NC Nursecast: Forecasting the Future of North Carolina's Nursing Workforce
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3/15/2022
NC Nursecast: Forecasting the
Future of North Carolina’s
Nursing Workforce
Erin P. Fraher, PhD, MPP & Sheps Health Workforce Team
Director, Program on Health Workforce Research & Policy
Deputy Director, Cecil G. Sheps Center for Health Services Research, UNC-CH
Associate Professor, UNC-CH Department of Family Medicine
NC BoN Education Summit
March 28, 2022
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Disclaimer and Funding
• This work was funded the North Carolina Board
of Nursing
• The content, conclusions and opinions
expressed in this presentation are mine and
should not be construed as the official policy,
position or endorsement of the North Carolina
Board of Nursing or the University of North
Carolina at Chapel Hill
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This presentation in one slide
• NC Nursecast website allows users to customize forecasts by
nurse type (RN/LPN) and geography (statewide, Medicaid
regions, AHEC regions and metro/non-metro) for various
practice settings
• NC was projected to face a nurse shortage before the
pandemic, shortages may get more acute if significant
numbers of nurses exit the workforce
• Model projects shortage of nurse educators. Educator
workforce is older and at higher risk of exiting workforce
• Graduate Diffusion Tool allows users to see “footprint” of NC’s
nursing programs--% of grads who remain in state, practice in
rural settings, and are employed in various settings
• The shift of care (and workforce) to ambulatory settings and
the rise in virtual care have important implications for nursing
education
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Why this work was important, even
before the pandemic
• Policy makers and nurse leaders seeking
information to inform decisions about
education, regulation, and deployment
• Especially important in context of rapidly
changing payment/care delivery models and
Medicaid transformation
• National models reported conflicting forecasts
of future nursing shortages vs surpluses in NC
• Federal government projected a surplus by
2030; other models projected a shortage
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Why this work is important, now
• Lots of discussion at state and national level
about strategies to ameliorate nursing
workforce shortages, including:
• increasing number of students in the pipeline
• funding loan repayment programs
• addressing faculty, preceptor and
clinical site shortages
• increasing pay
• addressing provider well-being
• retaining nurses
• reorganizing work to support team-based
models of nursing care
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What is NC Nursecast?
NC Nursecast is an interactive, web-based tool that
forecasts the future supply and demand for
Registered Nurses (RNs) and Licensed Practical
Nurses (LPNs) out to 2033
Graduate Diffusion Tool is an interactive data
visualization that allows users to see where
students from North Carolina nursing programs
practice after they graduate
https://ncnursecast.unc.edu/
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Who created NC Nursecast?
• Cecil G. Sheps Center at UNC-CH with
funding and collaboration from the NC BoN
• Expert advisory council
• ~3 years in the making
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How did we develop the model?
• Data
• Supply model based on licensure data from
the NC Board of Nursing
-how many nurses will we have?
• Demand model draws on health care
utilization data, nursing home licensing files
and population estimates
-how many nurses will be required?
• Nurse leaders from different employment
settings served as expert advisors for NC
Nursecast, assessing validity of results, and
helping us to refine our assumptions
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NC Nursecast enables users to see
results for different geographies and
settings
• NC Nursecast forecasts supply and demand at state
and regional-level (Medicaid, AHEC, metro/non-
metro) for nurses employed in:
― Hospitals
― Ambulatory Care
― Nursing Home/Extended Care/Assisted Living
― Home Health/Hospice
― Correctional Facility
― Mental Health Hospital/Facility
― Community and Population Health
― Nursing Education
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Forecasting the future is
difficult…especially during a
pandemic
• Workforce models are assumed to produce one
“answer” to the question:
Will RN and LPN supply meet demand in the future?
• The answer is: it depends
• NC Nursecast was developed based on historical
data, before COVID-19 emerged
• Pandemic is affecting nurse supply and demand,
but effects are not yet well understood
― Nurses may exit the workforce earlier than expected
(due to burnout, becoming a travel nurse etc. )
― The pandemic may trigger a “nurse hero” effect which
could increase supply of nurse graduates
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We model scenarios to understand
different possible futures
NC Nursecast model includes 5 scenarios:
1. Nurses exit the workforce 2 years earlier
2. Nurses exit the workforce 5 years earlier
3. State faces 2.5% decrease in out-of-state-
supply
Did you know that more than 50% of our annual
RN supply is from outside NC?
4. Supply of nurse graduates increases by 10%
5. Combination scenario: nurses exit workforce
five years early + a 2.5% reduction in out-of-
state supply + a 10% increase in NC graduate
supply
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What did we find?
