“Nursing is walking out of the building several times a week crying or crying while they’re [nurses] in the building trying to take care of more patients than they’re able to,” says an ER Level 1 trauma nurse in New York City. She adds, “We don’t want to offer poor care, and we do our best not to. But when you have the ratios nurses are facing now, there is no way to deliver the best health care that you want.”
“Patients are being sent home from the hospital with higher acuity and less community resources such as home health. This has resulted in higher hospital readmission rates, poor patient outcomes and lower job satisfaction for all in the health care industry,” claims another nurse from the Las Vegas area.
From a Texas nurse, “I used to have 4-5 patients per shift. Now I regularly handle 7-8. That means less time with each patient, more room for errors, and honestly, I go home exhausted and worried I missed something important.”
And this from a nurse in Michigan, “We’re losing experienced nurses faster than we can train new ones. When you do not have enough seasoned nurses to mentor newcomers, patient care suffers. I’ve seen new graduates thrown into situations they’re not ready for because we simply don’t have enough staff.”
I could go on with further alarming anecdotes from the nursing profession but instead let us reinforce the above pronouncements with some data. In January 2024, the U.S. Chamber of Commerce published Data Deep Dive: A National Nursing Crisis, which is compilation of statistics supporting the contention of a nursing shortage in the United States. Here are my summaries of some selected evidence:
- Anticipated demand for registered nurses (RNs) between 2022 and 2032 is 193,000 per year. However, the total number of new nurses entering the workforce for this whole decade is presumed to be 177,400. That does not satisfy even one year of demand!
- The unemployment rate in the nursing profession is often exceptionally low compared to the aggregate unemployment rate. Historically it is often under 1.25%. The pandemic saw an unemployment rate increase as many nurses left the profession with the rate getting as high as 1.6% in 2022. This is still low when compared to the general unemployment rate of 4.0% in January 2025.
- By the end of the current decade 42 of the 50 states are predicted to have nurse staffing deficiencies. At present, there is an average of nine nurses per 1000 people.
- As of June 2023, over half of all new nurses leave their job within their first two years. When all industries are examined the time it takes for half of new employees to leave their jobs is four years. The turnover rate among nurses exceeds most professional lines of work.
- There are now more Americans over the age of 65 than at any time in our history. By the end of the decade all the Baby Boomer generation will have reached retirement age. Boomer nurses are of course included in this trend with 20% of present-day nurses set to retire by 2030.
- Nursing pays well. Salaries for those holding degrees in nursing surpass the median annual income, which is just above $60K. For example, nurse practitioners earn well over $100K per year. Despite this good compensation we still do not have enough nurses.
The United States is in the grip of a nursing shortage. The anecdotal and quantitative evidence is indisputable. The nursing shortage matters for one simple reason — nurses are a crucial component in our overall health care system. Without enough nurses the citizenry experiences a lower quality of life at times when many need care and support the most. Given that a healthy society cares for all its members, a scarcity of nurses is perilous.
Nurses matter. They provide a range of services crucial for the wellbeing of those in need of medical care. The aid begins with direct patient care such as monitoring patient vital signs; administering medications, treatments, and wound care; and assisting with daily activities. But nurses supply much more benefit. They are patient advocates in that they make sure patients understand how to best heal, know their rights, and understand their options. Nurses coordinate communications among other medical providers, families, and the patients themselves. These professionals are trained in carrying out technical tasks from collecting lab samples to operating medical equipment to conducting diagnostic procedures. Nurses respond to emergencies, document interventions, and participate in a variety of specialized roles.
Acceptable nursing levels matter also because they help to assure better patient outcomes. How is this done? Adequate nurse to patient ratios lower incidents of mortality, lessen treatment complexities, and enhance patient safety. Hospital-acquired infections, medication administered errors, and hospital readmissions are all diminished. Patient recovery times are hastened due to more thorough communications, frequent monitoring, and timely interventions. Also of note, well-staffed nursing teams mean less burnout and greater professionalism among the personnel. In short, nurses are an incredibly valuable resource.
There are now about 3.9 million nurses in the US according to the World Health Statistics Report — and it is not enough. This is not the first time the nation has had to contend with a scarcity of frontline health care providers. From the 1930s onward we have not had enough trained professionals to care for the ill and infirmed for much of this period. The current shortfall, which began in 2012, is of the greatest concern. There exists an assortment of reasons for our present-day paucity of nurses. Let us examine some of the chief ones.
