Why are nurses in high demand? Is there a nursing shortage affecting us? How does it impact health care? These are questions that anyone in the health ecosystem ponders about. For many medical professionals, institutions, and researchers, it’s years we’re talking about. And the findings or answers are as complex and important as the questions themselves.
Nursing has always been associated more with a vocation rather than a profession. But it has evolved so much that, right now, nurses represent nearly 50% of the health workforce and are crucial to the entire health care industry in the United States.
Let’s find out which U.S. states suffer the most, what are the causes, and what are the solutions.
According to the American Nurses Association, nurses are going to be in high demand for a while, with more jobs available through 2022 than any other profession in the U.S. Moreover, The World Health Organization reported that there are about 29 million nurses and midwives in the world, with 3.9 million in the US and more than one million additional RNs needed by next year.
So, yes, being a nurse is both a wonderful calling and one of the fastest-growing occupations in the U.S., according to BLS Employment Projections for 2018-2028.
At first sight, the predictions are encouraging (at least for potential nursing learners). However, the healthcare system faces rather multifaceted problems that need to be addressed promptly in order to stop the nursing shortage from worsening.
Although BLS statistics suggest continued growth in employment, health professionals, administrations, and communities must tackle all the contributing factors relating to the nursing shortage to actually meet these projections.
Especially since, on a larger scale, the bigger problem is “the inequitable distribution of the nursing workforce across the United States”. As the Supply and Demand Projections for the Nursing Workforce: 2014-2030 highlighted, the nursing workforce makes a greater problem with distribution across states than proportion at the national level.
What are the factors that led to such high demand for nurse professionals, which states have the highest shortage of registered nurses, and what are the solutions and efforts to address it?
Why Is There a Nursing Shortage in the U.S.?
All in all, it is a promising time for any aspiring nurse, but also for professionals aiming for key positions in education, administrative, and management fields, due to the retiring of experienced nurses.
The RN workforce in the U.S. is estimated to grow by 28%, from approximately 2.8 million to 3.6 million in 2030, needing over 200,000 RNs annually to replace the retiring generation, as the HRSA projections show.
Even if most U.S. states keep up with the demand, there are some regions, such as the southern and western parts of the nation, that are expected to face higher shortages of registered nurses.
Since the average patient is older and requires complex care needs, the nursing team needs to be larger and well-trained for challenging settings, more difficult patients, higher standards, and new technologies.
But the list of factors contributing to the nursing shortage is much more extended:
- The aging population that changes demographics: As people grow older, the demand for complex care grows (especially for various chronic conditions). At the same time, the number of Americans aged 65+ will almost double by 2050.
- The retirement of more than 1 million nurses by 2030 (according to the HRSA study in 2017). This process challenges the healthcare industry with over 50% of RNs aged 50 and older (the average age of RNs is 51), according to the National Nursing Workforce Study, while the number of nurses leaving the workforce has doubled since 2010, according to the health care economist David Auerbach’s study.
- Nursing school enrollment is not growing fast enough to meet the projected demand for RN and APRN services, and the health care industry needs more nurse educators, researchers, primary care providers.
- The nursing faculty shortage directly affects the number of future nurses and RNs enrolled each year. According to the American Association of Critical-Care Nurses’ report on Enrollment and Graduations in Nursing, more than 75,000 qualified applicants from baccalaureate and graduate nursing programs were turned away in 2018, due to faculty shortage and not enough clinical sites, classroom space, and budget.
- Burnout and stress level for nurses due to insufficient staffing impacts job satisfaction, forcing many RNs to change or leave this profession. There is a large amount of data-backed studies that show how enhancing nursing skills (through higher education), empowering RNs, and balancing the patient ratio has been linked to better patient outcomes, fewer medical errors, and lower patient mortality rates. And, of course, lower nursing shortages.
When Did the Nursing Shortage Begin?
Registered nurses are a major segment of the essential personnel in the health care system. As a result, the lack of enough professionals has deeply affected hospitals since 1998.
Though, it’s not the first time such deficit appeared – since the mid-1930s, this phenomenon has persisted due to social, economic, technological or historical reasons (especially during wars), and have been addressed in various ways: better salaries, improved or modern medical settings, funding and speeding up nurse education, and other similar strategies.
Even though there is a way larger number of active registered nurses today, it’s the demand that has critically increased. And when you put together all the pieces of the puzzle – rising demand for nurses, high numbers of retiring professionals, a severe shortage of nurse faculty educators, growing patient needs that are getting harder and harder to be met by an overly stressed staff – what you get is far from a reassuring picture of the American healthcare system.
