A sign at a July A-B Tech career fair adorns the entrance to a campus building housing the college’s nursing program. // Watchdog photo by Starr Sariego

The acute nursing shortage plaguing Asheville and Western North Carolina will reach “crisis” levels over the next decade, experts say, with one estimate projecting the region to be short nearly 2,000 nurses across eight health care sectors.

A mix of retiring nurses, aging populations and longer life spans requiring a greater need for acute care services are contributing to the deficit, according to nursing leaders, workforce experts and nursing school department directors. Other contributing factors could be declining nursing student enrollment and healthcare workers’ increased workload due to high patient-to-nurse ratios.

“The potential shortages that you’re seeing are kind of the tip of the iceberg,” Western Carolina University Nursing School Director Terri Durbin said. “It’s not hyperbole to say really we could all double our nursing output tomorrow… and it might not be enough.”

Dennis Taylor, the immediate past president of the North Carolina Nurses Association, agrees.

“We are still in what I would call a crisis situation with the nursing workforce in North Carolina,” said  Taylor, who noted that hospitals’ increasingly common use of travel nurses and their assignment of more tasks to shrinking staff ultimately won’t reverse the crisis. “It’s almost like sticking your finger in a dam that’s getting ready to break —  it’s a short-term solution to what has been and continues to be a long-term issue.”

So dire is the issue that North Carolina’s departments of Health and Human Services and Commerce are promising to intervene, with the announcement this spring of a task force, assembled to strengthen the pipeline of caregivers.

Meanwhile, colleges are starting or expanding nursing programs, and they are partnering with hospitals to strengthen the students-to-professional pipeline.

The state will be short thousands of registered nurses or licensed practical nurses by 2033 and Western North Carolina will face a deficit of almost 1,700 RNs and LPNs, according to a University of North Carolina Cecil G. Sheps Center study and its workforce supply and demand tool, NC Nursecast.

The region will have the state’s highest deficit of LPNs overall and the highest deficit of RNs in assisted living and ambulatory care sectors, barring workforce increases, according to the data. It will face a deficit of 831 nurses in long-term care and nursing home facilities and 605 in hospitals.

As of July 18 there were 643 RN job openings in Buncombe, Transylvania, Henderson, Madison and Haywood counties, according to NCWorks Online, an online resource for job seekers and employers in the state.

Data projections from The Program on Health Workforce Research and Policy at the University of North Carolina’s Cecil G. Sheps Center show increasing shortages of nurses in a 19-county Western North Carolina region by 2033. // Credit: NC Nursecast: A Supply and Demand Model for Nurses in North Carolina.

“We are in need somewhere in the range of 10,000 to 12,000 new nurses every year, just to replace those that are leaving the profession, retiring, moving out of state,” Taylor said of nursing demand statewide. “We know that our educational system is only producing somewhere between 6,000 to 8,000. So we’re in a deficit every year.”

An effort to enhance recruitment, retention

The problem is multifaceted, experts say.

Taylor said nursing school faculty members need to be paid more. Asheville-Buncombe Technical Community College Chair of Nursing Christy Andrews said the school has seen declined enrollment this year and said negative media coverage of “the horrible side of healthcare” — long hours, short staffing and abusive patients — could be deterring nurse hopefuls. Nathan Ramsey, director of the Mountain Area Workforce Development Board, said some Western North Carolina nursing programs are sometimes turning students away because they can’t meet demand.

In 2017, Taylor said, when the Nurses Association urged the General Assembly to help boost salaries for nursing instructors, the statewide deficit stood at about 2,000 to 3,000 nurses; by 2033, according to the Sheps Center, the deficit will be more than 17,500 RNs and LPNs combined.

Aiming to reverse this trend, North Carolina’s departments of Health and Human Services and Commerce announced in March the creation of the Caregiving Workforce Strategic Leadership Council.

“Leadership Council members are committed to working together to create real solutions that build a workforce pipeline, forge career pathways and address financing strategies that support sustainable wages so we can avert this coming crisis,” NCDHHS Secretary Kody Kinsley said in a news release. 

