How the nursing shortage exposes cracks in the US’s healthcare and educational systems

Editor’s note: This is the fourth in a series of articles focused on workforce issues challenging US nursing, including immigration hurdles for foreign nurses who are poised to help fill workforce gaps and the many factors narrowing the nursing pipeline domestically. Visit the series homepage, Immigration and the US Healthcare workforce, to find all the series content. 

We offer this special article series in conjunction with our inaugural CompassionIT Virtual Summit, scheduled for May 20, 2025.  Our CompassionIT initiative explores the evolving relationship between technology and compassion in healthcare, including how AI, UX design, accessibility, and clinical innovation can ease burnout and build a more humane, inclusive, and sustainable healthcare system.  The summit program includes Insights from Nursing Informaticists for CIOs on how informatics and innovation can unite to develop technologies that care for the caregivers. Also, be sure to check out all of our CompassionIT-related content.

Immigrants play an essential part in the U.S. healthcare workforce, accounting for more than 18% of all healthcare workers and about one in six registered nurses. 

This reliance has helped health systems manage chronic shortages, but as immigration pathways tighten due to shifting policies, that workforce buffer is becoming less dependable. Restrictions on visas and green cards have made it more difficult for internationally trained nurses to enter or remain in the U.S., further straining hospitals already struggling to fill roles. 

With fewer foreign-born professionals available, the system’s underlying weaknesses have come into sharper focus. Nursing shortages in the U.S. aren’t just a recruitment problem — they’re the result of persistent issues in education, economics, and workplace conditions. Limited access to nursing programs, the rising cost of training, poor job support, and high burnout rates continue to drive workers out of the profession faster than new ones can replace them. 

Fixing this isn’t about restoring one pipeline — it’s about rebuilding the foundation. That means expanding nursing school capacity, reducing the financial barriers to entry, embracing supportive technologies, and creating safer, more sustainable work environments. Without that kind of systemic change, the healthcare workforce crisis will keep deepening—no matter what happens with immigration policy. 

The training bottleneck

That starts with addressing one of the biggest bottlenecks in the pipeline: the education system that’s supposed to prepare the next generation of nurses. 

In 2023 alone, more than 65,000 qualified applications to U.S. nursing programs were rejected, according to the American Association of Colleges of Nursing (AACN). The top reasons: a shortage of faculty, limited clinical training sites, and inadequate classroom space. 

Nearly 80% of open faculty positions in nursing schools require or prefer a doctoral degree, according to AACN data, but most institutions can’t offer salaries that compete with what those candidates could earn in clinical practice or the private sector. A master’s-prepared assistant professor in nursing earns around $80,000 annually — while nurse practitioners, who often have similar levels of education, make a median salary of about $120,000. 

These structural barriers create a choke point in the pipeline. Until schools are equipped with more funding, more clinical partnerships, and better pay for instructors, the shortage will persist, no matter how many students are willing to answer the call. 

“All stakeholders, including federal and state legislators, hospitals and healthcare organizations, the businesses, foundations, and advocacy groups must take a larger role in addressing barriers and facilitating pathways into nursing,” said Robert Rosseter, chief communications officer with the American Association of Colleges of Nursing (AACN). 

“AACN is advocating for sustained federal support for nursing students, faculty, and educational infrastructure, including funding available through the Title VIII Nursing Workforce Development programs. We would also like to see greater engagement from the business, practice, and philanthropic communities, including increased support for student scholarships, nursing career promotion, clinical training sites, and faculty salary supplements.” 

Cost barriers keep talent out

Even for those who get into nursing programs, the cost of education can be a significant deterrent, especially for students from underrepresented backgrounds. The average cost of a four-year BSN program ranges from $40,000 to $154,000, excluding room and board, and many students graduate with tens of thousands in debt.  

The high cost of nursing education doesn’t just keep potential students out—it also influences the decisions nurses make once they graduate. Many new nurses understandably pursue the most financially rewarding path available. 

Increasingly, that means becoming a travel nurse – which pays an average of $20,000 more than in-house RNs, according to data from AB Staffing. They also shared that between 2018 and 2024, the number of travel nurses in the U.S. increased by 430%. These short-term, high-paying contracts are attractive for individual nurses, but they come at a high cost for hospitals. Travel nurses are expensive to hire, require onboarding to meet each health system’s specific needs, and can’t offer the long-term continuity that builds institutional knowledge and stability. 