Because nursing shortage deeply varies by region and demographics, let’s take a look at which states need nurses the most then analyze the impact and potential solutions.
Nursing Shortage by State: Which Regions Suffer the Most?
It’s interesting to notice how almost four million registered nurses are so differently dispersed throughout the U.S. There are areas where there is actually a surplus of RNs, and there are cities where the job growth is so high because the number of nurses there can barely ensure basic medical needs for the community.
We can see big differences in nursing specialities as well, with many states needing more critical care and labor and delivery nurses. But in general, there is a growing need for RNs and APRNs in areas with high retirement populations.
What states have a shortage of nurses?
According to the comprehensive Supply and Demand Projections of the Nursing Workforce: 2014-2030 report issued in August 2018, there are major differences across states regarding the projected number of RNs for 2030 (the numbers are calculated for full-time equivalent).
At the top of the list of states projected to have the highest nursing shortage in 2030 is California (facing an estimated deficit of 44,500 RNs), which is nearly three times the deficit in the next several states suffering from a shortage: Texas (projected deficit of 15,900), New Jersey (projected deficit of 11,400) and South Carolina (projected nurse deficit of 10,400).
At the opposite pole, among the states with the lowest nursing shortage are Florida, with an estimated surplus of 53,700 RNs for 2030, followed by Ohio (estimated surplus of 49,100 RNs), Virginia (estimated surplus of 22,700 RNs) and New York (with 18,200 extra nurses in 2030).
Below you will find an alphabetical list that shows the projected supply and demand for registered nurses through 2030.
It is important to note that the study made the 2030 projections with the assumption that each state’s supply and demand were equal in 2014.
In the South region, Alabama is projected to have a supply of 85,100 registered nurses to cover a demand of 79,800 – thus, there won’t be a shortage, but rather a surplus of 5,300 RNs by 2030.
The projected demand for 23,800 would be covered by only 18,400 nurses, so the nursing shortage in Alaska by 2030 would be of 5,400 RNs.
This Western state is projected to have a surplus of 1,200 nurses, with a supply of 99,900 and a demand of 98,700 RNs by 2030.
In this Southern part, we’ll see a surplus of 9,800 RNs, due to the projected 32,300 nurse demand that would be covered by a supply of 42,100 professionals by 2030.
The state of California will face the highest nursing shortage by 2030, according to national reports, with 44,500 RNs needed. The projected demand for 387,900 professionals will not get covered by the 343,400 nurses estimated to be on the market by then.
In this Western state, there will be a surplus of 9,300 nurses by 2030. The projections show a supply of 72,500 nurses to cover the estimated 63,200 RN positions.
The projections show a demand for 40,000 that would be covered by 43,500 nurses, so here will see a nursing surplus of 3,500 RNs by 2030.
This state will face a 12,800 nurse demand that would be covered by a supply of 14,000 by 2030, leaving a surplus of 1,200 nurses.
District of Columbia
There are notable differences here. With a demand of only 2,300 registered nurses, but a supply of 8,800 in the District of Columbia, there would be a surplus of 6,500 RNs by 2030.
Another famous Southern state that will see a major surplus of RNs is Florida. With demand for 240,000 and supply of 293,000, the estimated number is about 53,700 extra nurses by 2030.
In Georgia, we will see a nurse shortage of 2,200 by 2030, due to the difference between a 98,800 supply and a higher demand for 101,000 nurses.
It seems that, for Hawaii, as well, the nursing projections look optimistic. The demand for 16,500 professionals will be easily covered by the 19,800 on the job market in 2030, leaving a surplus of 3,300 RNs.
Also, in Idaho, there will be 3,600 extra nurses by 2030. The supply of 18,900 registered nurses would cover the demand for 15,300 professionals needed.
The Midwestern state will have a 143,000 nurse supply that could cover the demand for 139,400. That is why Illinois will potentially have a surplus of 3,600 nurses by 2030.
Another U.S. state in the Midwest region that will see a surplus is Indiana, with 14,000 extra nurses by 2030. That is because of the projected supply of 89,300 nurses should cover the demand for 75,300 RNs.
Iowa will have 14,000 extra nurses by 2030. The projected supply of 35,300 nurses should be covered by 45,400 RNs.
We find another big surplus of 12,600 nurses by 2030 in Kansas, where the projections show demand for 34,900 registered nurses, but a supply of 47,500 to cover it.
In the South, we will see a surplus of 10,500 registered nurses by 2030. The projections show a demand for 53,700 RNs and supply of 64,200 in Kentucky.
