Future Nurses

In celebration of the annual observance of Nurses Week in May, we begin this issue’s editorial with cheers for all critical care nurses and a special shout out to members of the American Association of Critical-Care Nurses (AACN). As individuals and as members and leaders of health care teams, you improve outcomes for the patients and families for whom you care. Together, you enhance excellence in patient care through research and implementation of evidence-based practice and through promotion of healthy work environments to optimize contributions of all members of the health care team. Kudos to you!

As part of Nurses Week, May 8 is annually designated as National Student Nurses Day.¹  The recognition of student nurses is particularly resonant at this time. Nursing students are the next generation of nurses—they are future nurses. (We thank Dr Carol Biggs, Senior Vice President and Chief Nursing Executive, Jackson Health System, for introducing us to the term future nurses.)

The supply of nurses was in jeopardy before the COVID-19 pandemic. The average age of registered nurses was already over 50 in 2015, and loss of registered nurses to anticipated retirement indicated then that nursing shortages would continue through 2030.²  The pandemic has accelerated both nurse retirements and nurses leaving the profession before retirement age, and it has exacerbated long-standing issues related to nurse retention. Future nurses are crucial to replenishing and maintaining the nursing workforce. Neither future nurses (students) nor new nurses (entering practice) will have the knowledge or proficiency of experienced nurses. Fostering the development of future nurses and new nurses will facilitate their maturation into experienced nurses who can provide and lead the provision of high-quality, appropriately staffed nursing care. Because the proficiency gap between new and experienced nurses is especially evident in high-acuity care, we need to take special care to ensure that new nurses are able to thrive in acute and critical care.

Nursing students have faced substantial challenges during the pandemic, related to both their roles as future nurses and as college students.^3-6  In our January 2022 editorial,⁷  we cited research about negative effects of the pandemic among members of the health care team. Similar to practicing nurses, nursing students have experienced increased anxiety, depression, and sleep disturbances.⁶  They had concerns about their own safety, particularly in clinical settings. Many became ill, and many took responsibility for caring for family and friends. Students faced financial difficulties, housing insecurity, and food insecurity. These issues were a backdrop for significant disruptions in their educational experiences.

In a global survey of nursing education conducted by the International Council of Nurses, 73% of national nursing organizations around the world reported that nursing education was disrupted by the pandemic.⁴  Student nurses have struggled with abrupt, unanticipated, and often unwanted transitions to remote learning. Remote learning has presented unique problems for students with limited access to necessary technology, including computer hardware, software, and a reliable, fast internet connection. For example, students without appropriate technology who had to access virtual learning via cell phone with limited connectivity found it difficult to attend classes virtually and were unable to interact with learning platforms to download materials or submit required assignments. Research indicated that nursing students experienced moderate to extreme stress related to grades as a result of pandemic disruptions.⁸  Time-lines to graduation, licensure, and certification were uncertain and often extended beyond students’ original plans for reasons beyond their control.

Nursing education includes significant direct clinical experiences, and obtaining clinical placements was and has remained problematic. Early in the pandemic, a policy statement by the American Association of Colleges of Nursing urged health care organizations to view nursing students as members of the health care team and continue to involve students in provision of health care, limiting only their direct care of patients with COVID-19.⁹  However, clinical facilities faced multiple, wide-ranging concerns that led many health care organizations to suspend, reduce availability, or limit hours for clinical rotations. Examples of these challenges included staffing and staff burden during COVID-19 surges; lack of or rationing of personal protective equipment; concerns about staff, patient, and student safety before vaccines were available; redeployment of staff from elective care to COVID-19 care; and de-densification efforts that excluded nonessential personnel, students, and visitors from clinical settings. The International Council of Nurses survey reported that 46% of national nursing organizations experienced delayed or cancelled clinical rotations, and 41% experienced changes in the nature of clinical rotations (ie, limitations on types of patients or areas available for clinical placements).⁴ 

Despite adversity, the morale and commitment of future nurses and new nurses appear to remain high. Thematic analyses in recent research indicate that the pandemic has increased interest in and commitment to pursuing nursing as a career⁸  and that pride in the nursing profession and altruism continue to motivate commitment to nursing.³  Applications to nursing programs remain strong. In fall 2020, baccalaureate enrollments increased by 5.6%.¹⁰ 

It is imperative that we keep the pipeline of future nurses robust, successfully transition new nurses to the workforce, and facilitate the retention and professional growth of the next generation of nurses. As with nurse well-being, appropriate systems-level responses are necessary. The transition from nursing student to new nurse has always been stressful. However, the additional difficulties encountered by nursing students as a result of the pandemic amplify the challenges of transitioning to the role of new nurse.³ 

A culture where future and new nurses feel that they are part of a supportive interdisciplinary team is key.^11,12  A sense of belongingness from being part of a clinical cohort benefited nursing students during the pandemic¹³ ; inclusion as part of the health care team could convey similar benefits. In another study, new nurses feared making errors in patient care and recognized their need for guidance and continued skill development; they recognized benefit from membership in a supportive team.¹⁴  Supportive teams are friendly, helpful, and encourage questions. They embody the principles of a healthy work environment.¹⁵  Nursing faculty and experienced nurses who view students positively are essential as role models and mentors, but the support of physicians and every other member of the interdisciplinary team is also necessary. Focusing on nursing students and new nurses as contributors to the team (albeit less experienced) who add value fosters their professional and personal development and ultimately benefits the team. Viewing them as burdens that must be suffered undermines both the individuals and the team.

Developing and sustaining robust academic-practice partnerships benefits both future nurses and the agencies in which they will work. An academic-practice partnership builds formal, collaborative relationships between a nursing education program and a care setting. Such partnerships are well suited to responding to the pandemic.¹⁶  The American Association of Colleges of Nursing–American Organization of Nurse Leaders (AACN-AONL) Task Force on Academic Practice Partnerships articulated 8 key elements for the relationship.¹⁷  One shared commitment is for “partners to work together to determine an evidence-based transition program for students and new graduates that is both sustainable and cost effective….” Formal nurse residency programs have demonstrated success, but many were paused or closed during the pandemic. Reestablishing and expanding nurse residency programs is an important step in ensuring that new nurses will transition successfully. Similar programs that embed nursing students in clinical organizations are in development; such programs hold promise for smoothing the transition of future nurses to the role of new nurse.

As we celebrate Nurses Week and National Nursing Student Day, let us remember that the well-being of future nurses is important. The future of nursing, and of health care, will depend on their success.