For the past 16 years, nurses have ranked at the top of Gallop’s poll of the most trusted and ethical professions. Nursing offers diverse career tracks and good pay relative to the amount of formal training needed. However, for over a decade now, the United States has experienced a nursing shortage. And it is expected to get worse in the very near future.

Cracks in the System

Americans are rapidly aging and increasingly afflicted with chronic illnesses that require long-term care. By 2030, 69 million Americans will be at retirement age or older. The CDC reports that six in ten Americans now have one chronic illness and four in ten have two or more. These two factors are fueling the need for more nurses who will provide care for a rapidly growing number of older and sicker patients.

Nurses are also aging, and about one-third of the nursing workforce will reach retirement age in the next 10 to 15 years. The Bureau of Labor Statistics projects that employment of registered nurses will grow by 15% from 2016 to 2026, partly due to the demand for health care services.

It would seem like an ideal confluence of events: as a generation of nurses retire and leave the workforce within the next decade, a new generation will take their place. However, nursing schools rejected over 56,000 qualified applicants in 2017 alone. Despite a need for more nurses, schools are unable to expand class sizes because they do not have enough nursing educators.

Without experienced faculty to train more nurses, the United States seems to be on the brink of a crisis. One with worrying effects on patient outcomes, patient safety, and the well-being of nurses.

Under pressure to cut costs, the 1990s saw many hospitals implement restructuring plans that increased nurse workloads, eliminated continuing education programs, and reduced the overall quality of care a nurse could provide their patients¹. By 2005, demoralized and overworked, nurses were leaving the profession faster than they could be replaced.

It would seem that we value nurses when they take care of us, and we show our appreciation when answering a poll. However, the facts reveal a contradictory story. Hospital administrators, in particular, seem to undervalue nurses which has created an ever-increasing shortage.

Despite renewed interest in the profession, there are now simply too few experienced nurses left to fill faculty positions in nursing schools. In addition, finding clinical space to conduct adequate hands-on training is also preventing nursing schools from accepting more students. Without clinical training sites, students miss out on valuable training hours.

As a result, the country now faces a perfect storm. In the next few years, the health care system will be overwhelmed with more patients who require more care than they did in the past. New nurses entering the profession will be thrown into a hospital environment where they have received little if any, training or mentorship by veteran nurses.

Ultimately, patient safety and outcomes may suffer. Avoidable mistakes may be made due to a lack of experience. The experience gap, a lack of essential hands-on clinical training, must be addressed to prepare the new generation of nurses for the challenges of the modern health care system.

The tools exist to provide clinical training and bridge the gap in training due to a lack of experienced faculty; one of those tools is health care simulation. Through the incorporation of said tools, nursing schools can better prepare their students to treat a vast array of patients. More graduates can replenish the nurses who have left the profession. With a new focus on bridging the experience gap, nursing schools can begin to steer us away from the storm.

The Experience Gap

Part of the challenge to solving the nursing shortage is finding qualified and experienced nursing faculty. The shortage has left about two teachers per nursing school or a shortage of over 1,500 teachers. Not only can schools not open up more classes, but clinical hours also have to be cut back.

Moreover, the problem is not as simple as hiring more teachers. Schools rely on the knowledge and experience a veteran nurse can offer students. Schools want students to be mentored by someone who can provide guidance beyond what they have learned from a textbook. This is why new nurses are rarely hired as faculty. They simply lack the clinical experience to be effective mentors.

Nurses who enter the workforce with little to no clinical training have fallen into the experience gap. They may have acquired a lot of knowledge in school, but have little experience putting that knowledge into practice or managing patients. As such, more mistakes are made, and patient safety is jeopardized.

Through clinical hours, nursing faculty strive to close the gap between knowledge and practice for their students, so they can increase the quality of care patients receive². A veteran nurse can pass on current knowledge and skills that are acquired in the field through practice. Unfortunately, more nurses have to learn on the job. Nevertheless, nurses can make more mistakes than they would have if they had completed clinical hours with a veteran nurse.