Demographic shifts affect the nursing supply in a couple of ways. At present for example, the generation known as Baby Boomers, those born between 1946 and 1964, are requiring a proliferation of health care services. The sheer volume alone of this emerging cohort places a substantial burden on the health care labor force. The strain manifests in several ways.
Baby Boomers are demanding more chronic condition management. With age comes increased numbers of patients presenting maladies like hypertension, diabetes, arthritis, and heart disease. The care required for these patients needs to be well regulated for the long-term. Also, geriatric, or elder care demands health care specialists who know how to address physical and cognitive declines in mobility, dementia, and osteoporosis.
Home-based health care demands are growing. Not only are family members and private aides carrying this load, but so are nurses who are expected to visit, assess, and deliver care over a wide radius. Given the scale of the Baby Boomer generation the requests for qualified home health aides and medically trained caregivers are expected to rise.
Another area expected to command more nurses is in assisted living, memory care, and nursing care homes all eventually leading to end-of-life care. As this generation passes away the required involvement of greater numbers of trained institutional, palliative, and hospice care providers will swell.
In conjunction with aging Boomers is an attrition issue related to the expanding number of this generation who are retired or retiring, including many nurses. Just as the need for more nurses to support an aging demographic bulge is realized many of the current health care labor pool is aging out of their profession themselves.
Beyond the rapidly rising patient load due to an aging population there are other factors stressing the nurse workforce. Life expectancy is increasing, and medical advancements are also keeping people alive longer. There are also increased rates of illnesses such as heart disease, diabetes, and obesity. And no number of superlatives can adequately describe the distress the Covid-19 pandemic put on nurses.
While all of this is going on, there are economic burdens negatively impacting the nursing profession. Traditionally, nursing has been seen as a female profession, which unfortunately means salaries are less than many industries seen as more male. Hospital austerity measures have also led to hiring freezes and staff reductions along with increases in outpatient and home-based care settings, which together increase struggles for existing staffs. Technology can be amazing, but it can also increase workloads. Nurses now must input data into electronic medical records, for example.
A significant impediment to sustaining a sufficient nursing workforce is the lack of adequate education and training opportunities for nurses. The shortage extends to the number of qualified instructors who are unable to meet the demand of individuals who would like to pursue a nursing degree. The American Association of Colleges of Nursing reports that for the 2022-2023 academic year alone 65,766 qualified applicants were denied entry to a nursing program due to insufficient staffing. There simply are not enough Master’s and Ph.D.-level nursing educators, dashing the hopes of many potential nurses and postponing resolution to the nursing shortage.
Related to the shortage of qualified nursing educators is the rigor of the requirements to become a nurse. Of course, we want and should expect the best trained nurses possible, but it is worth noting that the expectations placed upon nurse trainees is significant and is discouraging for many would-be nurses. It begins with a competitive admissions process, including satisfying prerequisites, entrance exams, and interviews.
Robust academic records are required for admission to nursing programs and high-grade point averages must be maintained to stay enrolled. Among the subject areas nursing students must study are anatomy, physiology, pharmacology, microbiology, and other related sciences. The combination of demanding coursework and clinical rotations does not leave time for part time jobs or much leisure.
Clinical training is not to be taken lightly. A set number of hours must be worked in a variety of settings such as hospitals, clinics, and community health centers. Students are often faced with caring for seriously ill patients during these rotations. And as with the shortages of trained nursing instructors, there is also a scarcity of clinical placement sites further compounding the problem.
Upon completion of formal study nursing candidates must pass the National Council Licensure Examination (NCLEX), which is a stringent demonstration of critical thinking and decision-making skills. Preparation for the NCLEX takes months of study, comes with additional costs, and necessitates mental discipline.
To earn a nursing degree can take from two to eight years depending on the degree being pursued. And it is not cheap to do. For example, the price of a Bachelor of Science in Nursing can range from $20,000-$40,000 at a state school with in-state tuition to $60,000-$120,000 at private institutions. Master and doctoral degree programs are similarly priced and then there are the ancillary expenses like textbooks, supplies, uniforms, clinical and lab fees, insurance, immunizations, and ongoing continuing education. Clearly pursuing a nursing degree is a considerable mental, physical, emotional, and financial commitment.
