The essential role of professional nurses in the U.S. healthcare workforce: Challenges, innovation, and opportunities

There are nearly five million RNs in the U.S, making up the largest segment of healthcare workers.^{[1, 10]} The median age of the nursing workforce is 46 years, and a significant portion of nurses are approaching retirement.^[11] There are significant variations in the distributions of nurses across U.S. regions, where urban areas tend to have higher nurse supply while rural communities may struggle to recruit and retain qualified staff.^[12]

The overall diversity of the nursing workforce appears to be gradually changing. As of 2022, 80% of RNs identified as White, 7.4% Asian, 6.3% Black or African American, and 6.9% identifying as Hispanic. The proportion of men in nursing has increased, rising from 9.4% in 2020 to 11.2% in 2022.^[1]

Most RNs enter practice with either a baccalaureate degree from a four-year college or university or an associate degree from a community college.^[1] As of 2022, 71.7% of the RN workforce held a baccalaureate or higher degree as their highest level of nursing education. Employers increasingly favor baccalaureate-prepared nurses; according to the latest American Association of Colleges of Nursing (AACN) survey on the employment of new nurse graduates, nearly 28% of employers require a bachelor’s degree, while 72% strongly prefer it.^[1] Advanced education among nurses is also growing, with 17.4% of RNs holding a master’s degree and 2.7% holding a doctoral degree in 2022.^[1] However, the demand for nurses with graduate-level preparation for advanced practice, clinical specialties, teaching, and research roles continues to far exceed the available supply.

Within the last fifteen years, nursing education has embarked on repositioning the focus of nursing education from quantitative standards of hours of education to a competency-based education approach in which students demonstrate not only that they have learned material and skills but that they also have reflective knowledge of how to learn, apply, and develop lifelong learning.^[13,14,15] In 2021, baccalaureate nursing programs in the U.S. have been re-engineering their curriculum and clinical experiences through the AACN Essentials program to achieve competency-based education.^[13] Simultaneously, new approaches to highlight and prioritize academic and practice partnerships to ensure better transitions from graduation to practice. This is especially important in pre-licensure education programs where it is well known that new nursing graduates face barriers to transitioning to highly complex work environments and are at risk of burnout or leaving nursing positions. Academic-practice partnerships between schools of nursing and health care systems are increasingly formalizing ways to work together on curriculum development, short-term module courses, immersion in technologies, and shared faculty appointments for academic faculty to have practice opportunities and practicing nurses who serve as preceptors to be engaged in student academic learning.^[16]

Among the important accomplishments of the AACN Essentials program is the standardization of domains of nursing education across the U.S.^[17] These new nursing education changes and recommendations emphasize quality and safety, informatics and healthcare technology, systems-based practice, and interprofessional partnerships that are particularly relevant to potential nursing partnership with industry. Other relevant concepts within the domains include a revised nursing curriculum that nursing would bring to partnerships with tech/engineering are competencies in communication, ethics, clinical judgement, and advocacy through health policy.

Increasing enrollment in schools of nursing to address the workforce shortage is hampered by shortages of nursing faculty and clinical settings for learning.^[18] Academic-practice partnerships have brought solutions directly to these problems. Investment from health systems who employ nurses is increasing but not yet at a level that will completely address shortages, particularly in rural and less populated areas. Evidence shows that patient and system outcomes are better with a nursing workforce prepared with a baccalaureate education.^{[19, 20]} To address movement toward career ladders for licensed RNs prepared with associate degrees or diplomas, nursing for several decades has successfully grown accelerated bachelor’s and master’s degree programs for RNs and for those with bachelor’s minimum degree in other fields.^[21] These efficient fast-tracked programs are highly enrolled and along with the traditional baccalaureate programs have low acceptance rates.^[20] Employers have been highly receptive to graduates from such accelerated programs due to the breadth of general work experience that they bring to initial practice.^[22]

Nurses today face unprecedented pressure from overlapping challenges such as workforce instability, patient complexity, technological advancements, and the adoption of artificial intelligence (AI) platforms to enhance care. Ongoing staffing shortages, widening skill gaps, and systemic underinvestment in nursing infrastructure have created moral distress and operational inefficiencies across care settings.^[9] These practice pressures explicitly reveal gaps in the workforce pipeline and educational capacity, leading to increased burnout and attrition. Nursing’s role in high-acuity, technology-driven care environments now demands adaptive, ethical, and evidence-based leadership to ensure safe and effective practice.