A lack of experience negatively affects a patient’s perception of a nurse. At best, the nurse is seen as incompetent, further adding credence to the stereotype that a nurse is simply a doctor’s assistant, so their medical advice does not matter. At worst, a patient ignores their treatment plan, or an avoidable mistake puts their life in danger.

A nurse must be both proficient on paper and in practice³. Meaning nurses must be able to confront clinical situations and apply what they have learned in the classroom to the care of their patients. Experienced nursing faculty will bridge that gap. They will train nurses, so they have thoroughly practiced their clinical skills before they enter the workforce.

Nursing is a practice discipline. Nurses must spend time in a clinical practice setting in order to hone their specific skill set and to re-experience the realities of patient care2. This will make them much better prepared to deliver quick and competent care and avoid costly mistakes.

However, practice cannot be separated from theory. Nurses need an understanding of physiology and medicine before they can go near a patient. Mastering both the theory and practice of nursing is critical to improving patient health and safety.

The nursing shortage has created an environment wherein too many nurses are falling into the experience gap. This means schools cannot fill vacancies in nursing faculty fast enough. Hence, fewer classes and clinical training hours are available. The vicious cycle repeats itself.

Thus, the challenge is to find a way of merging theory and practice in the delivery of nursing education and patient care⁴. Once a training method can be established, then one of the repercussions of the nursing shortage can be addressed. Furthermore, a solution to the shortage may go hand in hand with better training.

Closing the Gap

As nurses quit the profession or retire, the nursing-education system has not replaced them fast enough. Thus, nursing schools have less faculty, clinical training sites, and classroom space for students. Many people who want to enter nursing are simply shut out. Those who get in might find that their valuable clinical hours have been cut.

In order to face the influx of older patients with chronic conditions who will swamp hospitals in the next few decades, nursing schools must commit to increased training and clinical hours. By focusing on properly educating and training the nursing students we currently have, we can begin to gradually build-up the workforce and address the consequences of the shortage.

As these nurses fill in vacancies and become veterans of the health care system, they become more desirable to schools who look for experienced nurses. Consequently, nursing schools can fill in their vacancies, opening up more classrooms and clinical training sites to more students. Thus, more nursing students can be trained and enter the workforce and reduce the shortage.

The process of correcting the shortage begins with closing the experience gap. Recently, the National Council of State Boards of Nursing (NCSBN) reported that up to half of traditional clinical hours could be replaced with training done on nursing simulators.

Simulation training can help nursing schools provide clinical training that closes the experience gap and helps them replenish the nurses that have been lost. Another benefit of simulation is that it can be used to merge theory and practice as it allows learners to apply the skills they have learned in the classroom in a hands-on and safe environment.

As was stated previously, nursing is a practice discipline. Through simulation, students can rehearse how care is given in practice. Students learn how to make clinical decisions based on the knowledge they have acquired in the classroom, mastering medical skills and increase their competence in avoiding errors.

One of the factors contributing to the experience gap is the limited number of hospitals and clinics available where students can gain practical experience. As a result, many nursing schools have formed costly partnerships with local hospitals or colleges to fill faculty vacancies and for the right to use their facilities to train students.

However, these costs often get passed onto the students in the form of higher tuitions. Moreover, these partnerships are feasible in urban settings where nursing schools are near many large hospitals, leaving rural nursing schools with few options.

Even when these partnerships are possible, students still do not receive the full breadth of training because certain medical situations are rare. During their clinical hours, a student might never see a live birth or an emergency situation like shoulder dystocia. Additionally, patients are hesitant to be practiced upon, so students might only get the opportunity to watch a procedure.

Simulation allows nursing schools to train students in a variety of procedures and clinical situations from the common and low-risk to the rare and high-risk. Schools can also avoid the long-term costs of partnerships and harness existing resources and space.

Low-cost skills trainers, for example, can be used to hone a variety of nursing skills. Students can practice how to place an IV or draw blood, so they don’t cause patients pain. They can also listen to and identify normal and abnormal heart and lung sounds, so they recognize the symptoms of a serious ailment.

Skills trainers also allow students to practice lifesaving resuscitation skills like CPR and they receive feedback on the effectiveness of their technique. This way students know when they are performing CPR correctly and practice until the technique becomes second-nature.