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Even before pandemic, NC was forecast to face an
estimated shortage of 12,500 RNs by 2033
Baseline projection
Nurses exit workforce 5 years earlier
If burnout or other factors cause nurses to exit the workforce
five years earlier, the shortage nearly doubles
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Hospitals and nursing home, extended care,
assisted living facilities face largest RN shortages
Registered Nurse Workforce Shortage and Surplus Estimates for 2033
Setting # in Shortage % Shortage or
or Surplus in Surplus in 2033
2033
Total -12,500 -11%
Hospital -9,927 -16.7%
Nursing Home/Extended Care/Assisted -1,888 -30.8%
Living
Home Health/Hospice -1,535 -17.9%
Nursing Education -132 -8.9%
Correctional Facility -128 -15.7%
Mental Health Hospital/Facility -26 -0.9%
Community and Population Health 86 1.4%
Ambulatory Care 363 2.3%
Note: Data from NC Nursecast, which includes NC Board of Nursing/Health Professions Data System, population data from
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NC Office of Budget and Analysis and Expert Input
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RN nurse supply and demand
varies by region
• Charlotte, Northwest and Wake AHEC regions projected
to have largest shortfalls
• Eastern AHEC holds steady at neither a shortage nor
surplus
• South East and Southern Regional AHECs forecast to have
surplus 15
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LPNs will face even greater
shortages, relative to the size of
their workforce
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Hospitals and nursing homes, extended care,
assisted living settings face largest LPN shortages
LPN Shortage and Surplus Estimates for 2033
Setting # in Shortage % Shortage or
or Surplus in Surplus in
2033 2033
Total -5,000 -27%
Hospital -314 -31.7%
Nursing Home/Extended Care/Assisted Living -3,510 -49%
Home Health/Hospice -504 -14%
Correctional Facility -9 -2.2%
Mental Health Hospital/Facility -58 -9.4%
Ambulatory Care -148 -6.7%
Note: Data from NC Nursecast, which includes NC Board of Nursing/Health Professions Data System, population data from
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NC Office of Budget and Analysis and Expert Input
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LPN nurse supply and demand
varies by region
• All areas of the state face LPN shortages
• Mountain AHEC and Wake AHEC face largest LPN shortages
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Educating more nurses can’t be our only solution.
We need to focus on retention
+10% new graduate supply
Baseline projection
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What does the model say about the
supply and demand of nurse educators?
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Challenges in modeling the supply
and demand of nurse educators
How Many Nurse Educators Do We Have?
• Number of RNs reporting they were nurse
educators was much larger than expected
• We reviewed and cleaned data so that only RNs
working in academic settings were included
How Many Nurse Educators Will Be Required?
• Demand model factors in rapid population growth
• Accounts for fact that even before pandemic, state
faced 7% vacancy rate
Nurse educators were invaluable resources in
reviewing NC Nursecast data, refining methods
and validating forecasts
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Shortage of nurse educators more
than doubles if educators exit
workforce 5 years early
Baseline projection
Nurses exit workforce 5 years earlier
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This is because nurse educator
workforce is older and more likely to
retire
95% Confidence Interval for Age
25 30 35 40 45 50 55 60 65
Hospital
Ambulatory Care
Nursing Home/Extended…
Home Health/Hospice
Public and Community Health
Nursing Education
Mental Health
Correctional Facility
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Nurse Educator Shortages and Surpluses by
AHEC Region for 2033
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What is going on in Southern Regional AHEC?
The Graduate Diffusion Tool Provides Clues
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Graduate Diffusion Tool
• Displays “footprint” of NC’s education program
graduates from 2013-2016
• For each ADN, BSN and LPN program, shows % of
workforce retained instate, in rural areas, and by
employment setting, two years after graduation
• NC nursing programs have high in-state retention
rates, and varying retention rates in rural areas
Retention in Non-
Nurse Education Programs in North Retention
metropolitan
Carolina Rate in NC
counties
Licensed Practical Nurse (LPNs)
92% 33%
Programs
Associate Degree Nurse (ADN)
92% 29%
Programs
Bachelor of Science in Nursing (BSN)
86% 10%
Programs 26
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UNC System BSN Programs Have Varying Footprints
Institution # of Grads % Working % in Mean distance
2013-2016 in NC Rural NC from program to
practice (miles)
Appalachian State University 127 89% 15% 90
East Carolina University 848 88% 9% 71
Fayetteville State University 50 74% 26% 20
North Carolina A & T State University 118 88% 4% 35
North Carolina Central University 190 89% 7% 15
University of North Carolina Wilmington 314 85% 3% 76
University of North Carolina at Chapel Hill 497 80% 2% 20
University of North Carolina at Charlotte 333 88% 3% 35
University of North Carolina at Greensboro 321 93% 3% 31
University of North Carolina at Pembroke 104 77% 49% 32
Western Carolina University 250 84% 12% 68
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Graduate Diffusion Model Allows Users to Visualize and
Compare Footprints
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Community Colleges in Southern Regional AHEC
are supplying employers with needed RNs
Footprint of Associate Degree Nursing Program Graduates in Southern Regional AHEC Region
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Community College ADN Program Footprints in
Southern Regional AHEC Region
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ADN programs generally have more local
footprints than BSN programs
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Geographic features also shape footprints
- The Rowan-Cabarrus CC LPN program is located between Charlotte and Winston-Salem
resulting in a narrow, compact footprint that follows the highway.