“What we’re really trying to do is to understand what is happening already in North Carolina, as there are many, many, many folks already working on this issue,” the secretary’s Senior Office Director Colleen Tapen told The Watchdog recently. “We are trying to come up with solutions that will be additive to what’s already happening across the state.”

The Leadership Council aims to enhance nurse recruitment and retention, Tapen said. The council plans to formulate a set of recommendations and initiatives by January 2024, she said, and may act on them by 2025-2026.

“We’re looking at both short-term and long-term initiatives,” Tapen said. “We understand that this has been a pervasive problem and there will be no solutions that ‘cure it overnight.’”

Heath Norman (left) and Jacquelyn Willis say the nursing shortage doesn’t scare them. // Watchdog photo by Starr Sariego.

The nursing shortage doesn’t scare Jacquelyn Willis and Heath Norman. Although they are certified nursing assistants and RNs in training at A-B Tech, they have already seen the front lines. Both 21, they grew up in Buncombe and work at Mission Hospital while attending A-B Tech. 

“When I first started in oncology we started with 40 rooms, and some shifts I was the only CNA for 40 people,” said Willis. “I was running from one end to the other and one day I walked like 12 miles in a shift. I looked at my phone and I was like, ‘Well, this has to be wrong.’ It was not.”

Willis said ultimately the workload was reduced, but that experience and others in the nearly three years she’s been working at Mission gave her a glimpse into a daunting world, one she’ll never leave, no matter the pressure, she said.

“I feel like it might give me more motivation to stay if there is less (nurses) ,” she said “If I know that I’m one of the few that have stayed and they’re still trying to make a difference, that’s just going to give me more motivation to do my best.”

Jacquelyn Willis, a CNA in Mission Hospital oncology, holds her stethoscope. // Watchdog photo by Starr Sariego

Mission uses state accreditation to train CNAs for six weeks and then hires them. Willis and Norman both graduated high school in 2020 months after the onset of the COVID-19 pandemic. Norman wants to stay at Mission and serve on a three-person crew on a Mountain Area Medical Airlift helicopter. Willis wants to continue her education once she’s done with her five-year bachelor’s degree, and has thought about becoming a travel nurse.

Norman gets up at 4:30 a.m. to prepare for his days working full time in an intensive care unit, declines evenings out with his friends and frequently misses meals during long shifts, he said.

“You almost feel guilty taking lunch,” he said.

Willis and Norman are actively trying to figure out ways to adapt to the challenges of their profession. 

Willis talked with an instructor after she was managing only one patient in RN clinicals and saw other nurses taking six or seven. 

“I’m like, ‘How am I ever going to get to this point?’” she said. “Now I’m taking two (patients), so I’m feeling a little bit more confident, but at the same time, I’m almost feeling more intimidated.”

Heath Norman is a CNA at Mission Hospital. // Watchdog photo by Starr Sariego

Norman recalled a time when he also was the only CNA on a floor of 40 patients. He came home frustrated and told his parents that, despite working as hard as he could, he didn’t make it to a woman who needed to use the bathroom.

He beat himself up about it, he said.

“I can’t do it,” he said he told his parents. “And they’re like, ‘You’re right. You can’t. You go, you do your best, and that’s all you can do sometimes.’”

Sometimes, “I’m the sole reason why this individual is alive,” Norman said.

“Nurses make a difference,” Andrews said. “Anytime that a child is born, a nurse is there. And … every time that birth story is told, that nurse will be there. When a person dies in a facility like a hospice facility or hospital facility, there’s a nurse there, and every time the story is told, that nurse will be there.”

Region has several nursing programs

“We’ve known for 15 years that a nursing shortage is coming and have been preparing for that,” said Andrews. “Maybe even 20 years.”

A-B Tech has a 140-student capacity in its nursing program and usually fills every seat, she said, but it currently has fewer applicants than in many previous years.

She suspects the lingering impact of COVID and media coverage highlighting hardships of the nursing career have played a role.

Partly to address the widening deficit, A-B Tech in 2022 went from a community college that had a nursing program to the only accredited community college in Western North Carolina with a school of nursing.