As is evident, nursing as a profession faces some headwinds. They face long hours, contend with high patient to nurse ratios, all while struggling with physical and emotional pressures. Anyone who has worked with the public know how difficult the range of people can be. Now consider that surly segment of the population most difficult to deal with and make them even more irritable because they do not feel well. We saw that at its worst during the pandemic when many of those suffering from the virus lashed out at the nurses who were caring for them. (They should have turned their ire toward those who were spreading the virus through their behaviors and rhetoric instead.)
Given the gravity of the nursing shortage problem a look at practical solutions is merited. Before looking at specific measures which can be taken however there is one alleged remedy that will not work. That is a reliance on market forces alone. Free enterprise has many areas of significant success in the economy and in the lives of ordinary citizens. But there are limits to what a self-regulated market can do. Turning around a predicament as vast and complex as what I have been describing requires more than just supply and demand tweaks.
Contending with work retention issues, the obstacles facing nursing education, and issues like the discrepancy between urban job placements and the vastly underserved rural parts of the country, all while maintaining a training and regulatory environment that produces the best nurses possible, is going to involve a multifaceted approach of policy interventions, investments in training and education, and employment enhancements.
Crafting and passing effective policy positions should play a crucial reform role. Several professional-level organizations have begun weighing in singly or jointly by putting forward proposed fixes that can be done at the legislative and industry levels. Associations such as American Nurses Association, National League for Nursing, American Association of Colleges of Nursing, National Council of State Boards of Nursing, National Nurses United, and others are putting forward recommendations to confront the problem.
Policy suggestions often involve two parts, targeting and funding. A problem is identified, and proposals are made to mitigate or eliminate the problem. Resources are needed to promote a perceived remedy and/or to discourage a threat in production. When the attention of those in control of the purse strings can be persuaded to fund a proposal, then resolutions become more likely. Nursing shortage policy initiatives can be grouped by the following classifications:
Resolving nursing education constraints, including increases of qualified human resources such as faculty and reducing the number of applicants being turned away from a dearth of programs is considered crucial. Clearly more educators are needed to staff more schools of nursing, which would allow for more nursing program applicants to be accepted and educated. Therefore, policies which incentivize nursing program educators with combinations of competitive salaries and attractive workplace conditions are common.
A key area of such funding is Title VIII under the Public Health Service Act, which was legislation passed in 1944 to codify the US federal government’s response to public health policy and programs. From this act have emerged the US Department of Health and Human Services, the Centers for Disease Control and Prevention, and the National Institutes of Health, among other agencies and programs. Funding for the growth of nursing education capability comes under the authority of this act so ongoing promotion and sustainability of the Public Health Service Act is believed to be vital.
In tandem with policy efforts to increase the flow of nurse applicants to training programs yielding high quality graduates ready to occupy the health care workforce is the strategic approach of retaining nurses for the long term once they are on the job. Contending with elevated rates of attrition by remediating factors which lead to nurse burnout and depletion of the nursing ranks is also a policy priority. Widespread unsatisfactory and insufficient working environments is seen as the prime transgressor.
Upgrading employment terms and conditions is multidimensional. Included in the mix is minimizing nurse-to-patient ratios, limiting overtime and unreasonable workloads, and funding placements of nurses to critical shortage areas. Together with more mental health services and peer support programming psychological endurance can be boosted. Also, robust safeguards against workplace violence, including making it a felony to assault a health care worker, can protect the physical wellbeing of nurses.
Further actions to be taken involve student loan forgiveness, increasing Medicare and Medicaid reimbursements to help strengthen the wages of nurses, employer tax incentives tied to issuing of nurse bonuses, additional funding to encourage career growth through expense-free or reduced continuing education for nurses, expanded leadership training, and streamlining documentation and administrative loads via smarter electronic health record systems.
As we all adjust to the escalation of AI into our personal and working lives it seems timely to speculate on how AI agents, the term being used to refer to artificial intelligence software interactions on the behalf of people, may benefit nurses and contribute to mending the nursing shortage problems discussed above. There are concrete ways AI agents can be useful, and we will soon see policy proposals that include AI utilization.
There are several ways AI agents can be applied. For example, administrative workloads could be reduced by having agents handle more of the documentation requirements necessary with the use of electronic health record systems, thereby freeing up nurses to provide more direct patient care. Agents can monitor patient health indicators resulting in fewer rounds and the issuing of important alerts for when interventions are most needed. Telemedicine and remote interactions with patients can become more common reducing the number of patients on site. Also, predictive analysis can anticipate patient demands allowing management to allocate nursing resources more effectively.
