue to face deepening strains on the nursing workforce, with consequences for access, cost, and quality of care. Yet the solutions are within reach for policymakers. Investing in nursing education, modernizing regulations, and prioritizing retention can stabilize and strengthen the nursing workforce for the future.
Declaration of Interests
The author has no conflicts of interest to declare.
Correspondence
Address correspondence to Tina C. Gordon, 4350 Lassiter at North Hills Ave. Suite 250, Raleigh, North Carolina 27609 (tinagordon@ncnurses.org).