Most students come from Buncombe County, Andrews said, and most go to work at Mission Health hospitals across the region.

Mission recently has provided $14,000 in scholarship money, textbooks, lab kits and other needed supplies, Andrews said. In 2022 it funded a faculty position at A-B Tech, too, along with others at Blue Ridge Community College and Western Carolina University. 

It also has helped establish the newest nurse education program in Western North Carolina, Galen College of Nursing, which is owned by Mission parent company HCA Healthcare. Galen College opened an Asheville campus in fall 2022.

Galen Asheville has enrolled an average of 40 students every quarter, HCA spokeswoman Nancy Lindell said. It has four cohorts of students on campus with the first group expected to graduate in March 2024, at which point the program may expand. 

Several other colleges and universities across Western North Carolina, including Blue Ridge, Southwestern Community College, WCU, and Mars Hill University, offer nursing programs.

According to their graduation data, these programs combined have graduated just shy of 930 RNs between 2020 and 2023, including some set to graduate from WCU in December.

South College has a campus in Asheville and offers a nursing program, according to its website, but did not respond to an email and a phone call.

A shortage of instructors

“The community colleges (and) universities that are offering nursing programs, they’re all doing what they can to ramp up,” Ramsey said. Southwestern plans to start an LPN program in 2024 and Blue Ridge is seeking national accreditation for its nursing program, for example.

But, according to Ramsey and Taylor, schools may be facing a different kind of shortage: faculty members.

“North Carolina ranks near the bottom in community college faculty pay,” Ramsey said. “These are the people that are turning out the workforce of tomorrow. … It’s even more extreme in Western North Carolina. I think if you go to every hospital, every large healthcare provider in our region, one of the first things that will come up is housing. Even for people making $60,000, $80,000 a year or more, when the average price of a home is a half million dollars in our region, a lot of people — even (those) making pretty good money — are going to struggle with that.” 

Taylor said he’s sounded the faculty pay alarm to the General Assembly since 2017, when he became president-elect of the Nurses Association.

“At that time … as a bedside nurse I can make significantly more,” Taylor said. “I’m talking about anywhere from 50% to 75% more pay as a bedside nurse taking care of patients than I can as a professor or an instructor in nursing. There is very little incentive for our seasoned experienced nurses to want to go into an educational role that requires a graduate degree.”

The Watchdog asked each of the higher education institutions interviewed what nursing faculty make on average. Responses from each included:

  • A-B Tech: The hiring salary range for a 12-month instructor is $67,740-$70,740.
  • WCU: The current average salary for a nine-month appointment for faculty, regardless of rank or tenure status, is $78,344.
  • Blue Ridge: The average salary is approximately $70,000.
  • Southwestern Community College:  The average salary for full-time faculty is $61,219, based on a one-year appointment for fall, spring, and summer.

Lindell did not respond when asked for an average salary for Galen instructors, and Mars Hill spokesman Mike Thornhill said his school doesn’t release salary information.

Durbin, the WCU nursing school director and a nurse anesthetist by training, knows the issue of pay firsthand.

“I could easily make twice what I’m making right now,” Durbin said, as a nurse anesthetist. “But this is important work. Everybody needs a nurse at some point in your life. Everybody’s going to need a nurse, and this is meaningful and I think it matters.”

The 2022 median salary for RNs in North Carolina was $76,430. In Asheville and five counties around it, the median 2022 salary was $76,151, according to the North Carolina Department of Commerce.

“Shortage” or corporate stubbornness?

In the Asheville metro area, HCA alone had nearly 200 RN job openings as of July 18, according to NCWorks. Lindell did not respond when asked the number of open nurse positions at Mission Health. She also did not respond when asked how many traveling nurses Mission currently uses.

Lindell said Mission Health has hired almost 200 full-time and part-time experienced RNs so far in 2023 and 100 new graduate RNs.

“As part of HCA Healthcare we have been aware of and addressing the national nursing challenges for several years,” Lindell said. “While our goal is to continue to reduce the number of travel nurses in favor of permanent staff, we are grateful that through HCA Healthcare, we have access to the resources to bring in supplemental nursing staff as needed – especially as we face ongoing national shortages.”

