How to Improve the Education to Practice Gap in Nursing

By Matt Phillion

ECRI recently revealed its Top 10 Patient Safety Concerns 2024 Special Report, an annual guide bringing attention to pressing patient safety concerns facing the healthcare industry.

The number one concern identified by the report is clinicians’ transition from education to practice. While employment prospects are strong—96% of new nurses find work, compared to 53% of new graduates in other fields—there is growing concern about how new clinicians transition from a learning environment to the bedside.

Without the right kind of preparation, support, and training, clinicians can run afoul in their practice. Studies show that newer clinicians:

• Lack confidence: Only 30% of new nurses reported they feel well prepared to practice on their own.
• Are working in an understaffed environment: In 28% of situations where a nurse enters an acute care setting, they are likely entering a unit nurses believe do not have appropriate staff on hand.
• Speak up less often: Just a third (33%) of new clinicians who worked less than a year in their work setting had voluntarily reported a safety event, where 50% of nurses with six to 10 years had made such reports.

“When I looked at this list, what stood out to me was that the real issue is we don’t have enough healthcare professionals at the bedside anymore,” says Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, chief nurse of Wolters Kluwer, Health, Learning, Research, and Practice business. “The fact that we don’t have enough people at the bedside anymore is really what’s creating many of these issues.”

Prior to the pandemic, the industry knew it could expect a wave of retirements in the near future, with the average age for nurses at the time in their early 50s. But what was unexpected was the number of nurses between 35 and 45 years old who would move into non-bedside roles so soon.

“Hospitals are struggling with the overall cost of healthcare, with the cost of medical devices and medications going up. We’re facing a shortage of the things we need as well as a shortage of people at the bedside,” says Woods.

A recent study from the JAMA Health Forum noted that we’re starting to see the total number of nurses improving, but the industry is still losing nurses at the bedside in acute care.

“The reason they’re leaving is the situation in acute care,” says Woods. “There’s not enough adequately trained nurses, and nurses can’t provide the care they want to provide, so they’re going into other areas, like ambulatory or community care, where they feel like they are better able to.”

Another result of the pandemic

In part, the lack of training is a remnant of the pandemic as well, Woods notes.

“What had been traditionally in-person education and training had to go virtual,” she says. “And because they couldn’t get into the clinical situations in the hospital to prepare, the preparation for new nurses was impacted. We need to prepare student nurses for the reality of practice they will face when they graduate.”

Specifically, Woods says, the training focuses on having nursing students being able to take care of two patients on a med-surg unit, for example. But the reality is nurses will care for four to six patients at a time.

“We’re doing a disservice by not adequately preparing them for the number of patients they’re going to see in reality,” she says. “We know they’re not practice-ready at an expert level. They’ve had simulation and clinical practice experience taking care of one to two patients. In the real practice world, they are thrust into taking care of four to six patients. So they will burn out in that first two years. A huge number of those newer nurses are leaving saying, ‘You just threw me into the frying pan.’”

This was a known issue before the pandemic, Woods explains, but it became clearer in the years that followed.

“We have to change how we orient new nurses and transition them into practice,” Woods says. “And this has to be solved as a collaboration between nursing education and nursing practice.”

Step one, Woods says, is to make sure the education is teaching these new nurses what they really need to know. And when they graduate, there needs to be a support system that is adequate to help them onboard and stay on board, she says.

“They really should be working with a preceptor, and going through a nurse residency program,” says Woods. “They currently go through a six- or 12-week orientation and then we let them fly, but it doesn’t work. Get them in a nurse residency program and working with a preceptor. Have someone work with them for six months to a year. Those new nurses stay. They feel like the organization has invested in their success and aren’t just throwing them into the frying pan.”

The fact, Woods notes, that just because you get someone through orientation or even their first year, that doesn’t mean they’re comfortable. A recent stat found that nurses with under two years of experience don’t feel qualified to practice by themselves.

“We have to make sure we have really good resources,” says Woods. “They need access to clinical decision support resources and people to answer questions and bounce ideas off of, creating a safety net.”

Access to expertise

For this, Woods points to the concept of virtual nurses. Virtual nurses became more commonplace during the pandemic, reaching out to ask patients how they were doing, but there’s now an opportunity to invest in these virtual nurses to connect new nurses with experienced professionals.

“All the new nurse has to do is press a button, and there’s an experienced nurse who can come on screen right in the patient’s room, with access to the patient’s medical record,” says Woods.

Providing resources like virtual nursing can be expensive, but so is the constant churn of replacing new nurses, Woods points out.

“Nursing is a great profession, but we see nurses are exhausted and tired. Our communities need to tell organizations to step it up and provide resources so these nurses will stay,” says Woods. “It’s important for communities to hold their facilities accountable.”

Healthcare, at the end of the day, is supposed to be there to serve the community, Woods says, and so the community needs to add its voice to what is needed and expected to help highlight these changes.

“But the majority of changes need to come from nursing education and practice centers and organizations. One side can’t do it without the other,” she says.

She also points out that a shift in focus from recruitment to retention is in order. It’s common to see signing bonuses to attract staff, but once they’re there, if the culture doesn’t foster a feeling that they are safe and supported, retention will suffer.

“It’s not recruitment bonuses we need, it’s promising nurses they will get an adequate orientation and once they’re part of the organization, you’re going to invest in them, so they never want to leave,” says Woods.

The risks of not addressing these pain points are clear, she notes.

“Nurses are going to continue to leave acute care, and we won’t have anyone left to care for our patients,” says Woods. “And when you don’t have adequately trained, competent nurses, research is very clear that people will die. You’ll see upswings in hospital-acquired infections, increased mortality rates. The bottom line is if we don’t fix these problems in practice by increasing the number of competent nurses caring for patients, you’re not going to have anyone left to care for your patients.”

Many of these challenges go beyond just nursing retention, Woods says. The issues of inadequate resources, lack of training, staff burnout—all of this impacts all healthcare clinicians.

“To improve, we really need to teach based on the reality of practice today,” says Woods. “If you’re not doing that, you’re going to have problems. Teach nurses in such a way that they can be successful.”

There’s also a necessity of acknowledging that new nurses are naturally not going to be at an expert level right out the gate; they are competent at a novice level and need time to prepare and learn to practice on their own.

“We need to support them for six months or a year and continue to support them with resources, so they don’t want to leave,” says Woods.

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.