Although the primary focus was on the U.S., the authors examined global perspectives on nursing shortages, both current and historical. One recent paper highlights the importance of addressing ongoing nursing workforce shortages to develop effective and sustainable solutions.^[9] Despite cyclical fluctuations in nursing workforce numbers, most regions worldwide continue to experience persistent shortages due to an aging population and post-pandemic turnover. These shortages differ by region, with rural areas and safety-net hospitals often being the most impacted because of limited recruitment options and lower wage competitiveness. Further, states and regions where there is limited access to nursing education programs and fewer clinical training opportunities tend to experience ongoing staffing shortages.^[12]

Forecasts indicate ongoing national deficits through 2037, with a 10% RN workforce shortage projected by 2027, gradually decreasing over time.^[23] Regionally and in some states, vacancy rates are a greater concern, with Human Resources and Service Administration projecting shortages in multiple states, including at least 10 states with RN vacancy rates of 17% or higher. Vacancy rates continue to surpass pre-pandemic levels, reflecting retirements and poor retention among early-career nurses.^[24] The World Health Organization (WHO) highlights persistent global inequities in the nursing workforce and calls for coordinated international efforts to build a more resilient and equitable system; in fact, the WHO predicts a shortage of 4.5 million RNs by 2030.^[24] Priorities include expanding nursing roles in underserved areas, strengthening education and regulation, improving working conditions and pay equity, protecting and advancing women in the profession, and preparing nurses to lead in fields such as digital health and climate-responsive care.^[25] These actions collectively aim to develop a well-prepared, equitably supported, and globally distributed nursing workforce for the future. Industries throughout the world rely on the health of local workers and could be supportive of nursing education and retention of nurses in local regions. This section explores drivers of nursing workforce instability, which are summarized in Table 1.

An aging workforce, early retirements, moral distress, and the appeal of flexible options like travel nursing and remote roles contribute to attrition. Transition challenges for novice and foreign-educated nurses worsen turnover.^{[26, 27]} Faculty shortages further restrict the number of new graduates and there has been a corresponding decline in nursing school enrollment.^{[1, 28]} In fact, approximately 138,000 nurses have left the workforce since 2022 and an additional 40% of nurses have recently reported that they plan to leave the workforce over the next five years.^[29] At the same time, it is projected that over 200,000 new nurse positions will be created each year over the next decade which contributes to an increasing gap in workforce sustainability.^[30] Given this gap, the U.S. Bureau of Labor Statistics estimates that an additional 275,000 nurses will be needed by 2030 to meet the demand.

The growing burden of chronic illnesses and complex comorbidities increases demands on nurses, especially in acute and community settings. Moreover, all health care professionals are confronted by emerging diseases and widespread care needs of a growing population with chronic illnesses manifesting at a younger age.^[8] As patient dependency grows, nurse–patient ratios are strained, and relational care diminishes. In the past, nurses in acute care settings earned higher fiscal compensation than those in ambulatory care clinics.^[31] However, in some organizations, this is no longer true, and nurses now realize they can contribute professionally for the same pay while maintaining a balanced life, shifting away from the traditional work-life balance model.

Through technological advancement and the individual patient’s desire to pursue extensive life-saving measures, ethical dilemmas are often created involving futile care, resource scarcity, and inequitable access, which may erode moral resilience.^[32] These pressures increase compassion fatigue and contribute to workforce instability. Nurses are often at the forefront of these challenging patient and family discussions, which further contributes to burnout.

Recently, most health care facilities, including acute care settings and outpatient clinics, have experienced a sharp increase in workplace violence. This problem remains widespread, impacting up to 70% of nurses annually, and includes physical assaults, bullying, and digital harassment.^{[33, 34]} Evidence-based prevention programs are still adopted unevenly.^[35] New cyber risks, such as online harassment of nurses, are emerging, with some harassers going to extremes that include attempts to publicly humiliate their victims.^[36]

Nurses who lack sufficient resources at work often seek employment elsewhere. Kohnen et al. identified several key factors that support nurse retention.^[37] These include job resources, work engagement, constructive feedback, autonomy, and growth opportunities, all of which are vital for retaining nurses. However, the most important factor is the relationship between the nurse and their immediate leader.^[38] In Raso, Fitzpatrick, and Masick’s nationwide U.S. study involving nearly 1,800 RNs, they found that authentic leadership by the leader significantly improves healthy work environments and supports nurse well-being.^[38] This underscores the importance of healthy relationships that foster two-way communication, trust, and ethical leadership.

