California Has the Most Nurses. Why Is It Facing the Nation’s Worst Projected Shortage?
This article is part of Nurse.org’s Nursing Workforce Benchmark, a new research series analyzing nursing workforce strain across all 50 states. This article takes a closer look at California, ranked #1, where the largest nursing workforce in the country is also facing the steepest projected shortage.
California does have the largest nursing workforce in the country, roughly 355,249 employed RNs. It does have the most robust public workforce data. And it does have mandatory nurse-to-patient staffing ratios, protections that nurses in other states have fought for and not won. Those things are real.
And yet California ranks #1 on the Nurse.org Nursing Workforce Benchmark with a severity score of 84.1, the most acute projected staffing gap in the country. The state doing the most to protect nurses is also facing the worst projected shortage. That tension is the center of California’s workforce story.
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The California Health Care Access and Information (HCAI) Supply and Demand Model breaks California’s nursing workforce into nine geographic regions. The picture that emerges isn’t a uniform shortage. It’s a distribution problem: nurses concentrated in some areas, critically scarce in others. Researchers call this maldistribution, and California’s data makes it unusually visible.
The same state, two completely different realities.
Nurse.org Nursing Workforce Benchmark: California RN Supply and Demand by Region
| Region | 2025 Gap | 2025 FTE Shortfall | 2033 Projected Gap |
|---|---|---|---|
| Northern and Sierra | -25.8% | -3,177 RN FTE | -38.2% |
| Central Coast | -11.0% | -1,771 RN FTE | -24.5% |
| LA County | -10.4% | -8,188 RN FTE | -18.3% |
| San Joaquin Valley | -9.6% | -2,760 RN FTE | -10.0% |
| Orange County | -6.9% | -1,563 RN FTE | -20.5% |
| Greater Bay Area | -4.3% | -2,664 RN FTE | -21.2% |
| Inland Empire | -2.0% | -582 RN FTE | -6.1% |
| San Diego | -0.1% | -33 RN FTE | -9.6% |
| Sacramento | +10.5% | +1,974 RN FTE surplus | -1.8% |
Source: Nurse.org Nursing Workforce Benchmark. HCAI Supply and Demand Modeling for California’s Nursing Workforce (updated November 2025). FTE = full-time-equivalent registered nurses.
Northern and Sierra face the deepest shortage today: more than 25% of RN positions unfilled, in rural areas where recruiting is hardest and healthcare access is thinnest. LA County’s percentage is more moderate, but 8,188 unfilled positions is an enormous real-world number, and it grows to 17,358 by 2033.
The Greater Bay Area has the steepest projected worsening of any major California metro: from -4.3% today to -21.2% by 2033.
And then there’s Sacramento. In 2025 it is the only region projecting a surplus: +10.5%, nearly 2,000 more RNs than currently needed. That surplus is real and temporary. By 2033, Sacramento flips to a -1.8% shortage. The one bright spot disappears.
The statewide 61,141 figure is accurate. It is an average of a state where some regions are already in crisis, others are accelerating toward one, and the one region with a current surplus won’t have it for long.
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California nurses are working. That’s what the data shows, and it makes the regional shortages more striking, not less.
Of California’s licensed resident RNs, 85.7% are actively working in nursing, the highest employment rate of any state in the Benchmark dataset. More of California’s licensed nurses are actually practicing than anywhere else measured. West Virginia, which has more registered nurses per 1,000 jobs than any other state, is unranked because the data needed to score it doesn’t exist. California is the opposite case: deep data, clear picture, and still facing a shortage.
The problem isn’t that California nurses aren’t working. They aren’t evenly distributed. And by 2033, even the regions that look adequate today won’t be.
How Mandatory Staffing Ratios Affect California’s Nursing Shortage
California is the only state that mandates specific numerical nurse-to-patient ratios, a policy established under AB 394 (1999) and in effect since 2004. In October 2025, Governor Newsom signed SB 596, which significantly strengthened enforcement by raising penalties and treating each day of noncompliance as a separate violation. Whether the ratios are working as intended depends on what question you’re asking.
For nurses in the rooms where ratios are met, the answer is yes. The floor is safer. The problem is that maintaining those ratios requires enough nurses to staff every shift to the required level. In Northern and Sierra regions, where the shortage is already above 25%, meeting ratio requirements puts direct pressure on hospitals trying to operate within the law while running short of staff.
This is the California paradox the Benchmark captures. The state has the strongest nurse-protective policy in the country, the best public workforce data, and the highest employed-RN rate. And it still ranks #1 on shortage severity. That combination of strong policy, deep data, and persistent shortage is what makes California the natural laboratory for understanding what workforce investment can and can’t solve.
California is not just the largest state or the hardest case. It’s the most transparent one. The HCAI regional model, the HCAI employment survey, and the mandatory ratio compliance data together represent the most detailed public nursing workforce dataset in the country.
What California’s data shows (regional maldistribution, a high employed rate that doesn’t prevent shortage, a surplus today turning into deficit tomorrow) is almost certainly present in other states. We can see it in California because California chose to publish it. The 20 states that couldn’t be ranked in the Benchmark didn’t choose that. The data gap, not the shortage, is what makes them invisible.
Read more from the Nursing Workforce Benchmark series:
🤔 If you’re a nurse in California, what does the regional picture look like from where you work? Share your experience in the comments below.
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Methodology
California figures are drawn from the HCAI Supply and Demand Modeling for California’s Nursing Workforce (updated November 2025) and the HCAI Survey of California Registered Nurses (2024). The 61,141 shortfall figure represents full-time-equivalent RNs, not headcount. Regional projections use the CHIS geographic framework.
The 85.7% employment rate reflects California-resident licensed RNs actively employed in nursing roles, from HCAI survey data. California is outside the Nurse Licensure Compact; its license counts represent in-state nurses, making this figure more directly comparable than compact-state employment rates.
Source: Nurse.org Nursing Workforce Benchmark.
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Published on
August 5, 2026
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