695,000 Licensed Nurses Not at Work — The Structure of Nurse Attrition and the 7-to-1 Staffing Trap
Japan faces a paradox: a job-to-applicant ratio of 2.47x alongside 695,000 licensed nurses who are not practicing. This article dissects the 7-to-1 staffing standard that concentrates nurses in large hospitals, the diagnostic fee structure that suppresses wages, and a reality where 52.5% of new graduate resignations cite mental illness.
TL;DR
- Against 1.363 million active nurses, approximately 695,000 licensed but non-practicing nurses exist, sustaining a paradoxical shortage with a job-to-applicant ratio of 2.47x
- The 7-to-1 nursing staffing standard introduced in 2006 concentrated nurses in large urban hospitals, entrenching outflows from regional and smaller facilities
- 52.5% of new graduate nurses who resign within a year cite mental illness, and 96% report experiencing workplace harassment
- Diagnostic reimbursement as a regulated price functions as a ceiling on wage improvement, making market-based solutions structurally insufficient
What Is Happening
With 1.363 million active nurses and 695,000 latent nurses, a paradoxical shortage with a 2.47x job-to-applicant ratio persists
1,363,142. This is the number of active nurses as of the end of 2024. Compared to two years prior, the figure grew by 51,455 workers (3.9%)—a trajectory that, on paper, appears steady and encouraging.
But another figure stands alongside it: approximately 695,000. This is the number of latent nursing workers under age 65—licensed but not practicing. By that calculation, latent nurses equivalent to roughly 51% of the active workforce exist outside the system.
Active vs. Latent Nurses (2018 Estimate)
Barriers to Return
Source: MHLW Research Grant (2018 estimate) / MHLW Health Administration Report (end-2024)
The job-to-applicant ratio stands at 2.47x. Given that the all-occupation average hovers around 1.2x, the supply-demand tightness in nursing is exceptional. Workers exist, yet they are not in the field. This paradox is the core of Japan's nursing crisis.
Turnover data deepens the picture. According to the Japanese Nursing Association's 2024 Hospital Nursing Survey published in March 2025, the regular-employee nurse turnover rate peaked at 11.8% in FY2022. FY2023 showed a modest improvement to 11.3%, but new-graduate turnover remained at 8.8% — stubbornly elevated. The overall regular-employee turnover rate reaching 11%+ had not been recorded since 2005.
Background & Context
The 7-to-1 staffing standard concentrated nurses in large hospitals; diagnostic fee dependency entrenched chronic wage stagnation
The Demand Distortion Created by the 7-to-1 Staffing Standard
The "7-to-1 nursing" standard introduced in the 2006 diagnostic fee revision awards higher reimbursement to acute-care hospitals that deploy one nurse per seven inpatients. Designed to advance high-quality acute care, it generated an unintended structural side effect.
Acute-care hospitals competed aggressively to recruit nurses in order to maintain the 7-to-1 ratio. Nurses gravitated toward large institutions offering superior compensation and conditions. Regional hospitals and smaller facilities lost personnel in a structural drain that could not be reversed by individual hiring decisions alone.
Structural Changes Triggered by the 7-to-1 Standard (Introduced 2006)
Source: MHLW FY2024 Diagnostic Fee Revision / Japanese Nursing Association 'Hospital Nursing Survey (2024)'
The FY2024 diagnostic fee revision abolished the "Nursing Necessity B-category" for the 7-to-1 tier, tightening inpatient severity criteria. A new community-based medical ward classification at 10-to-1 staffing was introduced to accelerate acute-ward restructuring. A base-up evaluation fee was included—+2.5% in FY2024 and +2.0% in FY2025—but the overall fiscal room for hospital management remains tightly constrained.
The Wage Structure Anchored to Diagnostic Fees
Diagnostic reimbursement as a publicly regulated price functions as a structural ceiling on nurse wage improvement. Hospital revenue is defined by diagnostic fees revised by the government every three years; the revision margin determines the resource available for wages. Even when labor market competition intensifies, raising personnel costs without a corresponding fee increase is structurally difficult.
The average annual income of nurses in 2023 was 5,081,700 yen. The average base salary for a non-managerial nurse with ten years of experience was 250,380 yen per month. The gap relative to similarly experienced workers in other industries diminishes the incentive for licensed nurses to return to practice.
Hospital financial strain compounds the problem. Major university hospitals reported growing deficits in FY2024, with rising utility and medical supply costs consuming the headroom for wage increases. The dual pressure of improving treatment and maintaining operations is itself a product of institutional design.
The Ministry of Finance argued in the 2024–2025 revision debates that the current diagnostic reimbursement system "overweights structural evaluation that incentivizes generous staffing, inhibiting efforts to deliver high-quality care with leaner staffing," proposing a shift toward outcome-based evaluation.