The result is a workforce that’s mobile, temporary, and harder to sustain. And while rural hospitals and public health systems may need nurses the most, they often can’t compete with the pay offered by staffing agencies or private-sector employers. 

Minimum staffing laws remain in limbo

Understaffing remains a pervasive issue, contributing to burnout and posing significant patient safety concerns. Studies have shown that inadequate nurse staffing levels are associated with higher rates of patient mortality, increased readmissions, and longer hospital stays. Moreover, nurses report experiencing moral distress, a lack of autonomy, and feelings of being unsupported in their roles, further exacerbating workforce attrition. 

In an effort to address these challenges, former Sen. Sherrod Brown (D-OH) and Rep. Jan Schakowsky (D-IL) reintroduced the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act in 2023. This legislation aims to establish minimum nurse-to-patient staffing ratios across hospitals, mandate the development of staffing plans tailored to patient acuity, and provide whistleblower protections for nurses advocating for safe staffing levels. Despite being introduced in multiple sessions of Congress, the bill has yet to be enacted into law. 

However, several states have successfully implemented their own minimum nurse-to-patient ratio requirements, with California leading the way in 2004.  

The state’s landmark staffing mandate was found to have a positive impact on nurse job satisfaction and safety, and reduced turnover costs, which estimate about $289,000 a year for each percent of turnover.  

A UK study published in April found that investing in permanent nursing staff is significantly more cost-effective than relying on understaffed hospital floors or temporary agency nurses. Researchers analyzed data from 185 adult acute units in four hospitals and concluded that eliminating nursing understaffing is cost-effective at £2,778 per quality-adjusted life year (QALY) when considering staff costs only, and could potentially save money (£4,728 per QALY) when accounting for reduced lengths of stay.  

“Hospitals typically measure their financial performance through metrics like average length of stay, cost per patient day, readmission rates, and bed turnover rate — which indicates how quickly patients move through the hospital,” shared Toni Laracuente, Senior Director and Head of Digital Health Analytics at the College for Healthcare Information Management Executives (CHIME), referring to the study. “When a patient’s hospital stay includes days with nursing shortages, their length of stay increases by almost 70%. During an average eight-day admission, if the first five days are understaffed, the patient will likely stay significantly longer. This extended hospitalization adds substantial costs and negatively affects quality of life.” 

Beyond direct healthcare costs, nursing shortages create ripple effects including more time away from employment, disruption to family responsibilities, and higher overall care costs, Laracuente shared. 

“These findings are entirely applicable to the US healthcare system, where we see the same impacts.” 

Between 2020 and 2022 – when nursing turnover skyrocketed to 27% across the country – California saw a net gain of roughly 30,000 registered nurses, many motivated by better working conditions and competitive compensation. These improvements, coupled with legally mandated staffing levels, have made California a desirable location for nurses looking for a more stable and supportive clinical environment. 

California’s sustained success shows that implementing minimum nurse-to-patient ratios is not only feasible but beneficial for both healthcare facilities, nurses, and patients alike. Some healthcare leaders argue that such a mandate would limit their ability to take in emergency room patients, while other health leaders say that more nurses would allow them to take care of more patients more efficiently. 

Many health systems have implemented technology as a workaround to the nursing shortage. AI-assisted tools and virtual nursing programs have allowed health systems to survive all while circumventing the more foundational issues contributing to the nursing shortage.  

“…the United States is not experiencing a nursing shortage, only a shortage of nurses willing to risk their licenses and the safety of their patients by working under the unsafe conditions the hospital industry has created,” said Bonnie Castillo, RN, Executive Director of National Nurses United, in a written statement to Congress. “By deliberately refusing to staff our nation’s hospital units with enough nurses to safely and optimally care for patients, the hospital industry has driven nurses away from direct patient care.” 

Other articles in this series

Amid healthcare workforce crisis, US immigration policies fall short

How foreign nursing schools are preparing for the U.S. market

Should the US create a healthcare-specific visa program?