By Jaymie Baxley

North Carolina’s health care workforce is growing, and acute staffing shortages have eased in several professions, but employers still struggle to fill open positions and retain workers, particularly in rural communities.

That’s the main takeaway from the third annual health workforce analysis released on Oct. 26 by the NC Center on the Workforce for Health, which tracks employer demand alongside the supply of people entering health care professions.

The findings show improvements in several key areas since last year, including vacancy and turnover rates for registered nurses, licensed practical nurses, certified nursing assistants and medical assistants. 

However, those vacancy rates are still high — and some employers lose workers almost as quickly as they can hire them. For instance, the state faces a shortage of 12,500 RNs and 5,000 LPNs over the coming decade. 

“Improvement doesn’t equal good necessarily,” Andy MacCracken, director of the NC Center on the Workforce for Health, said in an interview. “It doesn’t mean that things are where they need to be. Things are getting better, but there’s still a ways to go to actually close some of the gaps that we’ve observed over the years.”

The challenge is worse in rural communities, where employers have a harder time attracting and retaining workers. Plus, some health care settings, including behavioral health and long-term care facilities, have higher turnover than other kinds of care.

“When we say high, we mean that our metrics are exceeding national rates as well as recommended rates,” said Emily McCartha, the center’s senior policy analyst.

The findings come as North Carolina’s population ages, needing more health care services at a time when the number of younger people entering the workforce is not keeping pace.

Green shoots of progress

The analysis draws on employer demand data collected through the Health Talent Alliance, a partnership that brings together health care employers, educators and regional workforce organizations to identify staffing needs and develop local solutions. The report also incorporates data on the supply of health professionals coming through education and training programs.

The data shows meaningful improvement in several measures of staffing demand from 2025 to 2026.

Among the more than 150 employers surveyed, vacancy rates fell for registered nurses and for licensed practical nurses, who provide basic medical care under the supervision of registered nurses and physicians. Employers of certified nursing assistants, who help patients with daily activities such as bathing, dressing and eating, also had fewer staff vacancies. 

Employers of medical assistants, who perform clinical and administrative tasks in medical offices, saw vacancies decline, but it took, on average, as much as 10 weeks to fill those positions. Registered nurse positions also sat vacant for an average of 10 weeks. 

Churn — defined as the movement of employees into and out of an organization within a year — also fell across all four professions.

Employers hiring certified nursing assistants saw the most relief. In 2025, churn averaged 117 percent, meaning the number of employees who left or joined those positions over the course of a year was more than the total workforce. By 2026, that churn rate had dropped to only six in 10 workers leaving over the course of the year, on average.

It’s an improvement, but it still points to consistent challenges in retaining workers.

Vacancies remain a challenge. The employers surveyed reported that 16 percent of licensed practical nurse positions and certified nursing assistant positions were unfilled, as were 12 percent of RN positions.

Paramedics and emergency medical technicians are of particular concern: These vital workers, often the first people  patients encounter in the health care system, are highly trained and challenging to replace. Vacancies for those positions persist, on average, 110 days for paramedics and 94 days for EMTs, with more than half those positions unfilled after three months. 

EMTs also have the highest rate of churn of all the health professions surveyed. 

For emergency medical technicians and paramedics combined, the average number of openings was 840 workers, but the estimate of the average annual supply was only 400 workers.

Training gap

The analysis also found that the state doesn’t produce enough graduates to meet projected annual demand in several professions.

North Carolina employers reported an average of 6,930 annual openings for registered nurses, but the annual supply is only about two-thirds of the demand. The estimated annual supply also falls short of the demand for licensed practical nurses and medical assistants.

Certified nursing assistants seem to be an exception, with the estimated annual number of people completing training programs exceeding projected openings. But McCartha cautioned that the apparent surplus may be misleading because a nursing assistant credential can serve as a stepping stone to other health care careers. Some people who obtain the credential may never work as nursing assistants.

Among employers surveyed in 2026, only 4 percent of hiring was for new positions. The vast majority of hiring was intended to replace workers who had left their jobs. That makes keeping existing employees just as important as recruitment and training.

“Retention must happen, and that’s a really important part of the message,” McCartha told NC Health News. “The workforce will not even come close to sustaining if you don’t retain your people, particularly given what we’re seeing with population trends.”

Western woes

Workforce challenges are uneven across the state.

Among employers participating in the Health Talent Alliance survey, registered nurse turnover ranged from 10 percent in the southeastern region of the state to 38 percent in western North Carolina.

McCartha said western North Carolina has consistently recorded worse workforce numbers than other regions in recent years, sometimes posting the state’s highest vacancy rates. The remnants of Hurricane Helene, which devastated parts of the region in September 2024, appears to have compounded those long-standing challenges.

“The crisis happened, and a lot of people said, ‘Okay, well, my house is gone,’ or ‘I don’t have a place to work; I’ve got to go somewhere else,’” McCartha said.

Some displaced workers may have left the state entirely, she said.

“I would venture a guess that a lot of people moved to adjacent states like Tennessee and Georgia,” McCartha said. “For some parts of western North Carolina, you’re closer to Atlanta than you are to other places.”

Transportation was already a significant barrier for patients and employees, she added, particularly in the region’s more mountainous areas where travel between communities can take considerable time. 

