Since the eighth grade, Angela Crisp of Ventura, Calif., has known she wanted to be a nurse. In high school, she earned certification as a nursing assistant. Then, she enrolled at nearby California State University Channel Islands (CSUCI) and launched into the prerequisites for a bachelor of science degree in nursing (BSN)—anatomy, physiology and medical microbiology. “I was always interested in science and medicine,” says Crisp, 20. “And I just stuck with it.”

But this past spring Crisp faced a major disappointment. Though she was accepted as an alternate, her college’s nursing program just didn’t have room for her. “We had 313 applications for 37 seats,” says program director Karen Jensen. “Not all of them met our criteria, but a good 150 did, and these were good candidates, candidates you wouldn’t want to turn way.”

Crisp’s personal setback represents a serious problem for all Americans, and here’s why: At the point when Crisp might be approaching the height of her career as a well-educated, seasoned nurse, the country is expected to face a devastating shortage of nurses. Government estimates put the shortfall at more than 1 million registered nurses (RNs) by 2020. Peter Buerhaus, an expert on the nursing work force at Vanderbilt University Medical Center in Nashville, Tenn., projects a less dire deficit of 500,000 nurses by 2025, but says even that number would mean “lights out” for the health care system as we know it.

Hospitals would be forced to curtail needed expansions and cut back services. “People would have trouble getting into hospitals,” says Linda Aiken, an authority on nurse supply at the University of Pennsylvania. “You’d see long waiting times.” With the nation’s hospitals competing strenuously over a small pool of nurses, rural hospitals that serve aging populations—and that have long faced workforce shortages—could be especially hard hit. Nursing homes and home health care would also be left short-handed.

Once inside the hospital, patients could find themselves imperiled by staffing levels that leave RNs scrambling to hand out medications, with little time to look out for subtle signs of deterioration in patients. Aiken’s research examining conditions at 168 Pennsylvania hospitals found that a surgical patient’s likelihood of dying went up 7 percent for every patient added to a fairly typical nurse’s workload of four patients. Stretched nursing staffs also have been linked with a higher number of preventable infections, longer stays in the hospital and more cases of “failure to rescue,” in which people die from complications considered treatable.

In a 2006 study, Beatrice Kalisch, a professor at the University of Michigan School of Nursing, interviewed 107 RNs, 15 licensed practical nurses and 51 nursing assistants about which nursing tasks they routinely missed. Top answers included helping patients get up and moving, turning bed-bound patients on schedule, feeding and bathing them in a timely manner, and educating them about their condition. The most commonly cited explanation for this missed care? Too few staff to handle the workload and surges in patient demands. While there’s been little research on whether patients actually notice lower staffing levels, it’s clear nurses are a key part of their experience.

“The doctor you see once every other day,” says Edward Cohen of Fountain Hills, Ariz. “Nurses give the frontline care.” He say he’ll never forget the competence and compassion of the nurses who tended his 64-year-old wife, Luiza, when she was dying of uterine cancer four years ago. Despite being “stretched too thin,” he says, it was they who spent time trying to help Luiza walk again when the cancer spread to her leg bone. “For the 30 days before she died, whenever I was in the room, a nurse always came in to be with me.” Cohen honored his wife’s memory by establishing a scholarship to help local high school graduates pursue nursing degrees.

In 2004 California became the first and only state to mandate a minimum ratio of nurses to patients in hospitals. A dozen other states have implemented regulations that address staffing, and a number are considering legislation.

Why is the country staring down such a massive gap in nursing care? Put most simply, demand is swelling with the aging of the enormous boomer generation, and we aren’t training nearly enough nurses to meet it.

Indeed, during the ’90s, as managed care began trimming hospital stays, nurses’ employment rates fell and so did the number of new graduates entering the profession. That trend began to turn around after 2001 thanks to a number of factors: an uncertain economy that brought already trained nurses back to work; rising wages for nurses; and public service campaigns designed to attract new entrants to the field.

Health care institutions also began to recruit heavily overseas, with foreign-born nurses accounting for some 30 percent of gains in RN employment from 2002 to 2005. To keep this pipeline flowing, the Emergency Nursing Supply Relief Act, sponsored by Rep. Robert Wexler, D-Fla., and approved by the House Judiciary Committee in August, would provide 20,000 special nurse visas a year for three years, with related fees going into a fund to support more slots at domestic nursing schools.

