challenges in nursing education

7 Key Challenges Faced by Nurse Educators Today

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America is in the middle of a severe and long-standing nursing shortage. It is threatening the supply of registered nurses. The shortage has also affected the number of clinical preceptors and nursing faculty who prepare nursing students.

Nursing school enrollment cannot grow fast enough to meet the projected need. The shortage of nursing school faculty members has also limited enrollment numbers.

Nurse educators often are active clinicians, which is important to maintain quality nurse teaching . However, this also places a strain on educators with higher workloads, forcing them to work short-staffed in practice and education.

These stressors have led to a crisis in the profession. More nurses and nurse educators are seeking positions outside of nursing and feel less committed to their profession than in the past.

We interviewed several influential nurse educators who shared the challenges they face. We also explore the changes needed to improve the system and how nurses can advocate for those changes.

Nurse Educators Face Challenges Due to Nursing Shortage

The nursing shortage is expected to worsen as the baby boomer generation ages and more nurses retire. According to the American Association of Colleges of Nursing (AACN), faculty staff shortages limit student capacity at a time when growth is necessary.

There is a critical need to increase the number of nurse educators to meet the demand, but nurse educators are also under a lot of stress. To retain experienced educators and preceptors, it’s important to support their efforts.

Many challenges affect educators today. Nurse educators identified the following challenges that affect their ability to nurture and educate the future generation of nurses.

1. Lack of Resources

Nurse educators are well aware of a faculty shortage in programs around the country.

• Schools were forced to turn away 80,407 qualified students from undergraduate and graduate programs in 2019. This is an increase from the 68,000 turned away in 2014.
• In one survey of 892 nursing schools, 1,637 vacancies were identified. There is also a need to create an additional 134 positions to accommodate the rising demand.

Erica Jastrow has been a nurse educator for over 17 years and sees firsthand the lack of human resources in nursing facilities.

“In some schools,” she says, “faculty members manage all aspects for the nursing program from admissions, to advising, to instruction.”

This lack of human resources places additional stress on stretched-thin faculty members with limited time and resources. In addition to the faculty who have reached retirement age, other nurse educators are leaving the profession, furthering the issue.

Anne Dabrow Woods has witnessed and experienced the challenges facing faculty. She teaches in the graduate program at Drexel University and says it is imperative we address the issues faced by educators today.

Woods says we must:

• Increase nurse educator salaries and pay them what they are worth
• Provide learning opportunities for adjunct faculty
• Use academic and practice partnerships to develop and fund adjunct faculty programs.

2. Curriculum Challenges

Sherri Wilson, DNP, is the director of health career programs at Stride, a provider of tech-enabled education programs. She identifies several curriculum challenges that impact new nursing students and teaching faculty.

Students must overcome several barriers just to enroll in nursing programs. Once accepted, they face additional challenges to succeed in the program. Some students don’t have the tools they need, and others may not understand what the career involves.

Wilson suggests starting early by offering ways high school students can prepare for a nursing career . Students may learn more through classwork, clubs, mentorship, or dual enrollment.

“The sooner we can introduce students to the prerequisites, requirements, and opportunities in nursing and nurse education, the better,” she says.

Nurse educators also face curriculum challenges. Most programs are seeking faculty with doctorates. According to the Special Survey on Vacant Faculty Positions in 2019 reported by the AACN, 89.7% of faculty openings required or preferred a doctoral degree.

Wilson notes that doctorates are either research focused or clinical focused. Yet most programs do not include substantial academic coursework to prepare graduates for a teaching or faculty role, she says. It is necessary to reevaluate the curriculum used to teach future teachers.

3. Representation in Faculty and Training

Wilson also seeks representation of different cultural backgrounds in faculty and preceptors. A recent AACN study found that 93% of full-time faculty were female, and only 17% were from underrepresented groups.

“A more diverse nursing faculty can help to broaden the perspectives of nursing students and can provide sources of mentorship for minority nurses,” Wilson says.

The recent Future of Nursing Report 2020-2030 explored how the profession could develop different curricula. The goal would prepare nurses to reduce health disparities and inequities, like how nurses can address disparities in infant mortalit y, by using cost-effective strategies. These include technology and maintaining patient- and family-focus care.

