The addled 83-year-old woman repeatedly rips off her clothes in despair. The ambulance attendant had brought her last June to Wilmington’s Novant Health New Hanover Regional Medical Center five hours earlier, citing confusion and stroke symptoms. Over that time period, her behavior spirals “from sweet to ugly.”
The attendant refused to leave her unattended, though. Thirteen other ambulances idle outside, backed up on the arching driveway off 17th Street with its glowing “Emergency” sign. There were 164 other patients in the emergency department that evening, according to an inspector from the N.C. Department of Health and Human Services.
Ideally, 2,000 nurses would be on New Hanover Regional’s payroll. Some of them would be in the emergency room, aiding triage and assigning patients to one of the hospital’s 700 rooms. But last summer, the state inspector reported that 400 of the nursing jobs were unfilled.
Patient lives were in danger, he ruled, threatening the medical center’s certification to treat patients covered by the federal Medicaid health program for the poor. Novant rushed to fill the gaps, cutting nursing vacancies to 100, a spokesperson says. By last fall, the hospital was restored to good standing by state officials.
Sadly, the case isn’t unusual. In recent years, other Tar Heel hospitals including UNC Medical Center in Chapel Hill and Wilson Medical Center have faced similar critical orders from state officials — fix health and safety problems or else. It’s no empty threat because many N.C. hospitals rely on Medicaid and Medicare for more than half of their revenue. Both UNC and Wilson Medical, which is owned by a partnership of for-profit LifePoint Health of Brentwood, Tennessee, and Duke University, resolved their issues with federal officials.
The Wilmington hospital’s problems were exacerbated by unfortunate timing, when seasonal visitors swelled nearby beach towns, just as the coronavirus and flu were increasing patient loads. It had expected nursing shortages, but not as drastic as occurred, says John Gizdic, Novant Health’s executive vice president for business developments.
Details of the Wilmington’s patient’s experience were verified by public officials, but it’s unclear what happened to her because of privacy rules. But it’s symbolic of the life-and-death consequences that nursing shortages are creating in many areas, a swath of industry observers say. Like much of modern medicine, it’s clouded with paradoxes and complexities.
Nurses remain the nation’s most admired professionals, modern Florence Nightingales in Skechers, according to repeated polls. Most became nurses for altruistic reasons.
“When I was a teenager, over the holidays, I went to a hospital with a group to sing Christmas carols for the patients,” says a nurse at Asheville’s Mission Hospital. “I decided then if I could bring maybe the tiniest bit of happiness to them, I wanted to be a nurse.”
But now, more than one in four members of the 100,000-plus member North Carolina Nursing Association say they have been physically assaulted — punched, scratched, slapped, kicked — by patients and family members. U.S. Bureau of Labor Statistics numbers show health care workers are five times as likely to be victims of violence as others in the workforce.
A Durham nurse was stabbed to death by a patient last fall, and two Wilmington nurses were attacked by a patient now jailed in lieu of $7.5 million bail, awaiting trial on second-degree murder charges. Ben Davis, the Port City’s district attorney, says he’ll prosecute the 28-year-old man in the latter case, using a 2015 state law passed to combat such attacks with stiffer penalties for assaults on health care workers. “This is really the highest priority for us, because nurses especially are in harm’s way,” he says.
While such violence is fueled by anger and frustration over the costs and complexities of modern medicine, it’s also a worst-case outcome of the nursing shortage. Sadly, there’s little optimism about curing this problem.
“Are we in a nursing shortage — yes,“ says Crystal Tillman, CEO of the North Carolina Board of Nursing. The board ensures that nearly 200,000 nurses meet education and other standards. “Is it expected to get worse — yes. Is there light at the end of the tunnel — no.”
Tillman and health care executives, nurses, and other industry experts paint a grim picture that supports her conclusion. So do reports like the state inspector’s assessment of New Hanover Regional, which underscores that North Carolina’s $94 billion annual health care economy is reeling from staffing shortages. Nursing, a humanitarian mission that makes up a big slice of the state’s economic landscape, is in unprecedented upheaval.
N.C. Department of Commerce statistics show health care employs 620,000, eclipsing retail trade at 500,000 and manufacturing, with 475,000. The Board of Nursing says the state has nearly 192,000 nurses, ranging from registered and licensed practical nurses to practitioners, anesthetists and midwives, whose training is often just a step shy of medical doctors.
While hospitals struggle for nurses, officials say that they are meeting patient needs through huge infusions of overtime and the widespread use of travel nurses. The latter are hired from staffing agencies and often earn double or more the pay of nurses employed directly by hospitals.