Those steps have helped ease today’s shortage, which began in 1998. But they don’t amount to a long-term solution. While the nursing workforce braces for the retirement of many boomers, the biggest barrier to achieving an adequate supply of nurses is the educational bottleneck Angela Crisp is confronting. Because of limited capacity in the country’s nursing schools, tens of thousands of qualified applicants are turned away every year.

Crisp’s school, CSUCI, is a good example of the vigorous efforts local communities are making to educate more nurses; it also illustrates the need for more large-scale national initiatives to help them do that. The nursing program there—the first of its kind in Ventura County—began in the 2007-2008 school year, thanks in part to the pledged support of a consortium of local hospitals. A lab to simulate patient-care settings, which makes nursing education more efficient, is nearing completion. The hospitals’ support is expected to allow the program to nearly double enrollment to 66 students every other year, says Jensen. She also managed to secure state funding for an additional four spots this coming year.

As for Crisp, she says she’s thinking about going to community college to qualify for RN licensure on the strength of an associate degree, a path taken by the majority of newly minted RNs in recent years. This shorter route has helped beef up the workforce, but it doesn’t fortify the pipeline of young nurses likely to join a college faculty and teach the next generation. That requires a master’s or doctorate.

“What you might call the easier solutions have already been done,” says AARP’s Susan Reinhard, who heads the Center to Champion Nursing in America, a collaboration among AARP, the AARP Foundation and the Robert Wood Johnson Foundation. “Nursing faculty are as productive as they can be. They’ve doubled their class sizes.” Some are saying it’s time for the federal government to do more to subsidize faculty positions and help people like Crisp complete their education. The Nurse Reinvestment Act of 2002, which provides student scholarships in exchange for service and loan cancellation for faculty members, is “only symbolic,” says Aiken. “Something like 90 percent of applicants are turned down.”

Once nurses are trained, keeping them on the job is also critical to building their ranks. Though nurses tend to stay in the profession, turnover is a big problem for some employers. A 2006 survey of 2,323 experienced registered nurses in intensive care units across the country found that 17 percent intended to quit their jobs within the year. More than half of those cited poor working conditions as their reason, with limited opportunities to participate in decision-making and advance professionally as other significant factors in their decision to leave.

For the health care consumer and the nation, constant turnover of skilled nurses is a waste of health care dollars. It can cost upward of $30,000 to orient a new nurse to an institution, says Patricia Stone, an associate professor of nursing at Columbia University and lead author of the turnover study.

Increasingly wise to these facts, employers are not only paying nurses better—RNs’ median annual income stands at $60,000—but also taking steps to ensure they work in conditions that minimize burnout and allow them to do their jobs well. A small but growing number of facilities, for example, are being credentialed by the Magnet Recognition Program, run by a subsidiary of the American Nurses Association. The program rewards strong nurse leadership, attention to quality standards in nursing care and other factors conducive to nursing excellence and nurse retention. “Our data show that nurses’ satisfaction with their jobs has gone up,” says Vanderbilt’s Peter Buerhaus. More innovations are needed, he says, to allow older, highly experienced RNs to stick around and mentor younger nurses without having to lift patients and work grueling shifts. At Osmond General Hospital in rural northeast Nebraska, the average nurse is in her 50s, with one staffer in her 70s, says CEO Celine Mlady. In this setting, nurses must have the skills and confidence to deal with everything from head injuries to urgent labor. As a result, Mlady hangs on to experience whenever she can, citing one longtime nurse now working in staff education and infection control. “It’s terrifying whenever a registered nurse resigns,” says Mlady.

To some observers, underlying the quest to bolster the nursing workforce is the need to adopt a more realistic image of nurses. The American public consistently rates them among the most trusted and respected of all professionals. But few health care institutions include nurses on their governing boards, media rarely quote them on medical issues and the National Institutes of Health devotes only a minuscule fraction of its budget to nursing research. “The angel image allows decision makers to ignore nurses’ workplace conditions,” says Sandy Summers, director of the Center for Nursing Advocacy, “because angels can take error-free care of 20 patients on a mandatory 16-hour shift, and they won’t even have to stop for a bathroom break. Angels live in heaven, so they don’t need good salaries to pay the rent. But real nurses need workplace support to foster their lifesaving skills—and they’re not getting that support now.”

Katharine Greider is a freelance writer in New York.