To address these issues, there needs to be better representation in nursing and cultural competence in nursing . With a diverse workforce, nurses can serve communities better by understanding and identifying the social determinants of health.

“Finding ways to connect more nursing students to learning opportunities in the communities they serve will empower them to work with people of different backgrounds and from various life experiences,” Wilson says.

4. Fostering and Maintaining Student Relationships

Student-teacher relationships are important from elementary school through graduate school. They lead to:

• Academic achievement
• Increased motivation to learn
• Professional student development

Yet, stressed and overworked faculty often have little time to build constructive and authentic relationships with their students.

The lack of student-teacher relationships may have an unfortunate trickle-down effect on some students’ future career development. It could discourage students from furthering their education and choosing a career as a nurse educator.

Strong student-teacher relationships can help bridge the gap and support students’ efforts. Some students are working in healthcare while completing their education. Mandated hours or extra shifts are obstacles to completing assignments, maintaining grades, and attending class.

“Showing a student that you care about them and are there to support them may make the difference between a student who drops out or fails in the program and one that is successful,” Jastrow says.

5. Pay Inequality

Pay inequality in nurse educator roles is a significant obstacle to attracting new faculty. According to the U.S. Bureau of Labor Statistics , the median salary for a nurse educator is $75,470.

Nurses with comparable education levels make far more than nurse educators, with nurse practitioners making $114,510 annually , on average. This pay deficit causes master’s- and doctoral-level nurses to not pursue nurse teaching.

It is crucial that the compensation for nurse educators match their experience and education. This will help to attract quality faculty to nursing programs.

H. Eva Hvingelby is a faculty member at Walden University and clinical advisor at Optum. She sees the challenges with pay inequality and the need for immediate change.

She says that higher educator pay and smaller teacher-to-student ratios will make training new nurses more attractive to clinicians. But these adjustments will not come easily.

“While it is difficult to implement these changes when there is already an acute shortage,” she says, “not doing so risks further loss of capable personnel, worsened patient outcomes, and higher healthcare costs.”

6. Lack of Preceptors

Nurse educators and nursing students are impacted by the lack of preceptors available to nursing students. The nursing shortage has meant that many nursing units work short-staffed with higher than normal staff-to-patient ratios.

Nursing preceptors are a guiding hand and a steady voice for nursing students. When there is not enough available or low staffing, it can impact the quality of a nursing student’s education or new nursing graduate.

Tony Anno is a core faculty member at Walden University. He says online and traditional classroom learning face challenges from the restrictions and lack of access to clinical sites and preceptors.

However, nursing programs have a role in addressing the shortage in innovative ways.

For instance, Anno notes that Walden University has identified areas where students could complete some or all of their clinical hours using telehealth nursing services .

7. Lack of Opportunity to Update Knowledge and Skills

The nursing shortage in academia and clinically has stretched nurse educators’ resources thin. Nurse educators do not have the time to update their knowledge and skills.

This lack of opportunity was the most frequently described frustration for clinical nurse educators in one study. Additionally, this can contribute to the rising levels of nursing burnout as it contributes to nurse educators’ acute and chronic stress levels.

One study confirmed what most nurse educators know: Nurses value professional development and believe it is integral to improving patient care standards.

Access to continuing education for nurses to update knowledge and skill levels helps maintain high standards of care. This is essential when educating and training the next generation of nurses.

“Universities, as well as hospital systems and other healthcare providers, should look for ways to continually upskill their existing workforce and faculty on the latest practices and technologies,” Wilson says.

Wilson stresses the need for continued education and skill development in the face of rapidly changing technology. Nurse educators are expected to possess these skills to advance quality and address emerging needs.

What Needs to Change and How Nurses Can Get Involved

Despite challenges during the pandemic, turning away thousands of qualified candidates, and a shortage of nurse educators, enrollment in nursing programs across the country was up by 5.6% in 956 programs surveyed. However, significant changes must be made to raise enrollment and fill open nursing positions.

The pandemic has highlighted long-standing issues in healthcare that have contributed to the nursing shortage. Wilson says nurses are currently “uniquely positioned to become involved in the policy process to advocate for resources to address this complex issue.”