The Triple Burden Eroding the Workforce
In a field characterized by intense emotional labor, psychological exhaustion has been quantitatively confirmed as a primary driver of resignation. Among new graduates who left within their first year, "health reasons (mental illness)" topped the list at 52.5% of responses (multiple answers permitted). "Anxiety about suitability as a nurse" (47.4%) and "anxiety about nursing competency" (41.6%) followed.
The harassment data is equally stark. A survey conducted by SOKKIN in September 2024 found that 96% of nurses reported that harassment occurred at their workplace; 64% said they personally experienced it; 42% resigned or considered resigning as a result.
Night shift burdens add another layer. The proportion of wards operating two-shift night schedules reached 48.4% in FY2023—an all-time high. Among nurses, 82.8% worked more than one hour of overtime per month on average, and 76.1% reported unpaid or early-start work (up 8.1 percentage points from the prior year).
Reading the Structure
The paradox of "many nurses on paper but too few in practice" stems from three layered structural contradictions in institutional design
Japan's nurse-per-population ratio exceeds the OECD average. According to OECD "Health at a Glance 2025," Japan has 12.2 nurses per 1,000 population, above the OECD average of 9.2. Yet shortages persist. Why?
Three layered structural contradictions explain the paradox.
The first contradiction is Japan's exceptionally high bed count. Japan's number of hospital beds per population ranks at the top among OECD member nations. Because more beds require more nurses per bed, aggregate nurse numbers are consumed by demand even when total headcount grows. Data published by the Japan Medical Association in 2021 illustrates this structural outlier status clearly.
The second contradiction is the burden transferred from physicians to nurses. Japan's physician-to-population ratio approaches the lowest among comparable OECD nations. A persistent structure in which nurses absorb tasks conventionally assigned to physicians means the effective workload per nurse far exceeds what the staffing ratio alone implies.
The third contradiction is the 695,000 latent nurses who remain outside the system. The four barriers preventing their return—anxiety over skills gaps, incompatibility with night shift schedules, distrust of hostile workplace environments, and slow wage improvements—are not individual obstacles but structural ones. The Nurse Center re-employment support program exists, but awareness and utilization rates remain low.
Forward-looking projections are severe. By 2025, demand for nurses is estimated at 1.88 to 2.02 million, against a projected supply of 1.75 to 1.82 million—a shortfall of up to 270,000. Meanwhile, the number of nurses working at home-visit nursing stations surged from 24,000 in 2002 to 68,000 in 2020, and demand continues to accelerate beyond 2025. As healthcare shifts from acute inpatient settings to community and home-based care, nurses need to migrate from hospital wards to home-visit settings—but the current staffing standard and fee structure provide insufficient incentive for this transition.
If real wages continue stagnating and the image of nursing as an undercompensated profession takes hold, enrollment in nursing education programs will also reach a ceiling. Population decline from falling birth rates applies further downward pressure on the supply pipeline over the medium and long term.
The problem is not "too few nurses" in a quantitative sense. It is a structural one: institutions consume nurses and then discard them, while license holders are unable to return. A revision of the Basic Policy on Securing Nurses—the first in thirty years—is now under discussion. What that revision must address is not a numerical hiring target, but a redesign of how society values and sustains nursing as a form of labor.
For further reading, 看護師という生き方(Life as a Nurse) by Azusa Miyako (Chikuma Primer Shinsho) offers a candid account of nursing as emotional labor — both its considerable demands and its distinctive rewards — drawn from 26 years of clinical experience. The book raises questions that are directly relevant to understanding why skilled nurses leave the bedside, and what institutional conditions might make staying viable.
Related Columns
- The Structure of Japan's Care Worker Crisis — The 'Invisible Roadmap' to 2040
- Healthcare Cost Crisis 2030 — A Structural View of Expenditure
- Thirty Years of Real Wage Stagnation — Industry-by-Industry Comparison
References
2024 Hospital Nursing Survey Report (Research Report No.101) — Japanese Nursing Association. Japanese Nursing Association
Status of Securing Nurses (Reference Materials for the 195th Employment Security Subcommittee) — Ministry of Health, Labour and Welfare. Ministry of Health, Labour and Welfare
Factors Influencing Nursing Workforce Supply-Demand Estimates Responsive to New Working Styles (Subproject Report) — MHLW Research Grant Program. National Institute of Public Health
Nurse Harassment Survey — SOKKIN Inc.. PR Times
Health at a Glance 2025 — Nurses — OECD. OECD
FY2024 Diagnostic Fee Revision — Japanese Nursing Association. Japanese Nursing Association