UNC Health Pardee in Hendersonville currently has just over 200 job postings, clinical and non-clinical, Vice President of Workforce Development and Community Affairs Dr. John Bryant said, adding approximately 50 of the postings would ideally be filled by RNs and LPNs.

“The clinical and non-clinical staffing shortages predicted to impact healthcare for the past decade have only been amplified by the events of the past three years,” Bryant said. “This deficit is very real in WNC and at UNC Health Pardee.”

“The clinical and non-clinical staffing shortages predicted to impact healthcare for the past decade have only been amplified by the events of the past three years,” Bryant said. “This deficit is very real in WNC and at UNC Health Pardee.”

AdventHealth in Hendersonville did not respond to The Watchdog’s request for job opening data.

Mission Hospital is seen from the window of an A-B Tech campus building. The hospital and the college are neighbors. // Watchdog photo by Starr Sariego

The word “shortage,” said Hannah Drummond, is misleading when applied to Mission Hospital, where she is an ER nurse and a National Nurses United union member. 

“I get a little weird about the word ‘shortage,’’” Drummond said. “There are people that apply to positions that are posted. The struggle comes from the retention. I have seen almost a complete turnover of … the department that I’ve worked in for two years … and that’s not a lack of human beings that are qualified to fill the role in Western North Carolina; that’s the lack of people staying here.”

At a protest in April, nurses and supporters repeated demands for Mission Hospital, owned by HCA Healthcare, to create a safer work environment for nurses by increasing patient-to-caregiver ratios. // Watchdog photo by Starr Sariego.

Mission drives nurses away because of poor working conditions, Drummond and the union contend.

Nurses have left for the food and service industry rather than cope with the “heinous working conditions that HCA would love to leave us in,” she said. 

“The hospital industry has created the staffing crisis,” National Nurses United spokeswoman Chuleenan Svetvilas said. The union is pressing Congress to pass a federal safe staffing law, introduced earlier this year, which would limit the numbers of patients each RN can care for.

When asked what current average nurse-to-patient ratios are at Mission health, Lindell did not provide specific figures, instead saying,  “We continue to supplement our growing number of core staff with travelers as needed and review staffing every four hours to adjust to any changes that occur throughout the day.”

Union nurses have consistently complained about staffing ratios at Mission Hospital. They frequently gather at 509 Biltmore Ave., the site of the hospital, where they hoist protest signs, chant along with a brass band and excoriate HCA corporate leadership for nurse-to-patient ratios they say have reached as much as 1:8 and for generally unsafe working conditions.

Ratios vary by department, and many states do not have laws mandating or defining safe ratios. California is the only state with a ratio law requiring, for example, one nurse to two patients in intensive care and one to four in the emergency room.

“I love to invest in the next generation, and I want people to become nurses,” Drummond said. “But HCA has a reputation it’s built for itself and this community, and I think, the entirety of Western North Carolina is aware and unhappy about it. If there’s a recruitment issue there, it would be HCA’s fault.”

In its push for better staffing ratio legislation, the union cites a 2006 study that found nearly 5,000 patient deaths, nearly 60,000 adverse outcomes and high costs could be avoided if health care facilities increased RN staffing to match the best-staffed hospitals in the U.S.

Mission Health’s recruitment efforts currently are focused outside of Western North Carolina, Lindell said, “to attract talent to this area” instead of solely relying on local graduates.

Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Andrew R. Jones is a Watchdog investigative reporter. Email arjones@avlwatchdog.org. To show your support for this vital public service go to avlwatchdog.org/donate.

22 replies on “The Asheville, Western North Carolina nurse shortage is worsening. Here’s what’s being done to change that.”

  1. As a nurse with 45 yrs experience. I can attest to many of the issues mentioned in this article. One thing that was not addressed, is the large amount of nurses that are leaving or trying to leave bedside nursing for work from home positions. Although I currently work part-time in an ambulatory setting, I do follow a remote work facebook group.
    Many of the nurses in this group are relatively new nurses who have been totally disillusioned with bedside nursing, the poor conditions, low pay, and lack of support from administration. We may be graduating them, but we are not retaining them, which only adds to the problem. Retention incentives need to be looked at even more than hiring incentives.. what good is hiring 10 nurses, if 5 are not there in a year or two.

