Nursing schools are being asked to graduate more students at a time when health care itself is becoming more complex.
New nurses are entering hospitals where many patients require more complex care, technology is changing quickly and staff shortages can make the transition from school to bedside harder.
Data from Virginia Department of Health shows Virginia has one of the lowest registered nurse-to-patient ratios in the country, with 10.5 RNs per 1,000 patients, while nursing programs nationally turned away more than 80,000 qualified applicants in 2020 because of limited faculty and clinical sites.
WHRO spoke with multiple nurse educators in Hampton Roads, who said the state’s nursing pipeline is being squeezed by several problems at once: not just limited faculty and training sites, but traditional program schedules that do not work for every student and gaps in how nurses are taught to apply research to patient care.
Expanding educational resources
Janice Hawkins, a nurse educator for over 30 years and vice provost for academic affairs at Old Dominion University, said one of the biggest challenges facing nursing education is preparing students for a health care system that is changing faster than nursing programs can easily adjust.
New nurses still need strong clinical skills, she said. But they also need to be comfortable with new technology, artificial intelligence and electronic health records used in patient care.
“Overall, I believe nursing education programs do a good job of preparing students with the foundational knowledge and skills needed to begin professional practice,” Hawkins said. “However, graduation is really just the starting point. No nursing program can teach everything a nurse will need to know throughout their career.”
That makes transition-to-practice programs, mentorship and lifelong learning especially important.
Another problem, Hawkins said, is that nursing schools are already trying to fit more into programs that she says can’t keep getting longer.
She said topics such as AI have to be built into existing case studies and clinical scenarios, rather than added as separate layers on top of an already packed curriculum.
And beyond curriculum, the physical limiters remain a bottleneck. Hawkins said many nursing programs have qualified applicants they cannot admit because they do not have enough faculty or clinical training sites.
The faculty shortage is difficult to solve because experienced nurses can often earn more by staying in clinical practice than by moving into teaching.
“I was a nurse, I was already employed, obviously I could pay my bills, so why would I want to switch over to be a faculty that a lot of times pays less?” Hawkins said.
Loan forgiveness and other financial incentives could help more nurses become educators, she said.
Hospitals could also play a larger role by partnering with schools.
One model is a dedicated education unit, where hospital staff help train students in a real clinical environment.
“One clinical model is a dedicated education unit where our staff that work on that floor actually serve as preceptors for our students, and students go to report on that unit like they're going to work,” Hawkins said.
Stronger evidence-based practice skills
Other nursing experts say the education challenge is not only about producing more nurses. It is also about making sure nurses can use research and evidence once they are in practice.
Pamela DeGuzman, a nurse scientist at Inova Health System, which serves Northern Virginia, said nurses need to understand evidence-based practice, or EBP.
That means using the best clinical expertise and patient needs to guide care decisions, rather than relying only on habit or personal experience.
For example, how nurses assess whether patients are at risk of falling and put certain interventions in place reflects how well they understand and apply EBP in practice, DeGuzman said.
She conducted a study published earlier this summer looking at the competency among acute care nurse leaders nationwide.
The results were lower than expected, with only 20.8% of nurse leaders demonstrating a base level of EBP knowledge.
“If you have low competency, you're more likely to overestimate your knowledge,” DeGuzman said. “That can be sometimes part of the issue, because people with this, people who lack competency, but think they're competent.”
She said low EBP competency does not mean nurses do not care or cannot perform clinical skills. But it can affect whether a hospital unit is using the protocols in the right way.
If not, that can spread nursing resources too thin and make it harder to focus on patients who need the most help.
Lynn Wiles, an associate professor of nursing at Old Dominion University, said DeGuzman’s findings should be read with some caution.
Though nurse leaders still need enough EBP knowledge, she said researchers and clinical nurse leaders have different responsibilities and skill sets.
“It's unfair to judge clinical leaders outside of their daily role,” Wiles said. “Nurse leaders and clinicians do not necessarily need to be expert researchers to be effective. They should have the ability to interpret evidence, lead implementation efforts, engage staff, and sustain improvements in clinical practice.”
What surprised her more was that the study found little difference between nurse leaders with bachelor’s degrees and those with master’s degrees.
Wiles said graduate-level nursing education should build on clinical experience and help those concepts “stick” more deeply.
Because of that, she said she would have expected nurse leaders with master’s degrees to score higher than those with bachelor’s degrees.
DeGuzman said nursing schools may need more objective ways to test whether students have actually mastered evidence-based practice, instead of relying only on course grades or group projects.
Traditional nursing programs may not fit every student
Some workforce leaders said the pipeline problem is also about who nursing programs are designed for.
Sam Dreyfus, executive vice president at ECPI University, said many people who want to enter nursing are not traditional college-age students. They are working adults, parents, veterans or people changing careers.
“Many of our students, our median age is 31 years old,” Dreyfus said. “Many of them have kids, they’ve gone to college before, they have stuff going on, they’re busy.”
But many nursing programs still follow fixed semester calendars and admissions processes that can create delays before students even begin nursing coursework.
Dreyfus said more flexible schedules can help those students stay in school, though nursing programs still need structure and standards.
“You can have standards in terms of what expectations you have for students to graduate from the program with, while also being compassionate to his life situation,” he said.
Dreyfus said ECPI tries to make nursing programs more accessible through year-round classes, flexible schedules that can better fit students balancing school with work or family responsibilities.