“Nurses will still be there at these very crucial moments of your life,” says Cathy Madigan, chief nursing officer at UNC Health, which has 16 hospitals and nearly 1,000 clinics statewide. Because of vacancies in its normal 6,500-nursing staff, UNC has hired more than 1,000 travel nurses during times of peak stresses such as the coronavirus spikes.
Recently, UNC Health’s so-called travelers have dropped to about 600 systemwide, partly as COVID-19 abated, Madigan says.
Such measures come at a tremendous cost with annual nurse compensation and benefits totaling about $550 million this year. UNC Health pumped more than $65 million last year into additional nursing pay, partly to equalize compensation between staff and travel nurses. There are about 1,200 open positions now, nearly 1 in 6, a ratio common in hospitals statewide.
Registered nurses earn an average $71,000 in North Carolina, the U.S. Bureau of Labor Statistics reports. Travel nurses, paid by agencies and not directly by the hospitals where they work, cost hospitals an annualized average of $160,000 each as of October, according to VivianHealth, a division of New York-based IACT/InterActiveCorp. Most work at a given hospital for a few weeks or months before moving on.
At Greenville’s ECU Health, the system had budgeted $33 million for temporary nursing labor in 2022, but the actual bill soared to $152 million. Its total nursing budget was $307.7 million, but spending rocketed to $444.1 million. ECU Health offers service in 29 eastern N.C. counties.
ECU in January cited the cost of travel nurses as a factor for deciding to close clinics in five eastern N.C. towns: Aurora, Jacksonville, Snow Hill, Williamston and Wilson. The not-for-profit, which was formerly called Vidant Health, says its rural health division lost $46 million in 2022.
Wilmington’s Gizdic says the reliance on record numbers of travel nurses is “unsustainably expensive.” Novant Health, which has 15 hospitals in several states and serves 6 million patients a year, employs more than 8,500 nurses.
A Cone Health nursing executive calls the practice of travel nurses “gouging,” a not-uncommon view among hospital leaders. While travelers have been lifesavers in filling vacancies, they say, the travel-nurse agencies sometimes take advantage of that with exorbitant charges.
Officials at Atrium Health, the state’s biggest system, declined to discuss their nursing staffing. The not-for-profit boosted nurses’ base-pay by $180 million in the last year, while offering signing bonuses of as much as $25,000. Its Charlotte region exceeded its expense budget by $470 million in 2022, citing higher labor costs.
The state is on track for a shortfall of 17,500 registered and licensed practical nurses by 2033, projects the Cecil Sheps Center for Health Services Research, a UNC Chapel Hill affiliate. If nurses retire an average of five years earlier than normal because of job pressures, however, the shortfall could soar to 27,000 by then.
Average ages in most professions are middle-40s. The average Tar Heel registered nurse is 52, while LPNs are a year older, so the profession expects a crescendo of retirements in the next decade. That’s troubling given that North Carolina’s continually aging population is requiring more medical care and nurses in senior centers, hospitals and other settings.
“I hear our nurses saying, ‘I could have worked longer — to 65 or 70 maybe — but my body just can’t take it anymore,’” says Meka Ingram, who is president of the state nurses’ association. “I’m completely broken by the physical demands of the job.”
A nursing association member, speaking anonymously to avoid recrimination by her employer, says she no longer enjoys her job. “Due to staffing shortages, resource shortages and verbal assaults by patients and families, I dread going to work.”
An obvious answer to the nursing shortage is to create more nurses. A state law passed last year directs nursing programs to the state’s 12 public universities and 56 community colleges with nursing programs to provide ideas on how to boost their graduates by 50%. In 2021, the state’s 68 public nursing programs graduated about 4,200 new RNs and practical nurses. The goal is to produce about 6,300 graduates per year, hopefully by 2030, a faster pace than historic growth.
Keys to making that happen are reducing how many nursing students drop out before completing their programs at increasing the number of enrollees, according to a January report by the UNC System.
Gastonia-based CaroMont Health partnered with Belmont Abbey College to start a nursing program with the first 40 graduates expected later this year. The school is adjacent to CaroMont’s forthcoming $195 million hospital in Belmont.
High Point University opened a nursing school last fall with initial graduations in 2024. In December, HCA Healthcare opened a campus of its Galen College of Nursing in Asheville. Galen enrolls about 9,000 students across eight states.
Existing programs such as the nursing schools at Duke University, East Carolina University and UNC Chapel Hill have also expanded their programs in recent years.
Unfortunately, a lack of teachers is stymieing growth, says Tillman, the nursing board CEO. “Nursing faculties are getting older and older and retiring,” she says. “Younger nurses want to become nurse practitioners, which pays more, or they say, ‘Hey, I can make so much more if I go to a hospital.”