Woods believes the answer lies in innovation, perseverance, and resilience.

“Given this landscape, investing in learning technologies is no longer a ‘nice to have’ for nursing education but truly essential,” she says.

With the increased adoption of educational technology, we will also see a shift in funding to address previous hurdles that nurse educators faced in accessing these technologies, Wilson says.

What Needs to Change to Increase the Nurse Educator Retention Rates

• Bridge the wage gap between clinical roles and educators, so salaries align with other nurses holding graduate and doctoral degrees.
• Reduce teacher-to-student ratios to improve education and make the nurse educator role more attractive to clinicians.
• Better prepare nurse educators in their master’s or doctoral programs with academic coursework to prepare them for a teaching role.
• Increase human resource support for admission and advising so faculty can focus on teaching.
• Value the time and effort necessary to foster better student-faculty relationships, which improves a student’s education and faculty job satisfaction.
• Provide recognition for faculty members within the nursing program.
• Offer nursing scholarships that encourage students to pursue positions as nurse educators.
• Improve clinical working conditions, staff ratios, and work-life balance for nurses and nurse educators.
• Give faculty the opportunity and time to update their knowledge and skills.
• Partner academic centers with healthcare systems to develop adjunct faculty training programs.
• Invest in better mental health resources for nurses and nurse educators.
• Invest in innovation technologies.

Nurse educators can advocate for change and promote ways for nurses to effect change in their profession. They can provide information and perspective from professionals working in the field through taking advantage of professional nursing associations and advocacy groups.

Often involvement does not require hours of time and energy but rather phone calls and emails to state legislators to support or defend policy change.

Nurse educators may also consider working with the administration in their program to use creative strategies to meet the needs of the students and faculty.

It can be challenging to push for change. Yet, many colleges and universities are now recognizing the need for innovation to reduce the nursing shortage and attract qualified nurses as teachers and faculty.

Meet Our Contributors

Sherri Wilson, DNP

Sherri Wilson oversees the development and implementation of curriculum and partnerships in the healthcare field as director of health career programs at Stride, Inc. – a provider of tech-enabled education programs. Prior to joining Stride, Wilson served as a public health administrator with Fairfax County.

Wilson earned her doctor of nursing practice from Johns Hopkins University, a master’s in public administration from Seton Hall University, and a bachelor of science in nursing from Hampton University. In 2021, Wilson was named president-elect of the Virginia Nurses Association.

Erica L. Jastrow, Ed.D., MSN, RN, CNE

Erica Jastrow has been a registered nurse for over 20 years and a nurse educator in higher education for over 17. She has led several prelicensure nursing programs and currently serves as an assistant professor and RN-to-BSN program director at William Peace University . She has a BSN from Lenoir Rhyne University, an MSN in nursing education from UNC-Greensboro, and a doctorate in education from Grand Canyon University.

Tony Anno, DNP, ACNPC-AG, AGACNP-BC, CCDS, CEPS, RDCS, FHRS

Tony Anno is a core faculty member in Walden University’s master of science in nursing program. Anno currently practices in cardiology/electrophysiology at the Kansas City VA Medical Center and volunteers as the sole provider for Health Partnership Clinic. The clinic provides healthcare to patients regardless of income or insurance status.

Anno is certified by the International Board of Heart Rhythm Examiners as a certified cardiac device specialist and certified electrophysiology specialist. He is also a registered cardiac diagnostic sonographer.

H. Eva Hvingelby, Ph.D., ACNP

H. Eva Hvingelby is a faculty member in Walden University’s master of science in nursing program and a clinical advisor for Optum. She has 21 years of experience as a healthcare clinician. In addition, she spent seven years with the federal government researching and supporting outreach to marginalized populations. Hvingelby consults on strategies to improve clinical communication and collaboration across disciplines.

Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN

Anne Dabrow Woods is the chief nurse at Wolters Kluwer, Health, Learning, Research and Practice . She drives the strategic development of evidence-based solutions for nurses and nursing institutions. A nurse for over 37 years and a nurse practitioner since 1998, Dabrow Woods currently practices as an acute care/critical care nurse practitioner at Penn Medicine, Chester County Hospital. She also teaches in the graduate nursing program at Drexel University as clinical adjunct faculty.