- The Montgomery CC LPN program is in a more rural area resulting in more diffuse and
larger footprint
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What are Some Future Trends Likely
to Affect Nursing Education?
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Care (and Workforce) is Shifting from Acute to
Ambulatory and Community Settings
Number of Nurses in Ambulatory Care,
• Transition from fee-for-service
North Carolina, 2015-2020
to value-based payments
shifting care from inpatient to
ambulatory and community- 9,124 9,238 9,797
8,824
based settings 7,464 8,122
Number of RNs
• But we generally train the
workforce in inpatient settings
2015 2016 2017 2018 2019 2020
• This is especially true of the Year
nursing workforce
During same period:
• Hospital RN workforce grew by 2.9%
• Total NC RN workforce grew by 5.8%
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Implications for nursing practice
Shift will challenge educators, health systems, and
practices to build to:
• Develop curriculum and clinical placements that
better prepare nurses to provide primary,
behavioral and geriatric care in community-based
settings
• Retool existing nursing workforce to undertake new
roles (population health, care coordination etc)
• Develop team-based models of care that “share the
care” (Bodenheimer et al) between physicians, RNs,
LPNs, CNAs, social workers, medical assistants and
other team members
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Nursing Workforce Will Play
Increasing Role in Providing Virtual
Care
• Nurses are increasingly involved in providing virtual care
• Beyond telehealth, more health care will be provided
virtually and in home and community-based settings
• As of Nov. 11, 2021, 83 health systems and 187
hospitals in 34 states were participating in the Acute
Hospital Care at Home initiative rolled out by the U.S.
Centers for Medicare & Medicaid Services (CMS) about
a year ago
• Virtual care models place emphasis on team-based care
and will require new education and clinical placement
models 36
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Engaging Nursing Workforce
Stakeholders in Shaping Future
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NC Center for Health Workforce
Currently, there is no statewide health workforce planning
organization
Goal: To convene stakeholders to leverage data and promising
practices to develop and support NC’s health workforce
Approach:
• To be persistent, transparent, and accountable to policy makers,
educators, and employers for evidence-based approaches to
address health workforce needs (i.e., to produce outcomes).
• To leverage and expand data sources to identify health workforce
needs and solutions.
• To focus on progress toward implementing those solutions and
provide transparency, accountability, and regular updates.
• To recommend additional actions to address current and future
health workforce shortages and maldistributions.
Partnership between NC AHEC Program and Cecil G. Sheps Center for
Health Services Research
Plan to meet quarterly beginning early 2022
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NC Sentinel Network
Information from employers about their workforce challenges is
essential to developing timely and effective responses.
NC AHEC Program, in collaboration with the Sheps Center, is
collecting information from employers on local changes in workforce
demand.
A “Sentinel Network” of employers:
- Identifies skills needed and local conditions making hiring difficult
- Provides “how and why” perspectives behind demand signals
Timing:
• Initial questionnaire: Fall 2021 (closed mid-November 2021)
• Second questionnaire: early May 2022 (will close mid-June 2022)
• Plan to continue every 6 months as long as it’s valuable
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Results: Available to review at https://nc.sentinelnetwork.org/
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NC Sentinel Network: Who Answered the 1st Questionnaire?
About 300 unique respondents, who submitted responses for 338 facilities/organizations across the state
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Want to learn more about NC
Nursecast?
• NC Nursecast website
https://ncnursecast.unc.edu/
― Tutorials on how to use the model and grad
diffusion tool
― Key Finding brief
― Policy briefs that summarize findings
― Publications & Press
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Find us, Follow Us, Sign up For our Newsletter
Program on go.unc.edu/Workforce
Health
Workforce @UNC_PHWRP
Research &
Policy
nchealthworkforce.unc.edu
@WorkforceNC
Sign up for our newsletter directly at go.unc.edu/WorkforceNewsletter
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Contact Information
Erin Fraher, PhD MPP
erin_fraher@unc.edu
@ErinFraher
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