The current nurse workforce is experiencing a significant shift as professionals increasingly seek flexibility, autonomy, and opportunities to shape their own careers. These trends are reflected in the rise of the “gig or contract nursing workforce,” as Dr. Sherman describes.^[39] Generational changes, especially among Generation Z nurses, are fueling a move toward work-life balance and personal agency, diverging from traditional salaried and shift-based roles. This disruption is visible in the rise of entrepreneurial ventures such as nurse-led clinics, teleconsulting services, and health innovation advisory roles, all of which are characteristic of what Sherman and others have described.

Simultaneously, value-based payment models are transforming reimbursement by linking compensation to patient outcomes instead of labor input. This encourages healthcare systems to incorporate aggregate quality of care outcomes into employee payment models in an attempt to better reflect the measurable impact of nursing on quality and safety. In response, the profession must develop strong frameworks to capture which activities are specific to the profession and bill for nursing contributions within payer systems. Unfortunately, the U.S. has not explored this in depth, but international studies are emerging.^[40] A scoping review by Di Nitto et al. shows many efforts to understand how to unbundle nursing care costs, but due to complexity, none have succeeded.^[40] The authors identified one study that created a nursing relative value unit, similar to a provider model, but much work remains to shift to a nurse’s billing system. Only when a model like this is adopted will payers, administrators, and the public truly see and hence understand nursing’s clear value to healthcare.

Porter-O’Grady, Rollins, and Bailey argue that traditional hierarchical structures threaten the social responsibility and professional autonomy of nurses, advocating instead for models that promote full accountability and collaborative practice.^[41] Nurses should have agency over their scope of practice, and the path for this is through professional governance models where true collaboration exists between nurses and their leaders. In such models, nurses are not merely participants but hold decision-making authority over their practice, thereby transforming staff into professionals, empowered with ownership and accountability for outcomes. These structures shift the locus of control from top-down managerial edicts to the nurse as an expert in the field, aligning governance with nursing’s social contract and its obligation to advance care, quality, competence, and knowledge. When implemented effectively, professional governance fosters an environment of equality, so that nurse leaders and clinical nurses work interdependently rather than in silos, reinforcing shared accountability and collaborative practice. Ultimately, this shift supports not just nurse empowerment but better patient outcomes, higher nurse engagement, and organizational resilience. When nurses govern their practice, they bring expertise closer to decision-making and practice innovation.

Technological advancements are also transforming the field, with AI, big data, and industry partnerships improving clinical decision-making, remote monitoring, and patient safety.^[42,43,44] Nurse innovators are leading efforts to create user-friendly tools that are designed to fit seamlessly into workflows, though ethical implementation and human oversight remain essential to maintain compassionate care.^[45] Meanwhile, professional organizations continue to shape policy, advocating reforms in staffing, pay, licensing, and education to address the faculty shortage and ensure the profession’s sustainability and growth. Coordinated policy efforts at both state and federal levels will be crucial to support these emerging practice models while preserving nursing values.

Faculty shortage persists, resulting in nearly 66,000 nursing students being turned away for the 2023–2024 academic year.^[46] To overcome this, fundamental changes will be needed on both the academic and practice sides of the equation. Academic-practice partnerships require a significant transformation to develop a robust model that yields positive outcomes for both partners and supports the RN pipelines. In one study, Jarosinski et al. found that nursing program administrators face challenges like those of their practice partners, including faculty burnout, overburdening, and pay disparities.^[29]

Harder et al. emphasized the importance of advancing nursing education through AI and enhanced virtual reality (AI-VR) to supplement adequate hands-on patient care and real-world experience.^[47] Using AI-VR with standardized patient scenarios improves nursing education by supporting communication skills, clinical relevance, realism, and learner engagement. An AI-VR approach provides students with a structured, non-judgmental environment that encourages the development of empathy and authentic interpersonal communication skills. Students perceive it as a psychologically safe space for learning. Overall, a balanced curriculum combining both modalities, supported by faculty training and ongoing assessment, can enhance learning outcomes, strengthen communication skills, and prepare students for complex clinical interactions.

In response to the growing nurse faculty shortage, health systems are increasingly stepping into the educator role by formalizing split nurse faculty positions.^[51] These dual-role models allow experienced nurses to divide their time between clinical practice and academic instruction, thereby expanding nursing school capacity without requiring nurses to leave the bedside. This approach not only addresses faculty shortages but also enhances the quality of nursing education by integrating real-time clinical insights into academic curricula. Nurses who teach while practicing are better equipped to prepare students for the realities of bedside care, improving student readiness, and retention in the profession. Moreover, these models offer flexible career pathways for nurses at various stages, including those nearing retirement and early-career professionals interested in education. By leveraging their workforce as a teaching resource, health systems can play a pivotal role in sustaining the nursing pipeline and strengthening academic-practice partnerships essential to the future of healthcare delivery.

