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The Nursing Shortage in the United States

Partner Institute: 
Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management
Survey no: 
Petigara, Tanaz and Gerard Anderson
Health Policy Issues: 
Long term care, System Organisation/ Integration, Political Context, Funding / Pooling, Quality Improvement, Remuneration / Payment, HR Training/Capacities
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes yes yes yes no no no


The current nursing shortage in the United States is expected to grow to 12 percent by 2010. The federal and state governments, as well as hospitals and private foundations are undertaking a number of short and long-term strategies to address the shortage.

Purpose of health policy or idea

The United States is currently facing a nursing shortage which is projected to worsen in the future. The shortage is driven by a number of factors related to recruitment and retention. Fewer young women enter Registered Nurse (RN) programs as career opportunities in other fields have expanded. Many qualified applicants are also turned away due to a shortage of nursing faculty at schools.

This shortfall in recruitment has had two main consequences.

  • First, the current workforce is aging; more than one-third of nurses are 40 years or older.
  • Second, the workforce has to care for a larger number of patients and work longer shifts. High levels of job dissatisfaction and burnout have lowered the retention rates of both newly graduated and experienced nurses. Their negative experiences have had a cyclical effect making recruitment even more challenging.

The main objective is to increase the recruitment and retention of registered nurses through short and long-term strategies. Legislation at the federal and state levels have been introduced which increase grants for nurse education, mandate minimum nurse to patient staffing ratios, and restrict the amount of overtime hours. In the short term, hospitals are hiring temporary nurses from domestic and international agencies, and increasing salaries and bonuses. In the long term, strategies include increasing changing the structure of the work environment. A major debate is how to recruit intenational nurses and whether the home countries should be compensated.

Main points

Main objectives

Strategies to address the nursing shortage

Type of incentives

Financial incentives include increasing salaries and bonuses. Non-financial incentives include changing the hospital work environment and international recruitment.

Groups affected

Nurses, hospitals, nursing homes

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Characteristics of this policy

Degree of Innovation traditional neutral innovative
Degree of Controversy consensual neutral highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low low very high
Transferability strongly system-dependent neutral system-neutral

Current policies affect a broader range of issues related to recruitment and retention than in the past.

Political and economic background

Several studies have found an association between low nurse staffing and adverse patient outcomes. Medical errors are also more likely to occur when nurses work shifts exceeding twelve hours. Patient safety is a prominent health policy issue. Concerns that the nursing shortage affects patient safety has prompted legislation at both the federal and state levels. 

The nursing shortage also has important cost implications for hospitals. The cost of recruiting and training an entry-level registered nurse is approximately 100 percent of a nurse's salary, with the costs even more for specialized nurses. The additional costs associated with adverse events has encouraged hospitals to reexamine their workforce policies and work environment .

There is concern that the US is recruiting too many international nurses and this is affecting the health in the home countries.

Complies with

Nursing shortage, patient safety, high turnover costs.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes yes yes yes no no no

Origins of health policy idea

The United States has experienced cyclical nursing shortages for many years. In the past, policies to address this shortage have focused on increasing salaries and employing foreign-born nurses. However, these strategies have had a limited impact and the shortage is projected to worsen.  International recruitment is politically controversial and has raised concerns about nursing shortages in sending countries. The needs of an aging U.S. population as well as concerns over patient safety have prompted a renewed commitment to address this problem at many levels. 

Various tools to address nursing shortage

The tools to address this problem are varied. At the federal and state levels, legislation has focused on minimum nurse to patient ratios, limiting mandatory overtime hours, and increasing funding for nurse education. Hospitals continue to implement short-term solutions (e.g., wage increases, temporary staff) but are also investing in long-term strategies to restructure the work environment. Philanthropic organizations such as the Robert Wood Johnson Foundation are partnering with hospitals in this effort. The goal of the Robert Wood Johnson Foundation's Wisdom at Work: Retaining Experienced Nurses Program - which started in December 2006 and is expected to continue for 18 months - is to establish an evidence base for retaining experienced nurses in hospital settings. In 2006, the program funded 18 hospitals. The results will be disseminated nationally to health care organizations. There is a simliar program for nursing homes.

Initiators of idea/main actors

  • Government: Congress passed the Nurse Reinvestment Act in 2002. Since then, legislation to address this issue has been introduced but not passed in Congress.
  • Providers: The American Nurses Association has consistently supported legislation to increase funding for nurse education, mandate minimum nurse to patient ratios, and limit overtime hours. Hospitals are less supportive of unfunded, mandated nurse-to-patient ratios which can place a high financial burden on some facilities. Hospitals are more willing to contribute to nurse education programs, and restructure their work environment.
  • Patients, Consumers: Patients are growing more aware of the nursing shortage, especially concerning patient safety issues.

Approach of idea

The approach of the idea is described as:
renewed: The United States has faced a nursing shortage for many years. However, the complexity of the current shortage and future projections has resulted in renewed commitment at many levels to address this problem.