A childbirth trainer like Super OB Susie can be used to develop a student’s diagnostic skills as they use her realistic birthing canal to conduct a vaginal exam, visualize cardinal movements and cervix dilation, and even identify when fragments of the placenta have broken off.

Students also practice how to respond to emergencies like shoulder dystocia, breech deliveries, and umbilical cord complications by learning how to perform suprapubic pressure or rehearse lifesaving maneuvers like McRoberts’ and Pinard’s. By practicing on simulators beforehand, nurses will be prepared to quickly and accurately respond to these emergencies.

Likewise, a full-body, high-fidelity patient simulator like Victoria can further help close the experience gap by offering students more possibilities for skills development. Victoria’s reactive eyes can blink, follow movement, and her pupils can dilate. As such, students can perform accommodation tests to identify common signs of neurological trauma like strabismus.

Hal’s advanced airway can be used to practice techniques like intubation, and sensors will indicate the depth of intubation. This feature is vital to help students realize when they are making a mistake and work to fix it. With a real patient, a mistake could cause them harm, but simulation allows for mistakes to be made and corrected without that danger.

What’s more, HAL’s streaming audio allows students to work on their bedside manner and become effective communicators with their patients and teammates. In fact, research has found that nurses who demonstrate genuine courtesy, kindness, and security in their interactions with patients are more likely to establish a good relationship with their patients. Therefore patients are more likely to follow a treatment plan. Furthermore, studies have shown the significant link between poor team communication and preventable medical errors, high nurse turnover rates, and low morale.

While these are just a few of the features that make HAL so impressive, they are vital features to help train nurses on how to treat patients. Without practical experience, nurses will enter the workforce expected to learn as they go. This opens them up to making more mistakes and adds stress to an already overworked workforce.

A lack of nursing faculty does not have to hinder a student’s development as a medical professional. Simulators can be operated easily and by the same faculty members that conduct lectures. In light of reduced clinical availabilities, students can still gain hands-on practice.

A Bridge to the Future

Simulation can bridge the gap between theory and practice. It can also work to close the experience gap. Many studies have shown that simulation-based medical education can improve knowledge and skills and, increasingly, improve patient outcomes⁵.

Now more than ever simulation is needed to help address the issues caused by the nursing shortage. America’s growing elderly population will need highly trained nurses to provide them with care. Unfortunately, a lack of experienced faculty has left many nurses with gaps in their knowledge.

By using simulation to promote experiential learning, nursing schools will produce professionals who are prepared to handle the challenges of an aging population. These highly trained nurses will be better candidates for faculty positions and replenish the shortage in academia.

America has been stuck in the same defeatist cycle for decades. Too few nurses means too few teachers and too little training. Simulation can bring an end to that cycle. People are once again optimistic about nursing as a profession, and within the next few years, we could see a turnaround in the shortage.

By using simulation to provide nurses with more clinical hours, we could reduce the stress new nurses feel when they enter the workforce because they will be prepared. This means less burnout for nurses and better standards of care for patients.

We can see the storm on the horizon. There are tools available to help prepare us for the oncoming health care needs of millions of Americans. If we truly value the work nurses do, then we must make sure they will be there when we need them the most.

1. Gordon, Suzanne. Nursing against the Odds: How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care. ILR Press, 2006.
2. Ajani, Khairulnissa & Salima Moez. “Gap between knowledge and practice in nursing.” Procedia: Social and Behavioral Sciences, 15, 4, 2011, 3927-3931. Pdf.
3. Ajani, Khairulnissa & Salima Moez. “Gap between knowledge and practice in nursing.” Procedia: Social and Behavioral Sciences, 15, 4, 2011, 3927-3931. Pdf.
4. Ajani, Khairulnissa & Salima Moez. “Gap between knowledge and practice in nursing.” Procedia: Social and Behavioral Sciences, 15, 4, 2011, 3927-3931. Pdf.
5. Bearman, Margaret, et al. “Simulation-based medical education.” Oxford Textbook of Medical Education, edited by Kieran Walsh, Oxford University Press, 2013, 186-197.