Nursing teachers at an unnamed N.C. community college, cited in the February UNC System report, earned from $4,000 to $17,500 less per year than mid-level nurses in the same region. More than 20% of the nursing faculty at the Chapel Hill, Greensboro and Greenville campuses have resigned or retired over the last two years.
Meanwhile, burnout from longer hours and stress is prompting hospital nurses to retire earlier or bolt to nurse staffing agencies for higher pay.
“It’s a national problem, and we’re no different,” says Trish Baise, who joined ECU Health as its first chief nursing executive in January. A former Atrium Health executive, Baise arrived in Greenville to find about 870 of 3,800 nursing positions vacant, and nearly 300 travel nurses filling gaps.
ECU’s nursing school, currently with 1,200 students, is one of the nation’s most highly rated, and proportionately more of its students remain in North Carolina to practice. Baise says the school is changing to reflect new realities, including classes on de-escalating potentially violent patient behavior.
The turmoil in nursing is resulting in some once-unthinkable scenarios.
In downtown Asheville, in the late 1800s, local women calling themselves “The Little Flower Mission” sold flowers to raise money to start Mission Hospital for the poor. Nearby St. Joseph’s Hospital was created as a tuberculosis sanitorium in 1900 by Sisters of Mercy nuns. The hospitals later merged to create Mission Health, which was acquired in 2019 by HCA Healthcare, the biggest U.S. hospital operator.
The following year, nurses at Mission voted to join the Silver Spring, Maryland-based National Nurses United union, complaining that HCA had slashed nursing positions, skimped on safety precautions for nurses and patients and had sent workloads soaring. Some Mission nurses complain that staff shortages have caused patients to receive delayed medications, meals, and sanitary care.
National Nurses represent more than 200,000, including many of Mission’s 1,800 nurses. It was the biggest union victory in North Carolina since the 1970s.
The union blames the nursing shortage on increasing consolidation of hospital networks and greater influence of for-profit companies that put interests of stockholders and top executives over patients and workplace safety. Too many former nurses have quit because they can’t stand the increasing stress, union officials say. Federal data shows 3.2 million of the nation’s 4.4 million licensed registered nurses are practicing.
“We saw Mission cutting any way they could to improve the bottom line for shareholders,” says Hannah Drummond, 32, a trauma nurse there who became a union organizer. She cites a nursing unit for seriously ill patients that was enlarged from 36 to 44 beds, though its nursing staff dropped at times from a dozen to fewer than six. “We had fewer nurses on our unit, but sicker patients.”
The N.C. Department of Labor agreed last March with some of the union’s complaints in Asheville, fining Mission and HCA $30,000 for breaches for failing to provide personal protection equipment such as masks.
Mission officials say negative anecdotes are refuted by comments from a vast majority of satisfied patients and independent research showing excellent clinical outcomes at its N.C. facilities. HCA has made “investments in cutting-edge technology and automation, expanded training and education and research to drive better outcomes for our patients” according to a statement. The company, which owns 183 hospitals and 2,300 health care sites, reported profit of $5.6 billion last year on revenue of $60 billion.
Mission is the only major N.C. hospital that is owned by a for-profit company, and it’s become a major source of property tax revenue in the region. The other big N.C. institutions are not-for-profits, including Atrium Health, which has annual revenue of about $27 billion through its partnership with Illinois-based Advocate Advocate Health. Both HCA and Atrium, along with other big N.C. hospital systems, have received positive recognition from independent groups rating the quality of patient outcomes.
Mission’s union has an ally in N.C. State Treasurer Dale Folwell, a Republican who is the statutory administrator of the N.C. State Health Plan. It expects to pay $17.5 billion in medical bills for 750,000 state employees and retirees over the next five years.
Folwell calls HCA’s purchase of Mission “a disaster for the people of western North Carolina” because the company — and other large hospital systems — put ”profits over patients.” He has urged the company to sell the Asheville operation. HCA has not responded to that advice.
Now, some 160 years after Florence Nightingale earned her cap as the mother of modern nursing, her successors are confronting unimagined challenges. Are there solutions?
One hopeful sign: there’s no shortage of those wanting to follow in her footsteps, says Madigan of UNC Health. “We’ve not seen any decrease in nursing-school applications.” At Novant, reforms such as hiring incentives, more international recruiting, improved advancement opportunities and reduced workloads are paying off with better full-time staffing levels over the last six months, a spokespe 0rson says.
Some nurses say it’s going to take a lot to turn around a tough situation. “I have anxiety, panic attacks and have started therapy,” says one nursing association member. “I simply don’t want to do this anymore.” ■