  2. A-B Tech says nursing enrollment is declining. Ramsey in same graf says some nursing programs are turning students away. Is that a contradiction? Which is it?

    1. Hello, Larry. Thanks for raising the question. The enrollment situation varies from program to program.

  3. Thank you for starting down the path of fewer nurses. I agree with Hannah Drummond that here in WNC we have to separate out retention issues with shortages. Visiting 28 facilities regularly, what I see and hear from the MDs, RNs and LPNs is very different from HCA facilities to those that are independent of them. The largest disparity is retention, and the gap is wide. In addition, what is not reflected in the numbers is described above as “generally unsafe working conditions”, which doesn’t begin to illustrate the severity. Imagine for a moment half the support staff working with you don’t come to work tomorrow. In addition, your workload increases 150%, creating a pressure cooker. You are trying to do your job which just got a lot harder, while cleaning the office, answering the phone, and creating marketing which you must then place. There is no time to use the restroom, or eat. While all this is happening, your supervisor visits and tells you output needs to increase because you are not hitting quotas. To top it off, after a few months of this, you are run down to the point of falling ill yourself. You still drag yourself to work, albeit 10 minutes late, and are rewarded with a demerit. After 2 demerits, your job is on the line, leaving you carrying the stress of income instability. All the while, your clients are feeling the lack of support staff, thus, filing complaints. In this imaginary nightmare, it is work at a computer, in a chair, in an office, with clients. Imagine applying that to nursing. Life and limb are in your hands. Your “clients” are sick and injured people that are desperate for you to rapidly help them alleviate their suffering, or use a toilet instead of their bed. It is more than unsafe for the nurse and the patient. It truly is “heinous”. The role private equity firms acquiring hospitals have in the shortage cannot be overlooked. While the national shortage is a complex problem, requiring a multi-faceted solution, there is a Goliath standing on the neck of WNC’s healthcare system. Until there is a solution to our retention problems here, we are all at risk of having an accident and going in to an ER without sufficient staff to save our lives.

  4. The headline doesn’t match the content of the article. I was looking for “what’s being done about the problem”. All I kept seeing was more about what the problem is.
    I got it. There’s a shortage. It looks like HCA is putting in a small amount of money to help out. AB Tech seems to be doing all they can, but nothing more to solve the problem. The nurses union protests as always and they need to keep doing that because sometimes people listen to them and make changes. I read nothing about ways to attract more nurses to this area or to work for HCA. It seems to me that HCA is going to have to figure this out or lose patients. I found myself thinking that maybe next time I have to go to the hospital I probably should go to Pardee instead. I hate to drive farther but if Mission (HCA) won’t have enough nurses to take care of me, I might be willing to take a chance with another facility.
    Hopefully next article will actually include some solutions rather than a repetitious listing of the problems.

    1. Dave, thanks for reading and commenting about the article. There were several sections of the story that talked about the steps being taken to address the issue. For instance:

      Aiming to reverse this trend, North Carolina’s departments of Health and Human Services and Commerce announced in March the creation of the Caregiving Workforce Strategic Leadership Council.

      Partly to address the widening deficit, A-B Tech in 2022 went from a community college that had a nursing program to the only accredited community college in Western North Carolina with a school of nursing.

      It also has helped establish the newest nurse education program in Western North Carolina, Galen College of Nursing, which is owned by Mission parent company HCA Healthcare. Galen College opened an Asheville campus in fall 2022.

      Mission recently has provided $14,000 in scholarship money, textbooks, lab kits and other needed supplies, Andrews said. In 2022 it funded a faculty position at A-B Tech, too, along with others at Blue Ridge Community College and Western Carolina University.

      Thanks again for reading.

