Why We Don‘t Have Enough Nurses (It’s Not Low Wages)

Consider this: In the San Francisco area, a nurse with a bachelor’s degree can hope to start out with a salary of $104,000. The salary for a nursing professor with a Ph.D. at University of California San Francisco starts at about $60,000.

This goes a long way toward explaining why nursing schools turned away 42,000 qualified applications in 2006-2007—even as U.S. hospitals scramble to find nurses. We don’t have enough teachers in nursing schools and the fact that the average nursing professor is nearly 59 while the average assistant professor is about 52 suggests that, as they retire, the shortage could turn into a crisis. The most recent issue of JAMA (October 10, 1007) reports that in 2005 we had 218,800 fewer nurses than we needed and by 2020, it’s estimated that we’ll be short some 1 million nurses.

Hospitals have had to raise nursing salaries (as well they should), not just because nurses are scarce but because, in our chaotic hospital system, the work can be extraordinarily stressful.   

Nurses know better than anyone just how many “adverse events” occur each day –even in the most prestigious U.S. hospitals.

“I’m terrified of killing someone,” one young nurse confided to me
about a year ago. After working in a hospital in Bermuda for a number
of years, she was bored, and had come back to work in New York, where
she had friends and family. She had worked in New York before, but she
wasn’t at all sure that she would stay. “In our hospitals, it’s just
too crazy,” she said.

Her story also sheds light on why nursing professors are willing to
work for $60,000 a year when they could, no doubt, more than double
their salaries if they were willing to wade into the fray at local

But it’s not just a dearth of professors that prevents nursing schools
from admitting qualified students. The schools also lack the physical
facilities and equipment needed to increase enrollment. Medical Schools
receive generous contributions from their alumni. Nursing schools
don’t. (While nursing salaries have gone up, there are not many nurses
making $1 million or more.)

Meanwhile, hospitals continue to build and expand—without any clear
idea as to where they will find the nurses needed to staff new
facilities. (See my post “The Hospital Building Boom”.)

Today, hospitals report that they are not able to fill 6% to 8% of
their nursing positions, and surveys of doctors, hospital
administrators and nurses themselves confirm that the vacancies have
“seriously impaired communication between hospital staff members,
patient-nurse relationships, hospital capacity and patient-centered

Build the beds and they will come—but who will care for them?

In recent years, nurses from other countries have helped pick up the
slack.  But now, the entry of foreign nurses is blocked or delayed for
years due to a failure to “increase immigration quotas or establish an
appropriate temporary visa category for  nurses” concludes a new study released by the National Foundation for American Policy (NFAP), an Arlington, Va.-based policy research group.

“Fears that foreign nurses would overwhelm the U.S. labor market and
dissuade hospitals from active recruitment of U.S nurses are
unfounded,” the report observes. “Foreign nurses represent only 3.7
percent of the U.S. registered nurse workforce, well below New Zealand
(23 percent), the United Kingdom (8 percent), Ireland (8 percent) and
Canada (6 percent).

“Contrary to concerns that foreign nurses would harm the salaries of
U.S. nurses” the researchers add, a Department of Labor-funded analysis
on the impact of foreign nurses found no evidence that “foreign nurses
were paid less than U.S. nurses.”

Today, many believe that, in order prepare for an onslaught of aging
baby-boomers, we need to train more physicians—in particular more

But careful analysis suggests that this just isn’t true. What, we need
is more nurses—and more primary care physicians. I’ll write about this
in a later post.

12 thoughts on “Why We Don‘t Have Enough Nurses (It’s Not Low Wages)

  1. To mitigate the nursing shortage, I wonder about the following:
    1. How much does it cost to educate a nurse now?
    2. To what extent can tuition be raised?
    3. Would it be feasible to supplement the faculty through the use of adjunct professors with excellent relevant real world experience and good communication skills but who lack a PHD in nursing?
    4. If we could increase the supply of nursing professors, or at least induce some of the existing professors to postpone retirement, by increasing pay enough to make a difference, how much would that add to costs?
    5. How much would it take in federal subsidies to offset the cost of higher pay for faculty if increasing tuition is not feasible?
    Longer term, if we can find ways to safely reduce utilization as part of systemic healthcare reform, we may find that we can reduce our hospital capacity further. As a byproduct, we would not need as many nurses.

  2. Case management is an area where nursing skills are needed, but it’s less stressful, arguably because the point is to work with a patient to avoid crisis. There have been some very interesting and positive studies of community pharmacists in this role, especially in assisting with medication compliance. Of course, no one has solve the compensation problem for pharmacist cognitive work.
    Now, I’m probably speaking of too many outliers here, but I wonder about alternate pathways into nursing, even though the people that take that path might not want to do traditional hospital nursing. For a time, there was an assumption that advanced military medics were a natural stream for PA, but it was hard to give them advanced standing. Personally, and for informatics rather than direct patient care, several physicians have suggested I try to find a community college that would let me test out of the preclinical courses, do the clinical year, sit for the National Boards, and hopefully get a non-BSN RN.

