Clinical Training for Nursing Students Sidelined

Health-care workers are needed now more than ever, but obstacles to completing clinical education hours risk delaying graduation for thousands of nursing students in California. Many hospitals and other health-care facilities where students complete their clinical rotations have suspended these programs for students as the facilities respond to the COVID-19 pandemic.

The presidents of the California Association of Colleges of Nursing and California Organization of Associate Degree Nursing wrote to Governor Gavin Newsom last week asking for relief from a state requirement that nursing students complete 75 percent of their clinical hours in a direct patient care setting. The letter asks Newsom to issue an executive order giving nursing colleges flexibility to use simulations and online education models to enable students to fulfill their clinical hour requirements.

Newsom’s office referred a request for comment to the California Department of Public Health’s public affairs office, which said via email that the department had not yet made a decision on the issue.

A spokesperson for the California Board of Registered Nursing, which is known as the BRN, said via email that the board "is not contemplating curriculum changes for nursing students. BRN continues to monitor developments in the current public health crisis caused by COVID-19 and is continuously reviewing our operations and requirements."

Maryann Alexander, the chief officer of nursing regulation at the National Council of State Boards of Nursing, said there’s scientific evidence to suggest that students can do up to 50 percent of their clinical coursework via simulated methods without it affecting educational outcomes.

"To say 75 percent has to be face-to-face" is an outdated policy, said Sharon Goldfarb, the dean of health sciences for the College of Marin in Northern California. "These rules were written so many years ago."

“Let’s be practical about what do students need, what California needs, and let’s open things up a little bit,” said Goldfarb, who is also president of the northern division of the California Organization of Associate Degree Nursing. She surveyed nursing schools in the state and found that many had more than half their students displaced from clinical sites because of the coronavirus pandemic. Some schools reported that 100 percent of their students were displaced.

“We have this global pandemic, and the board is continuing to stick to antiquated regulations,” said Scott R. Ziehm, the president of the California Association of Colleges of Nursing and a professor and associate dean for prelicensure programs and accreditation at the University of San Francisco’s School of Nursing and Health Professions.

Absent relief from the 25 percent cap on simulated instruction, “we won’t be able to graduate individuals with associate degrees or baccalaureate degrees eligible for licensure,” Ziehm said. “We’ll be reducing the R.N. workforce if we adhere to their mandate. It’s literally going to put a freeze on any progression for all the students who are their last year.”

Joanne Spetz, associate director of research at the University of California, San Francisco's Healthforce Center, said potential graduation delays could affect up to 14,000 students expected to graduate from entry-level nursing programs this year.

Ryane Panasewicz, who is in her last 12 weeks of a bachelor of science in nursing program at West Coast University, started an online petition calling for the BRN to soften its restrictions on simulated learning. The petition had more than 70,000 signatures as of Sunday morning.

“A couple weeks ago, I signed a contract with Duke University Hospital. I was like yes, I’ve got a job, nothing can stop me now,” said Panasewicz, who is eager to get to work helping confront the pandemic. “I worked so hard to get that job. It’s my dream job, and it was like it feels like it’s being taken away from me. I’m doing all I can now, but it feels like the BRN is completely disinterested in having me licensed.”

The cancellation of clinical education opportunities for nursing students by hospitals and other clinical sites has caused stresses at nursing schools nationwide. Ann H. Cary, chair of the Board of Directors for the American Association of Colleges of Nursing and dean of the Marieb College of Health and Human Services at Florida Gulf Coast University, said nursing colleges are seeing a range of responses from their clinical partners.

"We're seeing clinicals cancel student rotations; we're seeing clinicals asking students to remain because they consider that students could be part of their workforce," she said. "And interestingly enough, they want to hire students as patient care technicians, so even though they may be excluding them as students, they want to hire them as patient care technicians in some areas because of their own workforce needs."

"For us on the other end, the question is how do we graduate a workforce when we've had disruption in our educational process," Cary said. "The accreditors and licensing agencies are still trying to figure out how they're going to respond."

Cary said there's a need for innovative solutions. "We've got to figure out how to deepen those simulation experiences," she said. "The second thing is we have to consider whether or not we're going to give students more time when we are able to get back into clinicals to do some intensified clinicals. We're not there yet because we don't know when this is going to end."

Cary said nursing colleges and state licensure boards all want to protect the health of the public.

"What we don't know are what are the pathways that are acceptable that would still ensure protecting the health of the public for the new graduates that are coming out under very different circumstances. Could there be a required residency, for example? So a student graduates, an agency hires them, but they hire them with a residency, an intensive supervised experience?"

Alexander, the chief officer of nursing regulation at the National Council of State Boards of Nursing, said some states are trying to get waivers and exceptions to existing rules on clinical education requirements, but that is a time-consuming process that may not yield immediate results.

In the meantime, she said the NCSBN is working on a partnership with the Department of Veterans Affairs to open up new clinical placements for nursing students to work as student nurse technicians in VA health-care facilities.

"They would be paid, but they would also get academic credit for it, so they would be helping the VA meet their mission of assisting in a national crisis and they would get academic credit and it would fulfill their needs for clinical hours," she said.

Nursing students are not the only ones whose clinical rotations have been disrupted. Alison Whelan, chief medical education officer of the Association of American Medical Colleges, pointed out that hospitals are dealing with a national shortage of personal protective equipment, known as PPE, that medical residents also use during their specialized training

"Right now, the majority of our hospitals and medical schools are really trying to focus on containment and limiting spread. For that reason they've taken the students off of clinical locations to preserve PPE and to limit the total number of people within their buildings to really try to limit spread," she said in a virtual press conference Thursday. Whelan said medical schools are redeploying students in various ways to help in a strained health-care system, including by having them help staff phone lines for telehealth services, and using medical students to check in with postoperative patients and patients who have recently been discharged from hospitals.

"I want to recognize that there are portions of our country that are beyond containment that are really facing a surge, and we recognize that if there is a surge of cases potentially combined with limited health-care professionals, that there may need to be a rethinking of how to use medical students, bringing them back to the front lines," she said. "We are working with our medical schools in developing principles and guidelines for this. The rapidity with which our medical schools are responding and how we are assisting them exceeds anything any of us have experienced."