      1. You need to look a lot deeper into the HCA involvement in nursing education. The superficial coverage sounds good until you dig into the indentured servitude which follows. Asheville could be in the cat bird seat—people want to live here, work here, retire here. If we treated hospitals as enterprises where the primary stakeholders are patients and health providers rather than secondary to obscene executive compensation and shareholder returns underwritten by unsafe and diminished patient care , we’d likely be very attractive to nurses, doctors, and the others who make hospitals work as they should. HCA is driving providers away, and based on the hardworking CNA interviewed here, gaslights those who remain. 40 patients to one CNA? No thanks.

  5. This article addresses an important issue but overlooks the root of the problem. Medical care in the US is sold; it’s purpose if to make a profit for company officers and shareholders, not attend to the health of our population or cure disease. Healthcare access and medical bankruptcy (50% of personal bankruptcy in our country) are at the top of the list of Americans’ concerns. General population health in the US is ranks at the bottom of the modern industrial economies. Private markets do not produce goods and services necessary to public welfare. As is evident in our region, the outcome of selling healthcare is monopoly with the inevitable increase in prices, erosion of quality, and neglect of less well-off people.
    The shortage of nurses lies in decades of cuts to funding of post high school education, the damaging impact of cost-cutting by for-profit corporate medicine on hospitals and providers, and the shift of the cost of education to students, especially in the form of loans.
    Traveling nurses do not exist because of a shortage of nurses. Willing to leave their homes for extended periods, these nurses work on temporary ‘at pleasure’ contracts so are not employees that require benefits (health insurance and retirement plans). In fact, they are paid more but ultimately cost hospitals much less. It’s outsourcing to increase profit. This article could have been more complete by interviewing more nurses and CNA’s who have spent more years in the current clinical environment.

  6. there is no question that in the 20 plus years I have lived here heath care has suffered and the fault is the creation of huge corporations whose major concern in the bottom line and what it can give to shareholders and corporate executive. HCA and ADVENT are billion dollar corporations and Mission showed profits over 50 billion dollars last year while they cut staff when they took over Mission and now say they cant get nurses. Mission used to have nurses who worked there for years and years and CNAS as well as housekeeping staff. That all changed when HCA bought it at a bargain price due to the avarice of the then executives who walked away with golden parachutes . As I believe was published in the ACT, Wilmington NC sold its local hospital for about twice as much as Mission sold and sold to a non-profit system. As I remember it, Mission didn’t even interview a non-profit contender buyer. The community lost a valued and vital service when Mission was sold to HCA.

  7. If only all of the problems at Mission were due to a nursing shortage. That’s the HCA narrative. There also seems to be ample proof they intentionally understaff all departments for financial gain. Any update on the cancer center?

  8. As a pediatric nurse practitioner, I was discouraged and appalled by the attitude of the two nursing assistants/students. No one should be attempting to care for 40 patients. It is unsafe for the them(staff) and patients. To think that one can continue to work under such under staffing is delusional at best. Better to advocate for safer staffing. I walked out of several nursing positions that could not provide safe patient care. They should do the same. Management/administration preys on staff self sacrifice. Don’t fall for it!

    1. Sue, excellent point. The new grads don’t know what they don’t know. HCA exploits this. Most experienced nurses have left and you have new grads and travelers running the show which translates into bad patient outcomes. The nurses who don’t speak up about the dangerous conditions are complicit in perpetuating the danger. First and foremost nurses are supposed to advocate for patients. That has become a lost art due to the abominable working conditions.

  9. Thank you for your reporting on this. Yet another example of HCA doing whatever it can to boost short-term profits at the cost of long-term retention and quality. What can be done about them?

  10. I was shocked to find out recently that AB Tech doesn’t have an evening nursing program. I graduated from one in a smaller community 31 years ago. It’s pretty difficult to work or to care for kids and go to school full time during the day. Of course, you would have to pay professors.

  11. As the parent of a “travel nurse ” I can tell you that she, as well as many other nurses, will not even entertain going to an HCA facility due to the poor working conditions.

  12. Back in the early 2000s, Mission hospital was a major reason retirees were flocking here, aside from the natural beauty of the mountains. Real estate companies even promoted it to lure the oldsters here. Now they are too old to uproot and are stuck here with this horrible hospital. Mission would shut down without the medicare money they reap in from the over 65s, it’s their bread and butter.

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