  3. great post Maggie-
    We need to make Nursing much less stressfull- especially in the insane hospital environments we offer up today.
    And yes -We don’t need more physician specialists.As you said we need nurses and primary care Docs and for that matter FEWER hospitals.
    Dr. Rick Lippin

  4. I was surprised by the low percentage of foreign nurses in the US, only 3.7%.
    I thought that nurses had a relatively smooth path emigrating to the US, perhaps that was the case a few years ago.
    The US must compete with countries like Britain, Canada and Australia to attract the skilled migrants needed to meet labour shortages.

  5. Justin–
    I agree. Though we also need to fund our nursing schools to create places for the many U.S. citizens who would like to become nurses.
    But even if we expand the supply of newly minted U.S. nurses we also need experienced nurses from other countries.
    Rick– Yes, we need more nurse practioners as well as more nurses–and fewer specialists.
    Barry– Even if there are fewer inpatients in our hospitals, we still will need more nurses and nurse practioners to staff clinics, to help manage chronically ill patients (so that they don’t wind up in the hospital) to expand preventive care, etc.
    I doubt that we want to increase tuition for nursing school. We want a broad pool of applicants–not just those who can afford to pay a high tuition.
    Whatever it costs to subsidize nursing schools, it’s less than it will cost to address the healthcare problems we’ll face if we don’t have enough nurses.

  6. I think the foreign born nurses are a very low percentage when the midwestern U.S. is factored in. Here in Arizona and California, a U.S. born person can be a minority amongst foreigners, e.g., Philippinas, on a unit. I notice that foreign-born workers are more likely to cave to pressure from management to have an increased ratio and acuity. I think that some of this may relate to culture and also past experiences. When you think that some foreign workers had worse situations in their native country, it makes sense that they would put up with work situations that an American would not.

  7. Arizonan–
    What you say makes sense. Often immigrant workers will put up with working conditions that are unfair–both to the worker, and to the customer (in this case, patients).
    This is why nurses and hospital workers need unions–to protect all workers, American and immigrant.

  8. I agree with this statement :
    3. Would it be feasible to supplement the faculty through the use of adjunct professors with excellent relevant real world experience and good communication skills but who lack a PHD in nursing?
    As an AD Nurse, with many years of experince, I would love to teach, but the cost of getting my masters to take a pay cut is not worth it for me.

  9. It’s not only the faculty shortage issue, it’s the working conditions! (a parallel to that campaign line from the ’90’s “It’s the Economy,…”).
    Even though mine is a late-entry comment to this post I want to add it in case others come upon this discussion. Barry Carol’s comment touched on the stressful work environment issue but he didn’t begin to tell the half of it, nor explore what can be done about it. Mandate minimum RN-to-patient staffing ratios to institute safe staffing and safe patient care. That’s what I’ll comment on.
    Registered nurses are being forced to care for too many patients at once, and patients are suffering the consequences in the form of preventable errors, avoidable complications, increased lengths of stay and readmissions. Piles and piles of rigorous, independent research results prove what we nurses who’ve worked on inpatient units already know to be fact.
    There’s an obvious way to begin to address this problem that greatly adds to the shortage of hospital nurses, but hospital management guided by next-quarter financial self-interest have repeatedly blocked needed progress to institute safe staffing. And they’re cutting off their noses to spite their face b/c better staffing levels would quickly save the hospital money in terms of less turn-over which means less money spent on recruitment and new-hire orientation, and less spent on expensive agency nurses.
    Just as we have minimum staffing ratio requirements for childcare settings to offset the financial pressures that exist for management to reduce staffing levels in those facilites, we must enact requirements for safe RN staffing ratios on inpatient units. It is absolutely crazy that this basic patient protection and worker protection doesn’t already exist.
    California is the only state so far that has enacted a RN staffing ratios law. Here in MA we have been working to pass our law for 10 years now. The current version, in the 2007-08 session is House Bill 2059, the Patient Safety Act. It calls upon the state Dept. of Public Health to review the research and set a safe limit on the number of patients a nurse is assigned at one time. In addition, the bill calls for staffing ratios to be adjusted based on patient needs.
    The bill also bans mandatory overtime and includes initiatives to increase nursing faculty and nurse recruitment.
    Learn more at

  10. The blog is really informative and all the posts regarding this blog really informative so in short i like this blog. Any way it is really admitted fact that we must dedicate our intention toward the gaining of the knowledge so for this purpose there are different blogs facilitate the students to get the knowledge and make themselves connect with the knowledge by a single click.

  11. Nursing shortage or not, nursing is a great career path. To anybody interested in becoming a nurse, I suggest taking a CNA program. It is a great career on its own as well as a fantastic way to begin working while going to school to become a RN.