In the same region, Louisiana would face a demand for 49,700 nurses, but a supply of 52,000, so there is no projected nursing shortage here for 2030. On the contrary, there seem to be 2,300 extra nurses in the next decade.
The projections show a demand for 16,500 that would be covered by 21,200 nurses, so there will be a nursing surplus of 4,700 RNs by 2030.
Another Southern state that will actually have extra nurses by 2030 is Maryland, with a surplus of 12,100 professionals. This is due to the projected demand of 73,900 nurses and a supply of 86,000 in the area.
The projections show demand for 89,300 by 2030, which would be covered by 91,300 nurses, so Massachusetts would see a nursing surplus of 2,000 RNs.
For this state, the projected supply of 110,500 nurses would cover the demand of 104,400 professionals by 2030, with 6,100 extra nurses estimated in ten years.
Another small, but important surplus will be in Minnesota, with 3,100 extra nurses. The demand of 68,700 nurses would be covered by 71,800 RNs by 2030.
This U.S. state would face a demand of only 35,300 nurses to be covered by 42,500 professionals, leaving a surplus of 7,200 RNs by 2030.
The demand for 73,200 nurses, while the supply is 89,900, shows that in Missouri we will see a major surplus of 16,700 RNs by 2030.
This state will see the smallest surplus of nurses, of 200, but it’s a good thing nonetheless. The supply and demand are close as numbers: 12,300 and 12,100 respectively.
Even though the differences seem small, Nebraska would have 3,500 extra nurses by 2030. The projected supply of 24,700 would cover the 21,200 nurse demand.
Here in the West, we will see a surplus of 8,100 registered nurses by 2030. The projections show a demand for 25,800 RNs and a supply of 33,900,200 in Nevada.
The projections show a demand of 20,200 nurses by 2030, which would be covered by 21,300 RNs, so this Northeastern state will see a nursing surplus of 1,100 registered nurses.
Another Northeastern state, this time with a projected nursing shortage of 11,400 nurses by 2030 is New Jersey. The report shows a demand of 102,200 nurses that would be covered by 90,800 by 2030.
Another Western state with a surplus of nurses is New Mexico. The projections show a number of 9,700 extra nurses by 2030, with a demand for 21,600 RNs and a supply of 31,300.
This big city will see a demand of 195,200 nurses that could be covered by 213,400 professionals, so there is no projected shortage, but rather a surplus of 18,200 RNs.
With a supply of 135,100 nurses and a projected demand for 118,600, North Carolina could have a surplus of 26,500 RNs by 2030.
There is little difference for the supply and demand in this state: with 9,900 nurses to cover 9,200 job positions in demand by 2030. There will be a surplus of 700 professionals by then.
Things look good for the state of Ohio. With a 132,800 nurse demand to be covered by 181,900 RNs by 2030, there will be a surplus of 49,100 professionals in the next ten years.
In Oklahoma, there will also be some extra nurses projected: 5,500 RNs, to be more specific. The demand for 40,600 nurses will be covered by the 46,100 estimated to be in Oklahoma by 2030.
In this Western state, we’ll see a surplus of 2,500 registered nurses by 2030. The projections show a demand for 38,600 RNs and a supply of 41,100 in Kentucky.
This state would have to meet a demand of 160,300 nurses with 168,500 nurses by 2030, so there is no projected shortage, but rather a surplus of 8,200 RNs.
This state would have to meet a demand of 12,500 with 15,000 registered nurses by 2030, so there is also no projected nursing shortage, but actually a surplus of 2,500 RNs.
The state in the South will have to meet a demand for 62,500 RNs with the help of only 52,100 nurses by 2030, so there is a big nursing shortage estimated here, of 10,400 nurses needed.
The projections show a demand of 13,600 nurses and a supply of only 11,700, which leaves a nursing shortage of 1,900 professionals by 2030 in South Dakota.
This state will actually meet the demand for 82,200 nurses with a supply of 90,600. There will be more nurses in Tennessee, with an estimated number of 8,400 ready to work, by 2030.
Texas will face a bigger nursing shortage than other U.S. states by 2030. The projected supply of 252,400 nurses wouldn’t cover the estimated need for 269,300.
Utah will face a supply of 33,500 registered nurses and a demand for 29,400 by 2030. The projections show a number of 4,100 extra nurses.
This Northeastern state will have to meet a demand of 6,800 RNs with the help of 9,300 nurses by 2030, so there is also no projected shortage, but actually a surplus of 2,500 nurses.
This state will register as many as 22,700 extra nurses by 2030, according to the projections. With 109,200 to cover the 86,500 nurses in demand, Virginia is among the top states with more nurses than needed.
