How America’s nursing shortage impacts health care

America has a nursing shortage, but where it is and who’s affected is not evenly distributed across the country. And even communities with an adequate or near-adequate supply must be vigilant to ensure that shortages don’t creep in. Too few nurses can endanger patients and community health.

Nurses are the “backbone of the American health care system,” according to Dr. Jason Altmire, president and CEO of Career Education Colleges and Universities, the national trade association for private postsecondary trade schools. Altmire is also a former congressman from Pennsylvania.

During a recent “TEDx” event in Salt Lake City hosted by Nightingale College, itself a private, for-profit accredited nursing school, Altmire extolled the value of nurses, who are tasked to “deliver hands-on patient care, manage complex treatment plans and coordinate services across every setting, from hospitals and nursing homes to schools and communities. They are the single largest group of health care professionals in the country.”

They are also — albeit unevenly — in short supply. Utah is not having a major shortage at the moment, faring better than some states, according to Marla De Jong, dean of the University of Utah Nursing School. But there are pockets of need in the state that are severe, including in rural communities, long-term care facilities, palliative care and hospice, she said. And Utah has to be vigilant, she added, to avoid falling back into shortages that are not a distant memory.

Besides that, the demand for skilled nurses will grow as new health care facilities open around the state.

A national crisis?

De Jong quotes a projection from the Health Resources and Services Administration that shortages will occur across the nation through 2038. “They are citing data of an 8% shortage of registered nurses in 2028, but by 2038 that shortage drops down to a projected 3%” — about 109,000 nurses, she said.

The projections include an 11% shortage of nurses in non-metro areas and just 2% in metro areas.

Altmire calls the nursing shortage an acute issue for the nation, a crisis “so severe it threatens patient safety and access to care. The chronic understaffing of nursing increases turnover, increases burnout among nurses, and increases attrition leading to a vicious cycle. The nursing shortage is associated with higher mortality rates, more medical errors, longer hospital stays, and higher readmission rates.”

A fact sheet from the American Association of Colleges of Nursing that was updated in 2024 reported 193,199 openings for registered nurses are likely each year nationwide through 2032, if nurse retirements and other workforce exits are considered. And more than 29,000 advanced practice registered nurses — a group that includes nurse practitioners, nurse anesthetists and nurse midwives — will be needed each year, as well, to meet rising needs in primary and specialty care.

The association said nursing school enrollment for registered nurses and advanced practice registered nurses is falling short of meeting projected demand, partly because there aren’t enough qualified nursing school faculty members, which limits the number of students who can be educated. With limited classroom space and lack of enough clinical training spots, nursing school applicants get turned away. Altmire said that “tens of thousands of qualified applicants” are turned away.

Besides that, the nursing workforce itself is aging. Altmire said the average nurse in the U.S. is in the mid-50s, and 40% plan to leave the profession by the end of the decade.

In Utah, the average registered nurse is slightly younger. About a quarter of Utah’s RNs are 55 or older, the average age 45, De Jong said.

The Health Resources and Services Administration in 2023 predicted significant shortages at least through 2030, and said the biggest registered nurse shortages would be in Washington, Georgia, California, Oregon, Michigan, Idaho, Louisiana, North Carolina, New Jersey and South Carolina. HRSA suggests there are currently 263,870 open registered nurse positions nationwide and 94,320 licensed practical nurse positions open.

Some believe it’s actually a worldwide dilemma. Nursing shortages create an issue the International Council of Nurses believes should be treated as a “global health emergency.”

There are plenty of factors to ponder that contribute to whether any area has enough nurses: As many as a quarter of registered nurses will retire within a decade. That, combined with the fact that the number of Americans age 65 and older is projected to increase from its 58 million in 2022 to 82 million by 2050 could create problems; all baby boomers will be at least 65 by the end of this decade and they are a generation 73 million strong. Older adults often have chronic health conditions and sometimes more than one.

Nurses will be a crucial member of any team that provides their care.

Tess Michaels, founder and CEO of Clasp and another of the TEDx conference speakers, sees other reasons that health systems lose nurses, starting with “degree inflation” that means it takes longer and costs more to get the needed education. She said it’s a career “front-loaded with financial risk.” Then, in the workplace, sign-on bonuses and contract labor in some communities — De Jong said not usually in Utah outside of perhaps rural and long-term care — encourage nurses to move around.

Looking for solutions

Michaels said that high turnover rates for nurses create a safety issue, because surgical and clinical teams often haven’t worked together long. Trust and familiarity are a key part of patient safety, she said.