Dabrow Woods earned a bachelor’s from West Chester University, a master’s from LaSalle University, a postmaster’s certificate from Drexel University, and a doctor of nursing practice from Texas Christian University. She is also a fellow in the American Academy of Nursing.

Page last reviewed December 16, 2021

Addressing the Current Issues in Nursing Education

The progress and advances in nurse education have constantly been shaping the way nurses advocate for their patients and provide optimal patient care. Historically, the nursing program has faced different challenges, such as standardizing the approach to teaching new nurses and improving the status of nurses from merely following orders to being primary collaborators in ensuring patient safety and care.

Still, in recent years, the field of nursing education has faced numerous challenges that need to be addressed to ensure the delivery of high-quality programs, allowing the facilitation of effective clinical learning. In this article, we will explore the current issues in nursing education and discuss potential solutions to overcome these challenges.

How Did the Pandemic Influence the Educational Programs for New Nurses?

The COVID-19 pandemic has presented various challenges and opportunities in healthcare and public health systems, reshaping different aspects of training for future health professionals, including nursing and medical education.

Higher education institutions shifted to remote learning to ensure the delivery of clinical knowledge and sustain the nursing workforce pipeline while ensuring the safety of students. Still, it posed a challenge in adapting teaching methodologies and providing remote care delivery.

With the need for social distancing and limited access to healthcare facilities, students have faced difficulties in gaining practical skills and hands-on clinical experience. A number of students also faced another setback in receiving their education, as financial cutbacks due to the pandemic have been rampant during its peak.

However, the pandemic also taught valuable lessons and reshaped how nursing programs are delivered.

The pandemic highlighted the need for innovation in nursing education, including developing and testing new learning and assessment methodologies, particularly for virtual learning and care delivery, to maintain a good quality of education. It also emphasized the need for nursing education and practice to collaborate to ensure that students and practicing nurses are prepared to address emergencies, pandemics, and the needs of vulnerable populations.

Challenges in Providing Good Quality Nursing Programs

Universities should ensure several key elements to promote the delivery of good quality education that prepares students for success in becoming registered nurses , such as the presence of qualified faculty, comprehensive student support services, technology integration, and provision of experiential learning. However, delivering high-quality nursing programs faces several challenges, including:

Accessibility Due to Location and Economic Challenges

Location and economic challenges pose significant obstacles to providing effective nursing education.

Rural and remote areas may lack proximity to academic institutions offering nursing programs, leading to limited access for individuals residing in these regions. Limited public transportation and inadequate infrastructure in certain areas can hinder students' ability to commute to educational institutions offering nursing programs.

However, even with the advent of remote learning, certain regions still have inadequate access to technology and the internet, impeding students' participation in online or distance learning nursing programs and limiting educational opportunities.

Economic challenges, including limited financial resources, may prevent individuals from pursuing nursing education due to the costs associated with tuition, textbooks, and living expenses. Some individuals may also be compelled to prioritize employment over education, making it difficult for them to commit to full-time nursing programs, especially if they need to support themselves or their families.

Shortage in Qualified Nurse Educators

Vacant faculty positions can lead to larger class sizes, increased workloads for existing faculty, and potential limitations on mentorship and personalized instruction for nursing students. The shortage can restrict the capacity of nursing programs to admit and educate a sufficient number of students, exacerbating nursing shortages in the clinical workplace and limiting access to nursing education.

Similarly, a deficit in nurse educators can also hinder the ability of academic institutions to conduct and disseminate nursing research, limiting the integration of research-informed teaching practices.

Accommodating Cultural Diversity in Nursing Education

In an increasingly diverse society, it's important for nursing education programs to be culturally sensitive and inclusive. Nurses interact with patients from various backgrounds, and it's essential to provide education that prepares them to deliver culturally competent care.

Fostering an environment that respects and celebrates cultural differences while promoting inclusivity and understanding requires intentional efforts and ongoing cultural awareness. As such, nursing schools should incorporate cultural competency training into their curriculum and ensure faculty members are well-versed in diverse cultural practices.