One of the greatest responsibilities of industry organizations is to provide innovative tools that are clinically intuitive, easy to use, and designed to help clinicians improve patient outcomes in a workflow-efficient manner. Recent examples include minimally invasive laparoscopic surgery, more efficient tissue biopsy sampling, and rapid deployment of novel diagnostics, therapeutics and enablement of unprecedented large-scale vaccine delivery during COVID-19, the worst pandemic within the last century.^{[52, 53]} However, most of those examples are geared toward physician decision making workflows and use cases. Given that nurses spend the most time with patients, especially those with complex needs, they also have a crucial role in patient outcomes. This presents a unique opportunity for industry to have renewed focus on supporting nursing workflows. By prioritizing time efficiency, ease of use, and continued education on instructions for use (IFU)-based teaching modalities, industry organizations can help address key challenges facing the nursing workforce, including staffing shortages, limited bandwidth, and burnout - all of which may adversely affect patient outcomes. Industry leaders can also increase partnership with nursing education leaders to develop scholarships for career paths in industry, innovation workshops in simulation centers, or engage with nursing faculty and students in product development.

This demand for more efficient and effective medical technology also poses an important opportunity for nursing professionals. Industry organizations are increasingly seeking nurse input early in the innovation process to ensure that there is alignment with nursing workflows and patient care needs. As a result, nurses may serve as needed on advisory boards or in a consultant role; some nursing professionals have decided to transition from the bedside into full time roles in science or engineering.^[54] The expansion of nurses into these adjacent and viable alternative professions is increasingly vital to the innovation process as it fosters partnerships between nursing professionals and industry organizations to positively affect patient outcomes. Given that nurses are often the primary end users of many medical devices, their participation in the creation and acceptance of new innovations will organically help drive a culture of change toward clinical and operational viable solutions that tend to have delayed adoption in healthcare. As an example, nurses represent the fulcrum of physician, pharmacist, and laboratory workflows. They deliver the care designed by physicians and prepared by pharmacists; therefore, nursing input and adoption of innovative product solutions can only help drive culture change toward creating new care paradigms that are also operationally compatible with how healthcare is delivered in a team-based approach.

A recent systematic medical literature review on major forces and barriers driving healthcare innovation reiterated that the integration of innovative medical devices, AI, and novel healthcare delivery models, are predicated on culture change, from a traditional treat the illness goal to one that also includes population health.^[55] Nurses are uniquely positioned to influence this evolving care paradigm, especially for vulnerable patients who are affected by social determinants of health, as part of nursing care involves post-care outreach and medication adherence programs designed for these high-risk demographics.^{[56, 57]} One example of nurse partnership is in the emergence of new non-acute care areas, where nursing care will be needed to help monitor patients and their response to therapy. Another example is in the emergence of virtual rounds where an experienced nurse may provide mentorship to newer nurse graduates for specialty acute care, such as Intensive Care Units, to help address the nurse shortage and lack of clinical experience in new nursing graduates.^[58] A third example is the growth of virtual reality training in nursing led bundles to prevent deleterious outcomes such as the mandatory reportable hospital acquired infections CAUTI (catheter associated urinary tract infection) and CLABSI (central line associated bloodstream infection). While these are just a few current examples, they highlight the significant opportunity for nurse professionals to create solutions and carry out practice in these innovative care settings.^[59,60,61] Collaborating directly with nurses is critical to ensure that new technologies are clinically relevant, easy to implement, and designed for rapid adoption and optimal use.

The emergence of nurse scientist roles within health systems marks a transformative shift in the integration of research and clinical practice.^[54] Traditionally rooted in academia, doctoral-prepared nurse scientists are increasingly embedded in hospital and community care settings, where they contribute to evidence-based innovation, protocol design, grant writing, and professional development. This migration is largely driven by the American Nurses Credentialing Center’s Magnet Recognition Program® designation’s emphasis on clinical nurse-led research, which has elevated the visibility and value of nurse scientists in clinical environments. Several health systems are expanding their nurse scientist programs, recognizing their capacity to bridge bedside care with scholarly inquiry. These professionals not only lead independent research initiatives but also mentor staff, influence national research priorities, and contribute to policy development. Their presence enhances institutional credibility, supports strategic planning, and fosters interdisciplinary collaboration. As hospitals seek to articulate the value of nursing and improve patient outcomes, nurse scientists are becoming indispensable agents of change, shaping the future of healthcare through inquiry, leadership, and innovation.