TURLOCK — California, like much of the nation, is not producing enough nurses working at bedsides to meet the needs of an aging and diverse population, fueling a workforce crunch that risks endangering quality patient care. Nearly 60% of California counties, stretching between the borders with Mexico and Oregon, face a nursing shortage, according to state data.
Democratic Gov. Gavin Newsom and state lawmakers have tried to bolster the state’s health care workforce, in part by implementing recommendations from the California Future Health Workforce Commission, a 24-member panel of state, labor, academic, and industry representatives. The state in recent years has expanded the scope of practice for nurse practitioners, allowing them to practice medicine — ordering tests and prescribing medication, for instance — without traditional doctor supervision, and has worked to expand academic nursing slots and training programs.
Still, California’s shortage of registered nurses is expected to grow from 3.7% in 2024 to 16.7% by 2033, or more than 61,000 nurses, due to inadequate recruitment, training, and retention, according to Kathryn Phillips, associate director of the Improving Access team at the California Health Care Foundation, a nonprofit philanthropic organization specializing in health care research and education.
Regional shortages, particularly in the Central Valley and rural North, are expected to swell. “There are major deficits and those could get even worse,” Phillips said.
Researchers say the gap between nursing supply and demand is exacerbated by inadequate career pathways and high turnover in a labor-intensive industry, but nurses and their unions argue the problem is driven primarily by a management-induced staffing crisis and poor working conditions. Nurses say nursing remains a noble calling, but many report feeling pressured to turn over beds and take on more patients, stress that can dissuade young people from entering the field and drive experienced nurses to leave or retire early.
Industry representatives cast those concerns as union talking points to drive up labor costs, but nurses say they are losing benefits while being overworked, hobbling morale and hampering their ability to provide even basic health care in hospitals, clinics, and nursing homes around the state.
Lorena Burkett, a registered nurse at Emanuel Medical Center in Turlock, an agricultural city in the heart of the Central Valley, recounted being so overloaded last year that she didn’t promptly log a medical chart after administering a psychiatric patient’s medication, a critical step for ensuring proper drug doses.
“I was being told get him out, and I forgot to scan his opioid medication; I missed it,” said Burkett, a 12-year veteran, who later updated the patient’s record. “After that I said no more. We have to prioritize patient care, but we are under a lot of pressure to get patients out and turn profits.”
Tenet Healthcare, the Dallas-based for-profit hospital system that owns Emanuel, declined to respond to Burkett’s claim, as well as questions about staffing levels. In a statement, Tenet spokesperson Rob Dyer said that the hospital provides “quality and compassionate care” and broadly disputed nurses’ concerns.
“We are currently in contract negotiations with the union which represents our nurses,” he said, “and suspect that this is what is behind these false claims.”
Improving Conditions for Nurses
Two years ago, state lawmakers approved $300 million to help financially struggling hospitals maintain operations, which can include retaining nurses. Lawmakers are also trying to improve nurses’ work conditions in hospitals and to protect patient care by strengthening minimum nurse staffing at health care facilities. Some also call for investing in a more robust nursing workforce.
“Nurses are working in hospitals and other places that are severely understaffed,” said Michelle Mahon, director of nursing practice for National Nurses United, a union that represents 225,000 nurses.
Phillips said the reasons vary. In the San Francisco Bay Area, nurses must contend with a high cost of living, a lack of affordable housing, and expensive child care. In the Central Valley, there’s insufficient education, training, and mentoring. And the rural North has a hard time attracting enough nurses to replace those who are retiring and to meet the needs of an aging population.
University of California-San Francisco researchers who have studied the nursing workforce say although people are still seeking jobs in nursing, student enrollments and graduations have declined.
The California Board of Registered Nursing shows nearly 552,000 active licensed registered nurses in California as of Oct. 1. Yet the California Nurses Association says significantly fewer were practicing, pointing to 2024 data indicating only 350,850 were working in the field. The same problem persists nationally, according to National Nurses United, which reported that, as of May 2024, more than 1.1 million licensed nurses were not working in the field.
California Hospital Association spokesperson Jan Emerson-Shea said hospitals around the state are facing “skyrocketing costs” for labor, pharmaceuticals, medical equipment, and compliance with government mandates. Patient care costs have soared 30% in the past five years and continue to rise, she said. Meanwhile, 53% of hospitals in the state “lose money every day caring for patients,” she said.
And it could get worse.
Under the GOP tax-and-spending bill that President Donald Trump called the “One Big Beautiful Bill,” the state estimates roughly 3.4 million Californians could lose health coverage due in part to major Medicaid cuts and new rules like work requirements that narrow eligibility for low-income and disabled residents. California is at risk of losing $30 billion in annual funding, and hospitals will be hit particularly hard because they rely on federal reimbursements and need enough insured patients to remain solvent.
Emerson-Shea said California hospitals stand to lose up to $128 billion over 10 years due to the law.
“This projection does not include the likely increases in uncompensated care due to Medicaid work requirements, coverage losses due to the elimination of the Affordable Care Act subsidies, more frequent Medi-Cal redeterminations, and coverage losses for those with unsatisfactory immigration status,” Emerson-Shea said.
