California, North Carolina, and Georgia top the list of states that need nurses the most, each facing shortages of 20% or higher by 2038. Federal projections from the Health Resources and Services Administration (HRSA) show that the nursing gap varies enormously across the country, with some states headed toward severe deficits while others, like Wyoming, are on track for a surplus. If you’re deciding where to build a nursing career, the differences are striking.
The 10 States With the Largest Projected Shortages
HRSA’s workforce projections estimate the gap between how many registered nurses each state will need by 2038 and how many it’s on track to produce. The ten states facing the biggest shortfalls are:
- California: 22% shortage, roughly 84,750 unfilled positions
- North Carolina: 20% shortage, about 25,710 unfilled positions
- Georgia: 20% shortage, about 25,110 unfilled positions
- Michigan: 18% shortage, around 20,290 unfilled positions
- Washington: 17% shortage, around 15,020 unfilled positions
- Maryland: 16% shortage, about 10,890 unfilled positions
- Oklahoma: 13% shortage, roughly 5,900 unfilled positions
- South Carolina: 12% shortage, about 7,250 unfilled positions
- Louisiana: 11% shortage, around 5,680 unfilled positions
- Virginia: 8% shortage, about 8,020 unfilled positions
California’s deficit alone is larger than the next three states combined. That 84,750-position gap reflects the state’s enormous population, its aging demographics, and persistent difficulties in training enough new nurses to keep up with demand. But percentage-wise, North Carolina and Georgia are in nearly as much trouble, each facing a one-in-five shortfall relative to projected need.
Why These States Can’t Keep Up
The shortage isn’t simply about too few people wanting to become nurses. Nursing schools across the country turned away nearly 92,000 qualified applicants in a single year, not because students weren’t prepared, but because programs lacked the faculty, clinical training sites, and classroom space to accept them. The western U.S. is hit hardest on this front, with about 33,000 qualified applicants denied admission and a faculty vacancy rate of 9%, the highest of any region.
Demographics are the other major driver. As recently as 2020, only three states (Maine, Vermont, and Florida) had more adults over 65 than children under 18. By 2024, that number had jumped to 11 states, adding Delaware, Hawaii, Montana, New Hampshire, Oregon, Pennsylvania, Rhode Island, and West Virginia. Older populations need significantly more healthcare, which means more nurses. States where the elderly population is growing fastest are seeing demand accelerate well beyond what their training pipelines can deliver.
Rural Areas Face a Steeper Crisis
The state-level numbers mask an even sharper divide between cities and rural communities. Rural areas currently have about 65 registered nurses per 10,000 residents, compared to nearly 100 per 10,000 in metropolitan areas. That gap is expected to widen. Federal projections show rural shortages reaching 24% by 2027, compared to just 7% in metro areas. Even by 2037, when the overall picture improves slightly, rural areas are still projected to be short by 13% while cities settle closer to 5%.
This matters in practical terms. States like Oklahoma, Louisiana, South Carolina, and Michigan all have large rural populations. In these places, the shortage isn’t abstract. It means longer emergency room waits, fewer available home health nurses for aging residents, and hospitals that rely heavily on temporary staff to fill gaps.
What Nurses Actually Earn in High-Need States
Raw salary figures can be misleading because what you earn matters less than what it buys. After adjusting for each state’s cost of living, the picture shifts significantly. Oregon leads the country with an adjusted hourly wage of about $51.71. Minnesota comes in second at $50.28, followed by Washington at $48.72, Nevada at $48.54, and Georgia at $48.42.
California pays the highest nominal wages in the country for registered nurses, but its high cost of living erodes much of that advantage. Georgia stands out as a state where demand is severe, cost of living is relatively low, and adjusted pay ranks among the top five nationally. For nurses weighing a relocation, that combination of high demand and strong purchasing power is worth noting. Washington offers a similar story: a 17% projected shortage paired with top-tier adjusted pay.
How States Are Responding
States are tackling the shortage from different angles. Sixteen states have passed laws or regulations addressing nurse staffing levels in hospitals. California and Massachusetts are the only two that mandate specific nurse-to-patient ratios, meaning a nurse can only be assigned a set number of patients at a time. The American Nurses Association supports a different approach: staffing committees where at least 55% of members are bedside nurses who help determine safe staffing levels, giving flexibility to adapt to each unit’s needs rather than applying a one-size-fits-all ratio.
These staffing rules matter to nurses on the ground because they directly affect workload and burnout. States with ratio laws or strong staffing committee requirements tend to have better retention, which in turn helps ease the shortage over time. States without such protections often find themselves in a cycle where overwork drives nurses out of the profession, deepening the very deficit they’re trying to fix.
What This Means if You’re Choosing Where to Work
High-shortage states generally offer more job security, faster hiring timelines, signing bonuses, and greater flexibility in choosing your specialty or shift. If you’re a new graduate, states like Georgia, North Carolina, and Michigan are likely to have residency slots and onboarding programs designed to attract and retain entry-level nurses. If you’re an experienced nurse considering travel contracts, the highest-paying states for travel nurses include Washington ($114,542 annually), New York ($110,642), Massachusetts ($110,449), and Alaska ($108,913).
The states with the deepest projected shortages are also the states most likely to expand loan forgiveness programs, tuition reimbursement, and rural placement incentives over the next decade. If you’re still in nursing school or weighing a return to the profession, the geographic mismatch between supply and demand is large enough that where you choose to practice could significantly affect your compensation, workload, and career trajectory for years to come.