California nursing shortage crisis lack space in schools

Oscar Mateo dreamed of being an artist, but after he contracted leukemia when he was 20, his life plans abruptly changed. The compassionate nursing care he received while hospitalized touched him so much that he decided he wanted to provide the same for others.

That goal led him to the registered nursing program at Mt. San Antonio College in Walnut. But getting there wasn’t easy, as he had to battle competition for limited seats in one of the highest-demand fields in higher education, a career offering purpose, plentiful jobs and potentially six-figure paychecks.

Mateo was rejected three times by Mount SAC before winning admission. To burnish his resume, he earned certification as a nursing assistant and got work experience.

“It’s so competitive and stressful,” Mateo said. “It definitely takes a toll on you.”

Mateo represents a paradox bedeviling the U.S. nursing landscape. There is enormous demand for nurses as retirement or burnout push many from the field. But despite tens of thousands of students vying to get into nursing programs, schools can’t accommodate the demand for two major reasons: They can’t find enough faculty to teach classes and there is a dearth of required hands-on training opportunities in hospitals and healthcare facilities.

The mismatch has hit California particularly hard, triggering a state audit, legislative proposals and funding initiatives. Some nursing schools want to allow greater use of training technology to widen access — such as high-tech mannequins that simulate heart attacks and other medical conditions. But others warn against that path. In the process, tensions between public and private nursing schools have flared as they battle for resources to expand their programs.

“It’s critical to supply the workforce to meet the need,” said Paul Creason, Long Beach City College dean of business, education and health sciences. “But there are too many obstacles and this will have ramifications for the cost and quality of healthcare.”

In California, only about a third of 57,987 applications by qualified students to nursing school were accepted in 2022-23 — the most recent data available — according to the state Board of Registered Nursing. Nationwide, nursing schools turned away nearly 66,000 qualified applications for bachelor’s and graduate nursing programs in 2023, the American Assn. of Colleges of Nursing reported.

California’s projected shortfall of working nurses is one of the largest in the nation, estimated to grow from 40,790 this year to 61,490 in 2035, according to the U.S. Department of Health and Human Services.

Shortages are projected for both registered nurses, who provide the more advanced skills typically acquired in a two- to four-year training program, and licensed vocational nurses, who offer more basic care after a typical one-year certification program. Among registered nurses, the biggest looming shortages over the next decade are in San Francisco, the Central Valley and Central Coast regions, UC San Francisco has found.

Scarcity of clinical training slots

The most contested resource in nursing education is the mandated, hands-on clinical training. California law requires students to complete at least 500 hours of direct patient care under the supervision of nursing staff at a hospital or other healthcare facility to graduate and qualify to take the national licensing exam.

“You have to have these spots or your program is dead in the water,” Creason said.

The competition for clinical placements is fierce. Requests are soaring just as some hospitals are scaling back on training because their staff nurses are too overloaded to take on more students. More than half of the state’s nursing school programs reported their requests for clinical placements were denied in 2022-23, according to the state nursing board, and 57.2% of the state’s 152 registered nursing programs cited a lack of clinical placements as the top obstacle to adding more seats.

Mount SAC, for instance, lost placements at multiple sites. In spring, a hospital withdrew two spots just weeks before classes started, forcing the school to scramble for a replacement. San Antonio Regional Hospital stepped in, opening a night shift for students.

Public campuses argue that their students should have priority for these clinical slots. Private nursing schools — both nonprofit and for-profit — disagree, urging a level playing field.

Reports that some colleges pay for the sought-after slots have riled many campuses, and in the 2022-23 Board of Registered Nursing survey, nine unnamed colleges reported they had provided “financial support” to secure a clinical placement. A 2023 state law bans such “pay-to-play” arrangements — but college officials say it is difficult to enforce and the law is vague about what exactly is forbidden.

State legislators and nursing organizations have begun rallying to better support public nursing programs.

Last year, Gov. Gavin Newsom and the Legislature approved $60 million for a five-year grant to expand community college nursing programs, including partnerships with four-year campuses for bachelor’s degrees. Beginning this year, another state law mandates health facilities to “work in good faith” with California community colleges and California State University campuses to meet their clinical placement needs.

Private institutions criticize those efforts as unfair.

Samuel Merritt University, a private nonprofit university in Oakland, petitioned the state board to add 72 seats to the nursing program at its Sacramento campus. But Cal State Sacramento, Sacramento City College and Sierra College told the board they opposed the request because they were losing clinical sites and worried about nurse burnout from training students. UC Davis also objected.