While some California hospitals lose money on patient care, financial data shows the industry is making money, earning about $11.5 billion in net income, or profit, in 2024, said Kristof Stremikis, director of Market Analysis and Insight at the California Health Care Foundation, pointing to preliminary state data comparing 365 hospitals. “The industry as a whole has returned to pre-covid profitability levels,” Stremikis said.
He acknowledged, though, that Medicaid cuts will reduce revenue for all facilities.
Hospitals will be burdened as uninsured patients, who often arrive with prolonged illness or injuries that can make treatment more expensive, increase in number. That will exacerbate health care challenges in high-poverty communities with large Medi-Cal populations, since the safety net program generally pays hospitals and providers less than private insurance or Medicare.
Already, some hospitals are closing due to financial struggles, before the impacts of the federal health care cuts are felt, and others are limiting access to care, including by shuttering maternity wards and emergency rooms. Officials at Glenn Medical Center, about 85 miles north of Sacramento, reported that it would be shutting down its ER at the end of September due to staffing shortages.
Pandemic-Era Burnout Persists
Front-line nurses said the well-documented burnout of health workers from the covid-19 pandemic, mixed with growing hospital demands, is still being felt today as many part ways with the industry. That is prompting some hospitals to hire more traveling nurses from out of state.
At Hazel Hawkins Memorial Hospital, a financially strained public facility in San Benito County near the Central Coast, the California Nurses Association said the hospital is employing 22 traveling nurses, although the hospital put the number at 16. Local nurses said temporary workers can ease workloads, but they worry hospitals are using traveling nurses to avoid labor contracts that require higher pay and benefits. They say hospitals should invest in well-trained, local staff familiar with the community.
ER nurse Ariahnna Sanchez said workers at Hazel Hawkins, a 25-bed critical access facility, are pressured to discharge patients quickly so more patients can be seen. As union contracts come up for renegotiation, union officials say, hospitals have slashed benefits and haven’t offered adequate raises to keep up with the cost of living. Salaries vary by region but the average annual wage for California registered nurses was $148,330 in 2024, according to the U.S. Bureau of Labor Statistics.
“The morale is so bad right now,” Sanchez said. “We’re trying to fight the good fight but we’re constantly holding people in the emergency room who should be admitted due to the hospital being at max capacity.”
State data shows San Benito County has an extreme shortage of nurses and needs about 180 more to accommodate the local population. But Hazel Hawkins disputes it has a shortage. The California Nurses Association said 40 nurses have left since last year, whereas the hospital said it has replaced 15 of 21 departing nurses.
Hazel Hawkins spokesperson Marcus Young said nurses are conflating staffing levels with protocols for handling ER patients when there aren’t enough beds. “There is no material shortage of nurses and hospital operations are not being impacted today,” Young said. “We are in full compliance with state-mandated nurse-to-patient ratios at all times.”
California law dictates staffing minimums at hospitals, ranging from one nurse for every three patients to one nurse for every five patients, depending on the level of care the patients require. Research has shown that clinical errors can increase in hospitals and other health care workplaces when nurses are stressed and overwhelmed. Studies indicate that burnout related to work overload, career satisfaction, and patient satisfaction is a major concern and can lead to mistakes.
The state has issued 32 citations to California hospitals since 2020 for violating these minimum nurse staffing levels, financial penalties totaling $840,000, according to the state Department of Public Health. Neither Hazel Hawkins nor the Turlock hospital Emanuel had any citations. Spokesperson Mark Smith said the agency could not provide information on any “potential, pending or ongoing investigations” into health care facilities alleged to be in violation of state nursing ratios.
Burkett, the nurse in Turlock, said though she can see up to five patients at a time, she exceeded her ratio twice in the past year. In its latest quarterly financial filing, Tenet reported $288 million in net income, up from $259 million over the same period last year.
“I’ve taken that assignment against my will,” Burkett said, noting that the union distributes forms protecting nurses from repercussions if mistakes happen on their watch when they take on more patients than the state allows. “It says I’m taking these patients against my better judgment and I’m protected because I am not agreeing to this, but the hospital is making me do it,” she added. “It’s tough. I mean, you just have to juggle and do what you can and hope you’re not going to miss something important. It’s not safe.”
State Sen. Caroline Menjivar, a Democrat representing part of the Los Angeles region, has legislation on Newsom’s desk to strengthen the state’s nurse-to-patient ratio law by requiring hospitals to work harder to identify available nurses to meet staffing mandates.
“Hospitals for years have been getting a pass on minimum nurse staffing,” said Menjivar, a former emergency medical technician. “If we do not provide more support to our nurses, then we do not get the quality care that is needed.”
Menjivar’s niece Megan Noguera-DeLeon is excited about becoming a nurse, despite workplace challenges. A nursing student who expects to graduate next year from West Coast University in Southern California, she said relatives who work as nurses have warned her how tough the job can be. She’s worried about burning out but remains committed to the mission.
“I think taking care of people is a beautiful thing,” Noguera-DeLeon said. “I know this job can be really hard and a lot of nurses are experiencing burnout, but honestly I’ve seen firsthand how much nurses can help people even on the darkest of days, and I want to help people.”