She believes that the Army ROTC model holds a solution to nurse turnover, cost and other issues that can lead to nursing shortages. ROTC programs engage early with promising recruits and offer meaningful incentives. She describes what that approach could look like in the health care arena: “A hospital would identify promising second-year nursing students and make early offers for a commitment: If you graduate, pass your licensure exams and join us, we will help repay your student debt on a monthly basis over your first few years of employment.” It’s an approach she said could work in any clinical role, helping with student loans while building multi-year retention.

Critics say part of the problem is the pressure that nursing accreditation boards put on nursing schools, measuring the school’s success by how many students graduate and pass their boards on the first try. That came up several times in the TEDx discussion.

Passing a licensure exam is just the first step after graduation from nursing school — but it’s an important one, De Jong said, harking back to the days when students had to wait months to retake the exam if they failed the first time, which created a costly gap between school and employment.

But “what is really, really, really important is that when you go work in whatever setting you’re working in, that you’re delivering safe, evidence-based, patient-centered, team-oriented healthcare. Because I can pass a licensure exam and that’s super important. Please, do not hear me underemphasize that. But at the same time, it’s then what you’re doing with all of that where you’re working that makes a tremendous difference for the patients and families and communities who we’re privileged to serve,” she said.

While not supplanting direct patient care, Altmire said expanding clinical partnerships to include hybrid and online nursing programs “paired with rigorous accreditation standards,” could increase capacity while maintaining quality and rigor. He cites the use of “simulation labs, virtual clinical scenarios and remote collaboration tools” to give students opportunities to practice complex skills in controlled environments.”

Said Altmire, “No, they cannot replace direct patient care, but they can supplement and prepare students to enter health care settings.”

The cost of failure to stabilize the nursing workforce will be borne by patients, families, communities and taxpayers across America, Altmire warned.

Most nursing schools use simulations as part of immersive training to prepare nursing students to handle in-the-moment health care crises. According to Ann Butt, executive director of Simulation & Experiential Learning at the University of Utah, “Simulation is part of every semester of our nursing program and happens alongside students’ classroom and clinical learning experiences. The Sim Center gives students a safe place to practice skills, make mistakes and learn without risking patient harm. This kind of experiential learning helps students build the clinical judgment that every good nurse needs.”

Butt added that “beyond performing tasks and psychomotor skills, nurses are constantly assessing, prioritizing and making complex decisions. In simulation, students get the opportunity to practice and develop those abilities along with the hands‑on skills everyone wants their nurse to have.”

By the time nurses face real situations, they will have handled them in a lower-stakes but realistic situation that prepares them.

A Utah ‘paradox’

Utah has a paradox: The population that benefits from care is younger than in most of the country, which likely helps explain why its nurse concentration is lower than the national average. An older population drives up the need for nurses.

But the average registered nurse wage in Utah is about 20% lower than the national median, according to the Utah Health Workforce Information Center. In Utah, the average in acute care settings is $74,000 — and that’s a big jump from what it was in 2020, around $60,300, De Jong said. It’s even lower among those working in long-term care, where the average registered nurse wage increased from $40,000 in 2020 to $44,000 in 2024.

In urban settings like Salt Lake’s metro area, Lightcast first quarter 2025 data reports the median salary for a registered nurse is in the $80,000 range, which puts Salt Lake City, for example, just 7% below the national average.

The same report said that while unemployment is low, the number of new RN graduates in Utah has declined, “tightening” the pipeline.

De Jong said she doesn’t believe sign-on bonuses are currently popular in Utah, “with perhaps an exception for long-term care or rural Utah.”

De Jong notes that Utah ranks 49 out of 50 when it comes to nurses per 1,000 population in the state. But a lot more than that goes into figuring whether there’s a shortage or how big a shortage is. A state with a younger population like Utah’s might not need as many nurses, because it doesn’t have the same proportion of older adults seeking care that requires them, for instance.

How many nursing job openings are there? It depends on who you ask, but several sources suggest there are a few thousand nursing positions open in the Beehive State. Others suggest far fewer, perhaps even in the hundreds, not thousands.

And like much about the nursing situation, what’s true today could change, she adds. In 1980, 8% of Utah residents were 65 or older. In 2020, it was 12%. By 2060, it will exceed 20%. “The healthcare system has to be ready for the fact that there’s going to be a lot more older patients in Utah,” she said.

A lot of building has taken place in recent years or soon will, the number of health care providers expanding. With the growth in health care capacity comes growth in need. “We have to start educating for that now,” De Jong said, “because if we don’t stay ahead of that, then we will be back into a deficit.”

“There are far fewer vacant positions in Utah at least today than there were a few years ago. However, the roles for nurses are expanding. There’s a lot of new facilities that are going to be opening; we’re going to need nurses. There’s still needs for sure in long-term care and rural areas,” De Jong said. “And even though things are not as dire as they were a few years ago, it’s imperative that we continue to educate nurses and that we prepare nurses for all the very different ways that they are impactful within practice.”