Washington is projected to face a demand of 79,100 RNs, but a supply of 85,300 by 2030, leaving a surplus of 6,200 nurses available in the job market.
Things look good in West Virginia. With a projected supply of 25,200 to cover the demand for 20,800 nurses, the number of extra nurses goes up to 4,400 for 2030.
In Wisconsin, we’ll see a surplus of 6,200 RNs, thanks to the projected demand of 72,000 nurses to be covered by a number of 78,200 by 2030.
This state will see a growing workforce, with a demand for 5,500 nurses and a supply of 8,300, leaving another big surplus of 2,800 nurses by 2030.
The Impact of the Nursing Shortage
Not only the national deficit of nurse professionals but also the major gaps between supply and demand projects for various states across the U.S. are important factors to consider when looking for the best solutions to solve the nationwide nursing shortage.
Another thing to consider when classifying the top states with the highest nursing shortage is the size of the workforce and the percentage of the demand/supply should be taken into account. (It’s not only about the number of needed nurses, but also about the number of needed nurses reported to the overall size of the workforce.)
For example, California has the highest nursing shortage by numbers (a deficit of 44,500), but 11.2% of demand will be met in 2030. On the other hand, Alaska suffers the biggest percentage of demand with 22.7%, even though the number of nurses needed in 2030 would be of only 5,400 RNs.
So, we can say that the most impacted states by the nursing shortage are Alaska (missing 22.7% of the workforce), South Carolina (16.6%), South Dakota (14%), California (11.5%), New Jersey (11.2%), and Texas (5.9%).
At the other end, we have Wyoming (50.9%), New Mexico (44.9%), Ohio (37%), Vermont (36.8%), and Kansas (36.1%) as the states projected to have too many nurses.
Nursing Shortage Nuances
The nursing shortage is, unfortunately, not a simple black and white matter. Even in the states where the supply outranks the demand severe shortages are still common, specifically in the rural areas and smaller towns.
Fresh nursing graduates are typically interested in working in urban areas, where they have easier access to better-paying jobs and enjoy an increased number of job opportunities, leaving hospitals in rural areas severely understaffed.
The lack of professionals is not the only issue smaller towns encounter. Rural areas generally have more residents aged 65+ compared to urban and suburban areas. Also, the older population in suburban counties has increased due to large shares of adults relocating.
Therefore, rural hospitals (even in the states that foresee a surplus of nurses by 2030) are left in a troublesome situation: increasing numbers of people to attend to, most of them older and with specific health issues, and no nurses to fill the jobs. So, the predictions stay grim: rural areas nationwide have nursing shortages to worry about.
Factors Leading to the Nursing Shortage
The impact of such considerable gaps in the nursing workforce, but also of the many contributing factors to the national nursing shortage, is tremendous.
- A nursing faculty deficit that turns away too many aspiring nurses
The current faculty shortage at nursing schools across the entire country is one of the most critical issues this profession is facing. With a growing aging population and many experienced professionals retiring each year, the academic field suffers the most.
Faculty shortages are limiting the enrollment and the number of graduates a school can provide, at a time when the need for RNs continues to grow. That is why becoming a nurse educator after graduating from an MSN program is a top career choice for the future.
- Low quality of care and patient safety, affected by higher patient-to-nurse ratios
The National Institute for Health and Care Excellence details how, if the ratio of eight patients per nurse is surpassed, the hospital is exposed to major risks, while the mandatory staffing policies in the U.S. set a limit of four to seven patients per nurse in acute settings.
In clinical settings with high patient-to-nurse ratios, RNs suffer from burnout, frustration, dissatisfaction while trying to meet the needs of others. This situation leads to errors, higher morbidity and mortality rates. Furthermore, an improper staffing ratio may lead to higher failure-to-rescue rates as well.
- Insufficient number of RNs employed
As the population ages, the need for health services increases. With an aging population that suffers complex health problems (such as chronic conditions) and the need for more advanced care in the long term, a growing volume of qualified nurses is strongly needed in most of the U.S., instead of adding more assisting personnel to the team.
- Nurse burnout
Although this health profession is a valuable, meaningful and high-paying job, the nursing shortage affects especially bedside care. Due to this deficit, RNs often have to work longer hours in very stressful conditions, which more often than not leads to burnout. Over 15% of nurses are reporting feeling burnout at work, according to a 2019 study. Assuredly, nurses who experience burnout demonstrate a diminished capacity to care for themselves and their patients. Also, one-fifth of nurses working in Emergency Department settings declared they felt unengaged at work, which is not a good sign as far as job retention goes.