Although Samuel Merritt offered to pare its proposed enrollment to 40, the state board denied the expansion request. The original 72-seat increase was subsequently approved in August after the university found clinical placements outside the Sacramento area.

“What we find to be the most frustrating is the state schools, the four-year institutions and the two-year institutions — they’re kind of banding together to prevent any growth by the private schools,” said Steven Rush, dean of Samuel Merritt University’s college of nursing.

Creason, of Long Beach City College, argues that community colleges should get priority for state funding and clinical placements because they deliver quality nursing education at a significantly lower cost than private programs, and typically to students who reflect the state’s cultural and linguistic diversity.

California nurses’ organizations agree, saying that community colleges and CSU campuses in particular offer a pipeline to nursing jobs for lower-income, first-generation students of color and that these graduates provide culturally sensitive care.

Creason said the total cost for an LBCC two-year associate degree in nursing — the college’s most popular major along with business — is about $5,000. Under a newly established partnership with Cal State Long Beach to jointly prepare students for a four-year bachelor’s degree in nursing, the total cost would be about $43,000, he said.

That compares with $148,000 for a four-year bachelor’s degree at West Coast University — a private, for-profit institution that runs the state’s largest nursing program, with campuses in Los Angeles, Orange County and the Inland Empire.

But the more affordable public nursing programs are also far more difficult to get into. Long Beach’s admission rate is about 3.3%, with room for 80 students among 2,400 applicants each year, although the partnership with Cal State Long Beach will allow it to grow to 120 seats in about two years, Creason said. West Coast, by contrast, has a 100% admission rate and an annual approved enrollment of 2,880 seats.

That ease of entry is why Oscar Mateo was close to enrolling at West Coast before finally winning admission to Mount SAC on his fourth try. He said he would have needed to take out a loan of more than $100,000 to afford West Coast but was so driven to become a nurse he would have been willing to make that investment. He was ecstatic when he got his Mount SAC financial aid letter and saw that state grants and fee waivers would cover the entire cost of his nursing program aside from books.

“Once I was in Mount SAC, it was a no-brainer to go to a community college,” he said. “The low cost made it so enticing and the respect the school has from the hospitals are big reasons for attending this program over others.”

For Ray Ayranian, the heftier tuition and fees at American Career College, a private for-profit institution, are worth it.

Ayranian, who was inspired to pursue nursing after seeing the care given his sister when she underwent neurosurgery, started out at Pasadena City College. But he said he wasn’t a great student and thought the private-school route would be easier — and faster. He and his parents took out a loan for about $30,000 to pay for the 12-month licensed vocational nurse program, he said, but he figures he’ll work extra shifts once he earns his degree and gets a job to pay off the debt.

“I just wanted to do something fast because I’m a pretty hands-on person,” he said.

A spokesperson for ACC and West Coast declined to comment.

Possible solutions

One potential solution to ease the crunch is state financial incentives to hospitals and other medical facilities to provide more clinical placement slots. Virginia offers tax-free grants to nurses and other health professionals who mentor nursing students, while Georgia, Maryland, Colorado, South Carolina and Alabama are among states that offer tax credits or other financial incentives. Federal legislation to give a $2,000 tax credit to nurses who provide at least 200 hours of clinical training is pending.

Nursing student Diva Bailey uses a virtual reality headset to evaluate a simulated patient at Mt. San Antonio College.

(James Bernal / For The Hechinger Report)

Michelle Mahon of National Nurses United says better working conditions for nurses would entice more of those who got burned out and left to reenter the field. That, she said, would help ease the pressure to create more nursing school seats.

Another idea is expanding the use of technology. At Mount SAC, for instance, classrooms have high-tech mannequins that can be programmed to blink, shriek and simulate a variety of medical conditions, including heart attacks, bleeding, respiratory failure — even giving birth. Virtual and augmented reality programs offer interactive 3D environments with animation or actors simulating patients.

Given the shortage of clinical placements, some nursing educators argue that accredited programs with high student licensing exam pass rates should be allowed to balance simulation training with hands-on training, rather than meet the state’s minimum 500-hour requirement.

But others say technology can never replace human connections. Nicole Ong, a Mount SAC nursing student who worked as a certified nursing assistant before starting her RN program, said experience with real people is crucial for learning how to bond with patients in their most vulnerable moments.

“You have to get trust from a patient and you can’t get that from a mannequin,” Ong said.

Teresa Watanabe is a former staff reporter for The Times. This article is co-published with the Hechinger Report.

Watanabe is a former staff reporter for The Times. This article is co-produced with The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education.