Nursing education can also be enhanced with AI agents that provide virtual reality and other enhanced simulations and tutorials to assist nursing students in understanding crucial information more efficiently. Chatbots can even provide potentially useful mental health information and suggestions for nurses experiencing early signs of burnout or fatigue.
I would like to bring this essay to a close by examining one solution, which when applied along with the others proposed above, could have a meaningful impact alleviating the negative outcomes of this country’s nursing deficit. This requires America to look closely and more acceptingly at immigration. That a paucity of nurses exists has been made clear. What is also evident is that there are many nurses from around the world who would like to work in the United States for what is seen as enhanced compensation, more attractive working environments, and professional growth.
The Commission on Graduates of Foreign Nursing Schools, the American Association of International Healthcare Recruitment, and The National Council of State Boards of Nursing are examples of professional organizations with indicators demonstrating strong demand overseas for job placements in the US. Further evidence is revealed when noting the number of recruitment agencies that specialize in placing international nurses such as Avant Healthcare, O’Grady Peyton International, AMN Healthcare International, Health Carousel International, and Conexus MedStaff. It is also reported that online communities and social media anecdotally show this trend.
Of course, supply and demand are only part of the story concerning whether international nursing placements in the US is viable. This nation also needs to come to terms with its anti-immigration politics if there is to be any chance of benefitting from this opportunity. The liabilities of immigration in general have been over emphasized and politicized to the point where we are rightly questioning whether the US labor force can adequately meet the economic needs of the country. Painting all immigrants as a threat is not only irresponsible, but it is immoral. It perpetuates social division and bigotry. And in the context of the nursing shortfall, a jingoistic attitude does nothing to remediate the problem.
From the perspective of a nurse in say Philippines, or Pakistan, or Ghana, or in any number of countries with prospective talent, they are increasingly aware of the hostility Americans are showing to outsiders. If that does not discourage them from trying to come here to work, then they must contend with other hurdles, many of which are necessary, so that we can generate and sustain a high-quality workforce which after all is the main goal. A review of these conditions shows that safeguards are indeed in place to protect and support the American public with its health care needs.
An aspiring nurse from another nation who wants to work in America must demonstrate specific proficiencies. Completion of a degree in their home country that is equivalent to a US degree as recognized by the state nursing board of the state in which the aspirant intends to work is mandatory. Home-country credentialing must also be evaluated by an appropriate US-based agency such as the Commission on Graduates of Foreign Nursing Schools. Additionally, for Registered Nurses the job seeker must pass the National Council Licensure Examination for Registered Nurses to work in the US along with being issued a nursing license from the state’s nursing board.
If a would-be nurse comes from a country where English is not the primary language, then an English proficiency test must be passed such as the Test of English as a Foreign Language and/or the Occupational English Test-Nursing. Besides, some health care employers could require some amount of work experience in the nurse’s home country, possibly up to two years.
There is also the area of meeting the requirements pertaining to immigration, visas, background checks, and health prerequisites. Usually, an international nurse must be sponsored by an employer in the US so the nurse can receive a work visa commonly known as a green card. EB-3 Visa, and H-1B Visa are common ones. Passing a criminal background check and being required to produce medical records showing good health with specific vaccinations is also demanded.
As should be obvious, the rules and regulations are in place to carefully screen and approve immigrant nurses. As domestic professional organizations like the US Chamber of Commerce, which has co-signed a multi-industry plea for Congress to pass comprehensive immigration reform, try to communicate the urgency of action on this front before our law makers, US citizens should also get on board to encourage more nursing immigration to alleviate the nursing shortage.
“Nursing is not just a career, it’s a calling. The ability to comfort, heal, and make a difference in someone’s life every day is what makes this job so fulfilling.” – Sarah, RN
“The best part of being a nurse is seeing a patient smile after a difficult battle. Knowing I played a role in their recovery makes every challenge worth it.” – James, ICU Nurse
“Nursing is the art of caring. It’s not just about medicine; it’s about listening, holding a hand, and bringing hope when it’s needed most.” – Maria, Pediatric Nurse
These are the kinds of quotes Americans need to see and hear from our treasured nurses. The better this profession can be viewed and lived the greater becomes the lives of the patients, like you and me, who will eventually need the care and expertise of a great nurse.
