Nursing Homes Fill the Skills Gap Left By Training Shortfalls, Accelerated Programs

While clinical leaders in skilled nursing facilities welcome new hires to their staff, many are seeing an influx of nurses with less real-world experience.

Nurses fresh out of school were unable to complete their clinicals on-site due to Covid, leaving students to learn as best they could in online skills labs and other solitary training, according to clinical leaders.

Some graduates had never laid hands on a patient until they were “in our world,” Cheryl Townsend, senior director of clinical education at Brickyard Healthcare, told Skilled Nursing News.

“They’re coming to us and they’re terrified because they’ve literally never had any experience outside the classroom,” Townsend said. “I can’t even begin to imagine what that would feel like a new nurse, never having seen a patient in the bed until now. They’re suddenly expected to have a few days of orientation and then take care of people.”

Megan Abbott, a GAPS Health nurse practitioner for Western North Carolina Baptist Home in Asheville, NC, equated dropping a new nurse into a post-acute care setting these past two years to a war zone.

“You pretty much are hitting the ground running and I believe that a lot [of new nurses] are more or less in survival mode, you know, coming straight in from being in school and going into something that really no nurses have experience in. This was all new to all of us over the past two and a half years,” Abbott said.

Early on in the pandemic, hospitals had to close their doors to nursing students looking to complete their clinicals, according to Jasmine Travers, assistant professor at NYU Rory Meyers College of Nursing. Travers was also a researcher for the landmark National Academies of Sciences, Engineering, and Medicine (NASEM) report on the nursing home industry.

“For the entirety of that spring semester of 2020, many nursing students across many schools did not have an actual site to do their last location. This is when you typically spend a large amount of time with a nurse, a certain amount of hours with the nurse, following their schedule, really learning the craft – that’s your transition from nursing student to novice nurse,” said Travers. “That was not able to happen.”

Nursing students are usually in school for four years before they can practice somewhere, Travers added, while some accelerated programs can get nurses on the floor within 12 to 24 months.

In-person rotation requirements usually add up to about 200 hours, according to Travers, although there isn’t a national standard.

“At the end of the day, we’re hurting,” Travers said of nursing schools. “The hospitals, the nursing homes and other sites now have to put more resources into training and filling in the gaps of that new nurse.”

On-the-job training and filling the gap

What did happen, Travers said, was more simulation, case studies and paper assignments for that spring 2020 semester. Such training “doesn’t really replace” in-person practical experience, she added.

“When the pandemic hit, there was a massive nursing shortage because they weren’t prepared for this huge influx of patients,” said Maggie Mullican, a GAPS Health nurse practitioner for Avalon Healthcare. “I know that a lot of nursing schools developed fast-paced nursing programs to get these people into the workforce as fast as possible.”

As a result, their clinical experience is being cut short because they’re pushed to “hurry up and start working,” Mullican told Skilled Nursing News.

Mullican said she has had to do some on-the-job pharmacology training with newer nurses. For example, one of her trainees de ella did not recognize when a patient was on a diuretic, a common drug prescribed to patients with heart failure.

“It’s hard work and it is a lot to remember, but I do see that education is a little bit lacking in the new nurses that are coming into the field,” added Mullican. “I think it’s just too fast-paced, and nursing is a very heavy, heavy program.”

Amie Barrio, director of nursing for Cascadia Healthcare, also noted that there’s “a very big learning curve,” with brand new staff managing processes that would have been commonplace prior to the pandemic.

About two in 20 new staff members knew the procedure to pass out medication while residents took their meals in a large dining room, Barrio said. Most were only familiar with handing out medication to individual rooms, where residents were taking their meals during Covid surges.

Some licensed practical nursing (LPN) programs in Oregon have been shortened from a year-and-a-half to nine months, Mullican added. Mullican, who worked as a nurse in Arkansas prior to her nurse practitioner position in Oregon, said the same thing was happening in that state as well.

Abbott said North Carolina LPN programs near her facility usually last one to one-and-a-half years, but there isn’t a set number of clinical hours needed in a medical setting; required hours can be anywhere between 300 to 400 hours, she said.

“It still doesn’t change the way nurses need to develop and learn; there’s important critical thinking pieces that are developed when you’re able to actually be in the clinical setting,” Travers said.

Travers hasn’t seen schools revert back to pre-pandemic clinical hour requirements and she is unsure if such alternatives will stick around long term. Schools must still move nurses along their path with available resources, but educators can’t keep this as a permanent model, she said.

No streamlined program, nursing home clinicals

There continues to be a definite lack of streamlined requirements – including clinical hours and timeline to graduation – for nursing school programs, according to Travers and Abbott.

The matter was further complicated when schools and nursing boards were asked to come up with clinical alternatives during the height of Covid.

“There was no uniformity,” said Travers. “Nursing schools structure their programs differently.”

Some programs, she said, have 200 or more clinical hours as a requirement. Even then, sometimes the student is with the nurse while other schools allow the nursing student to stay with administration.

Even pre-pandemic, nursing students didn’t spend a lot of time touring the nursing home setting, according to Travers. It’s “unheard of” for a nursing student to spend all 200 hours of his or her rotation in a nursing home.

Some schools and universities like NYU, Penn State and Villanova have started to incorporate a more robust nursing home experience as part of clinical rotations, but it’s not its own rotation — at most it’s one day out of the week.

It’s not a universal model, Travers said, but many nursing schools are trying to advocate for more nursing home hours as part of a student’s in-person experience.

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