Innovation or pilot project

Pilot project - RWJF's Wisdom at Work: Retaining Experienced Nurses program funded 18 hospitals in 2006. They will implement interventions to retain experienced nurses. The results will be disseminated to other health care organizations nation-wide.

Stakeholder positions

Nurses are supportive of legislation and efforts by hospitals and nursing homes to improve their work environment. Hospitals and nursing homes generally oppose unfunded, mandated nurse to patient staffing ratios. The federal and state governments are supportive of a range of efforts to address the nursing shortage, especially those which affect patient safety.

Actors and positions

Description of actors and their positions
Congressvery supportiveneutral strongly opposed
American Nurses Associationvery supportivevery supportive strongly opposed
Hospitals and Nursing Homesvery supportiveneutral strongly opposed
Patients, Consumers
Patientsvery supportivesupportive strongly opposed

Influences in policy making and legislation

The Nurse Reinvestment Act of 2002 established nursing scholarships, a loan cancellation program for nursing faculty, and grants to improve recruitment and improve patient safety. Since then, several pieces of legislation which address the nursing shortage have been introduced in Congress but either did not become law or are currently circulating through Congressional committees. The Quality Nursing Care Act was introduced in 2003 and 2005 to impose minimum nurse staffing levels in Medicare-participating hospitals. The Nurse Staffing Standards for Patient Safety and Quality Care Act of 2007 proposes similar legislation. The Nurse Faculty Education Act of 2005 was introduced to award grants for hiring and retaining nurse faculty. Similar legislation was introduced in 2006 and 2007. The National Nurse Act of 2006 would establish an Office of the National Nurse to encourage recruitment and retention efforts. The Safe Nursing and Patient Care Act of 2007 would prohibit mandatory overtime for nurses.

State governments have also been active in addressing issues related to recruitment and retention. Thirteen states have passed laws prohibiting nurses from working mandatory overtime. In 2007, seven states introduced staffing ratio legislation. They are also investing heavily in nurse education. For example, in 2006, Maryland appropriated $6 million over 5 years for nursing student and faculty scholarships and initiatives to retain nurses.   

Legislative outcome


Actors and influence

Description of actors and their influence

Congressvery strongstrong none
American Nurses Associationvery strongneutral none
Hospitals and Nursing Homesvery strongweak none
Patients, Consumers
Patientsvery strongweak none
American Nurses AssociationPatientsHospitals and Nursing HomesCongress

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The nursing shortage is being addressed at many levels, and by a wide variety of strategies related to recruitment and retention. Adoption and implementation will depend upon the commitment of all actors involved.

Results of evaluation


Expected outcome

The nursing shortage is driven by a complex set of factors related to recruitment and retention. In the past, hospitals have relied mainly on wage increases and recruitment of foreign nurses to cope with the shortage. These strategies will not have a large impact over the long-term, and can be politically controversial.  The current set of strategies addresses a wider range of issues related to the nursing shortage, but it is too early to evaluate their impact on recruitment and retention over the long term.  

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable system more equitable system more equitable
Cost Efficiency very low high very high

Improving recruitment and retention of nurses will postively impact quality of care. Increasing nurse staffing levels in hospitals is costly, but could be partially offset by cost savings associated with reductions in adverse outcomes.


Sources of Information

  • Rogers, AE., Hwang, W., Scott, LD., Aiken, LOH., and DF. Dinges. "The Working Hours of Hospital Staff Nurses and Patient Safety". Health Affairs 23(4) 2004 July-Aug. 202-211.
  • Hasmiller, SB. and M. Cozine. "Addressing the Nurse Shortage to Improve the Quality of Patient Care". Health Affairs. 25(1) 2006 Jan-Feb. 268-274.
  • Neddleman, Buerhaus, Stweart, Zelevinsky, and Mattke. "Nurse Staffing in Hospitals: Is There a Business Case for Quality". Health Affairs 25(1) 2006 Jan-Feb. 204-210.
  • May, JH., Bazzoli, GJ., and AM. Gerland AM. "Hospitals' Responses to Nurse Staffing Shortages". Health Affairs 25 2006. w316-w323.
  • Brush, BL., Sochalski, J, and AM. Berger. "Imported care: recruiting foreign nurses to U.S. health care facilities". Health Affairs 23(3) 2004 May-Jun. 78-87.
  • Aiken, LH., Buchan, J., Sochalski, J., Nichols, B., and M. Powell. "Trends in International Nurse Migration". Health Affairs 23(3) 2004 May-Jun. 70-77.
  • Robert Wood Johnson Foundation. Wisdom at Work: The Importance of the Older and Experienced Nurse in the Workplace. June 2006.
  • American Nurses Association. Nation-wide State Legislative Agenda. 2007 Reports.

Author/s and/or contributors to this survey

Petigara, Tanaz and Gerard Anderson

Johns Hopkins Bloomberg School of Public Health

Suggested citation for this online article

Petigara, Tanaz and Gerard Anderson. "The Nursing Shortage in the United States". Health Policy Monitor, October 2007. Available at