Hospitals and clinics in rural areas are finding it increasingly difficult to hire nurses on their own, and the amount of referral fees they are paying to private agents are significantly on the rise, a recent research report shows.

To employ a full-time nurse the fees were about ¥870,000 ($8,100) on average in fiscal 2016, according to the report released by the Japan Medical Association Research Institute.

In the year that ended in March 2017, the total amount of fees paid by 844 medical institutions surveyed had ballooned to roughly ¥1.6 billion, compared with ¥1.1 billion in fiscal 2014, it said.