If we also consider the verbal violence or emotional aggression present in some health care settings, mostly due to difficult patients (especially in the psychiatric and emergency department), it’s understandable why nurses experiencing burnout may decide to leave the profession after a while. A 2018 poll concluded that more than ⅔ of nurses were harassed by a patient and another 2017 survey has exposed that over 40% of nurses have been verbally bullied.
Solutions for the Nursing Shortage
This national problem within the health care ecosystem needs sustained efforts in several directions including education, policy and regulations, delivery systems, strong collaboration between nurse leaders, educational institutions, government, and media.
These collaborative efforts seem to be directed toward several long-term and short-term solutions, such as:
- Proper patient-to-nurse ratios
Nurse staffing is a crucial health policy that ensures the delivery of high-quality patient care, as the Institute of Medicine concluded in their reports. These policies depend on many factors and can be decided upon by health care providers. Fortunately, a growing number of U.S. states started to take action and introduce legislation to ensure an optimal nurse-to-patient ratio.
However, it is left to each state to decide if staffing is appropriate for patient needs and high-quality care, while the American Nurses Association prefers to leave the decision to nurses working in each hospital since they know best all the aspects of their workplace.
One exception is California, which has legally set the minimum nurse-to-patient ratios to be followed at all times: The ratio in a critical care unit must be 1:2 or fewer, while for emergency departments, the ratio must be 1:4 or fewer. As a result of California passing this legislation, nurse employment rose by 15%. Also, occupational illness and injury rates fell by 30% among the nurses.
- Opportunities for nurses who want to become faculty educators
Solving the faculty shortage will help solve the general nursing shortage – there’s an increased demand for MSN-level nursing professionals to educate the next generation.
According to AACN’s report on 2018-2019 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing, “nursing schools turned away 75,029 qualified applicants from baccalaureate and graduate nursing programs in 2018 due to an insufficient number of faculty, clinical sites, classroom space, clinical preceptors and budget constraints.”
Some states are already focusing on providing job opportunities for learners who choose to become nurse faculty after graduating. We, at Nightingale, offer the online MSNEd Program for future nurses aspiring to work in a non-clinical environment, where they can guide the new generations of nurses. Becoming a nurse educator is an ideal choice for many people, being one of the least stressful nursing jobs and a well-paid one.
- Nurse empowerment
Institutions and facilities should be more focused on understanding the needs of RNs working in stressful workplaces, to make sure they can offer the highest-quality and safest care to all patients in the long run. In order to succeed, it has been proven that working in a motivating and empowering environment can sustain these efforts.
Empowerment and more autonomy, including in deciding staffing ratios can critically lower the burnout level and the desire to leave the profession. One sure way for hospitals to acquire this goal is to earn Magnet Recognition. This means 100% of nurse managers have a BSN or higher degree, and they must provide proof of plans to increase their BSN workforce to 80% by 2020.
- Facilitating access to education for more aspiring nurses
There is a growing number of educational facilities and nursing programs that aim to fill all their vacant places and also attract more aspiring nurses. With several enrollment periods each year, these educational efforts are trying to generate as many prepared nurses as possible.
Access to education is now simplified through accredited hybrid or online programs that prepare future nurses no matter where they are located, besides the on-campus programs. These options are ideal for those working or having a busy schedule and want to get a BSN, but also for aspiring professionals, in order to lower the impact of the nursing shortage. At the same time, these nursing programs offer hands-on training through experiential learning.
- Financial help for nurses who want to further their education and pursue advanced roles
Offering as many opportunities as possible to nurse professionals is another solution to solve the nursing shortage in the U.S. Having the chance to advance their career and feel more satisfied with the responsibilities they have may lead to lower turnover. For example, nurses may not leave their profession if they feel appreciated in their jobs.
That is why many learning facilities and educational institutions offer financial aid, grants, and scholarships, as well as loan programs to aspiring nurses or nurses who want to land specialized positions with more autonomy and responsibilities through a BSN or an MSN program.
It’s no wonder the World Health Organisation chose 2020 as the ”Year of the Nurse and Midwife,” honoring the 200th birth anniversary of Florence Nightingale. WHO will also launch the first-ever State of the World’s Nursing and the World’s Midwifery 2020 reports, to strengthen the nurse profession and its implications, and solve the major shortfall of RNs in the USA.
Strengthening these efforts on all levels and working toward more accessible education and the best policies to ensure optimal conditions and high-quality patient care will help nurses pursue their dream career with more flexibility and motivation, slowly and surely solving the national nursing shortage.