North Carolina could face a shortage of nearly 12,500 registered nurses and around 5,000 licensed practical nurses by 2033, according to projections from the NC Nursecast model developed by Erin Fraher, program director of health workforce research and policy, and her team at Cecil G. Sheps Center for Health Services Research.
Hospitals could be short nearly 10,000 RN positions by 2033, the center estimated, and nursing homes, extended care and assisted living facilities could be short more than 3,500 LPNs by that time.
To address this, a North Carolina Institute of Medicine task force released eight recommendations in a report on May 8. It aims to tackle issues like the shortage of nursing educators, stressful work environments, insufficient staffing and trauma and burnout exacerbated by the COVID-19 pandemic, according to the NCIOM press release.
“I am burned out. I don’t feel appreciated and the quality of care we are providing is not fair to the patients,” said one nurse quoted in the report from a survey by the North Carolina Nurses Association in November 2022.
The solutions call on lawmakers, educators, employers, trade associations and the public to act, NCIOM said.
Ernest Grant, vice dean for diversity, equity, inclusion at Duke University’s School of Nursing, Hugh Tilson, director of North Carolina Area Health Education Centers and Catherine Sevier, president emerita of AARP NC, co-chair the task force. All three talked with Carolina Public Press about its findings and recommendations.
Fixing the problem requires both recruitment and retention, Grant said.
“We need to make sure people not only want to become nurses, but they want to remain nurses,” he said.
The COVID-19 pandemic aggravated the issue and the state’s aging population is growing rapidly, so there’s greater healthcare demand, Sevier observed.
“This is kind of a perfect storm for North Carolina and those things just keep hammering on us, as we are already playing catch up,” she said.
The NC Nursecast estimations also used pre-pandemic data, and analyses of more recent data show the supply of nurses is even smaller than previously forecast, Fraher said to CPP.
The LPN supply dropped partly because those positions are often in long-term care facilities, which were hit hard during the lockdown, Fraher said.
That’s also partly because this is a predominantly female workforce, which meant juggling a lot during pandemic lockdown, such as home care for children, she said.
North Carolina imports half of its RNs from out of state each year, Fraher said, so our state is also competing with other states for nurses.
“I have been in health workforce research for 30 years, this is the most worried I’ve ever been about a workforce,” she said.
Nurses recruitment
One of the task force’s recommendations is to increase the number of North Carolinians graduating with nursing degrees.
Increasing the number of nursing graduates by 10% will reduce the projected shortage by about 2,000 nurses, NC Nursecast found.
That also requires addressing the shortage of nursing faculty and preceptors, who train nurses in clinical placements, the task force found.
Part of that stems from uncompetitive salaries, as nurse faculty salaries remain uncompetitive with bedside positions, despite the General Assembly increasing salaries in the latest budget, according to the task force’s project director, Brieanne Lyda-McDonald.
Nurse educators are also more likely to be older and therefore more likely to leave the workforce sooner, according to NC Nursecast data.
Supporting nursing students economically and academically would improve graduation rates, the task force found.
Sevier said the legislature could help provide scholarship access to nursing students who might otherwise have to work full time while going to school.
The task force also focused on diversifying the nurse workforce to reflect the communities they serve, Grant said.
That will mean more inclusive educational environments and curriculum, the task force found, as well as expanding early pathways, such as collaborating with middle and high school counselors.
Nurses retention
Recruitment alone won’t work, Fraher said, because “we can’t educate our way out of this.”
For rural areas in the state, investing in local community college nursing programs helps long-term retention, as people who come from a community are more likely to stay there, Sevier said.
But because rural areas have less workers, those places have less flexibility, Tilson said.
The General Assembly should implement expanded loan forgiveness programs and other incentives for committing to practice in rural areas, the task force said.
The task force also outlined retention strategies such as improving workplace culture and giving nurses more decision-making power.
Health care workers make up 14% of workers in the U.S. but experience around 75% of nonfatal, intentional workplace injuries, according to a research brief published by the Carolina Health Workforce Research Center.
Black health care support workers and practitioners face rates three times higher than white workers in the U.S., according to data the center cited from the Bureau of Labor Statistics.
Sevier said nursing has been her career since she graduated in 1970, and the violence nurses used to face was more “diluted” back then. People aren’t doing a good job managing their frustrations and feelings, and nurses need to know to defuse the situation, she said.
The task force outlined strategies for workplaces to keep nurses safe from violence and called on the General Assembly to designate funding for organizations to access training and tools to do so.
The recommendations also included reporting mechanisms and training to address discrimination and biases in the workplace. The report cited a national finding that 63% of nurses surveyed said they experienced racism in the workplace, according to the National Commission to Address Racism in Nursing.
The task force also recommended making scheduling more flexible and decreasing high workloads.
Beyond nurses in acute care, the state should also support schools in billing Medicaid to provide additional funding for school nurses, the task force said, as well as explore other funding methods.
As for long-term care, North Carolina Medicaid should also help address shortages in the long-term care workforce, such as evaluating funding and reimbursement levels for long term services and supports, the task force said.
Taking action
Sevier said nurses can’t solve this issue alone, so others in power need to understand its urgency and the potential consequences of inaction.
That goes beyond the General Assembly, Fraher said, as a huge piece of the issue isn’t under their purview – the organizations that control nurses’ workplace environments also need to follow some of the task force recommendations.
Still, Fraher said, North Carolina is ahead of other states with its data and task force recommendations, because many other states are still trying to figure out their nursing workforce shortages.
“In North Carolina, people do work together and that matters,” she said.
Sevier and the other two co-chairs all said they are optimistic that these recommendations will be implemented.
Tilson also said the NC Center on the Workforce for Health aims to act as a forum for organizations to continue working on this issue and monitor progress.
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