The region also has fewer educational institutions than other parts of the state, and graduates who train there do not always stay in the area after completing their studies.

McCartha said the uneven distribution of health professionals matters because statewide averages can obscure the severity of shortages in individual communities. A region with enough workers overall may still have substantial gaps in particular professions or health care settings.

The report argues that workforce strategies must be tailored to local conditions. Some communities need to expand training capacity, it said, while others may have enough qualified workers but struggle to recruit them, retain them or persuade former employees to return.

Beyond pay and benefits

Compensation is an important factor in health care staffing, particularly in rural areas where employers may struggle to compete with the wages offered by larger health systems or other industries.

McCartha said the average registered nurse pay in North Carolina has consistently been below national rates. However, she and MacCracken stressed that pay is only one part of a more complicated problem involving working conditions, opportunities for advancement and workplace safety.

“In national surveys of nurses, for many years, the most important thing that they ranked wasn’t pay,” McCartha said. “The work environment was the most important thing to them.”

MacCracken said the diversity of nursing jobs also makes it difficult to identify a single solution. An emergency room nurse’s job is very different than one in a nursing home or a doctor’s office. 

“Pay matters, but there’s not a number that anyone would tolerate if every single day your dignity and your safety is at risk when you show up to work,” MacCracken said. “Workplace violence is a very present reality for nurses.”

Workplace violence can include physical assaults, threats, verbal abuse, harassment and other aggressive behavior. The problem is particularly relevant in settings like emergency departments and walk-in clinics, where employees regularly interact with patients who are distressed, confused or experiencing a behavioral health crisis.

Citing federal data, a 2022 report by the Cecil G. Sheps Center for Health Services Research at UNC Chapel Hill noted that health care workers accounted for roughly 14 percent of the U.S. workforce but experienced about 75 percent of nonfatal, intentional workplace injuries.

“It’s a very established problem that was increasing before the pandemic, and some people theorize that it got worse during the pandemic,” McCartha said. “I think that, from a workforce standpoint, what exacerbates it is having fewer workers and fewer people on a team.”

Knowing the true extent of the problem is difficult because many incidents of workplace violence go unreported.

“From a data standpoint it’s really hard to quantify because the only way it’s tracked is if someone reports missing work because of violence,” McCartha said. “Sexual assault probably happens daily, easily, but you may not report it — and you’re definitely not calling out from work. 

“If you’re a nurse in the ER and you’re experiencing that perpetually, I can’t imagine that wouldn’t affect you and make you say, ‘Why am I doing this? Why am I here every day? I’m leaving.’”

Building a stronger workforce

The NC Center on the Workforce for Health highlighted several efforts to address the shortages, including initiatives that connect students with local employers, improve the experience of current employees and help experienced professionals return to practice.

During a webinar unveiling the center’s new analysis, workforce leaders described approaches designed to address different parts of the problem.

One effort in Lincoln County connects high school students with nursing education. Lincoln County Schools, Gaston College and Atrium Health Lincoln partnered to create an accelerated pathway that lets students start preparing for health care careers before graduating from high school.

Another effort focuses on retaining employees who are already working in health care. Eleven hospital systems across North and South Carolina are participating in the CaroNova Workforce Experience Accelerator, which gives employers a forum to share strategies for improving employee experience and reducing turnover. They discuss what has worked, what has not and how lessons from their experiences might be applied elsewhere. The NC Center on the Workforce for Health is working with CaroNova to make those resources more widely available.

During the webinar, Kristen Lakus, assistant vice president of employee experience at Duke University Health System, described how important it is to prepare workers for the realities of their jobs and to help them feel supported after they are hired. Her team works on employee engagement, well-being and responses to workplace conflict and violence.

Lakus said employers must help employees preserve the sense of purpose that often draws them to health care, even while preparing them for the challenges they may encounter in clinical settings.

The webinar also highlighted efforts to bring experienced nurses back into practice.

Jill Forcina, director of nursing and education for North Carolina Area Health Education Centers, said the state has a substantial number of licensed nurses who aren’t working in nursing.

She cited Board of Nursing data showing that nearly 170,000 registered nurses held active licenses, but only about 127,000 were working in nursing. Another 81,000 nurses had inactive licenses.

Those figures suggest a sizable pool of experienced workers who might be able to help ease shortages if barriers to returning can be addressed.

“Many nurses who leave the workforce didn’t really intend to leave nursing permanently,” Forcina said. “There are life circumstances like caregiving responsibilities, military moves, health concerns and retirement that pull people away from practice.”

NC AHEC operates a refresher program for nurses who have been away from direct patient care or whose licenses have become inactive. The program includes 140 hours of self-paced coursework and another 140 hours of supervised clinical experience.

Forcina said the program helps nurses update their clinical knowledge and rebuild confidence before returning to practice. Its clinical requirements have also been adjusted to better reflect the types of jobs participants intend to pursue.

The analysis acknowledges that no single fix will work everywhere. 

Two regions may have similar vacancy rates for very different reasons, McCracken said. One may have enough trained workers but struggle to recruit or keep them, while another may not have enough training programs to produce workers in the first place.

“I think the most important thing is that people are using the data,” McCracken said.

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