Merging Technology and Clinical Practice for Compassionate Care

Advancements in technology have the potential to revolutionize nursing education and can no doubt provide a lot of benefits for students and educators alike. For example, integrating technology into clinical practice can enhance students' learning experiences and improve patient care. Virtual reality (VR) simulations can provide students with realistic scenarios to develop critical thinking and decision-making skills.

However, integrating technology while maintaining a focus on compassionate, patient-centred care requires a delicate balance and the development of specific educational approaches to ensure that technology enhances, rather than detracts from, the human connection in nursing practice.

Similarly, addressing the ethical and legal implications of technology use in nursing practice, including issues related to patient privacy, informed consent, and the ethical use of health information technology, requires specialized education and training. Comprehensive training on the use of advanced medical equipment and healthcare technologies also requires access to cutting-edge resources and ongoing faculty development to keep pace with technological advancements.

Constantly Evaluating and Updating the Nursing Curriculum

Constantly evaluating and updating the nursing curriculum poses several challenges for providing effective nursing education.

Healthcare is continually evolving, and rapid changes in practice, technology, and policy require agility in updating the curriculum to keep up with current trends , which can be challenging to achieve while maintaining educational coherence. However, the continuous evaluation and updating of the nursing curriculum require substantial time, expertise, and financial resources, which can strain academic institutions, particularly those with limited budgets.

Similarly, striking a balance between retaining foundational nursing knowledge and integrating new technologies and evidence-based practices requires careful consideration and consensus-building among faculty and stakeholders, all while taking measures to ensure that accreditation and regulatory requirements are met.

Addressing Challenges in Clinical Education and Other Aspects of Nursing Education

Addressing challenges in nursing education requires ongoing collaboration, investment, and innovation to ensure the delivery of high-quality education that prepares graduates to meet the complex needs of modern healthcare systems. Here are some ways to overcome such challenges:

Offer Scholarships or Financial Aids

Many students face financial constraints when pursuing clinical education. Offering scholarships or financial aid for clinical placements can alleviate this burden and ensure deserving students have equal access to valuable learning experiences. Educational institutions should explore opportunities to expand their reach through online programs and partnerships with local healthcare organizations.

Hire Additional Staff to Ease Administrative Duties of Nurse Educators

Nurse educators often have heavy administrative responsibilities, which can limit their availability for clinical supervision. Hiring additional staff to assist with administrative tasks can help nurse educators focus on providing quality clinical education to students, where they're effectively imparting relevant clinical skills and knowledge to their students.

Bridge the Pay Gap for Nurse Educators

The compensation for nurse educators often lags behind that of clinical nurses. Addressing the pay gap is important to attracting and retaining experienced nurses in academia and preventing them from considering their return to the bedside.

Competitive salaries and benefits packages can incentivize nurses to pursue teaching careers and enhance the quality of clinical education. Additionally, mentorship programs and professional development opportunities can also help nurture and retain nurse educators.

Invest in Technologies that can Help Teach Students Effectively

Incorporating innovative technologies, such as simulation labs and electronic health records, can enhance the effectiveness of clinical education. These tools provide students with a realistic learning environment and promote critical thinking and decision-making skills.

Consider Inter-Professional Education

Collaboration among different healthcare disciplines is essential for effective patient care. Introducing inter-professional education opportunities during clinical placements can help nursing students understand the roles and responsibilities of other healthcare professionals, fostering teamwork and enhancing patient outcomes.

Promote Academic and Practice Partnerships

Collaboration between academia and healthcare organizations is important to address the challenges in nursing education. Establishing partnerships can provide students with a broader range of clinical experiences and ensure that the curriculum aligns with the needs of the healthcare industry. Academic institutions should actively seek partnerships with healthcare organizations, offering mutually beneficial opportunities for both students and healthcare providers.

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Addressing the current issues in nursing education is essential for the future of healthcare. To achieve this, it's important for nursing schools, healthcare organizations, and policymakers to work together to ensure the delivery of high-quality nursing programs that meet the evolving needs of the healthcare industry.

At Caring Support, we aim to help post-secondary institutions provide continuous student support throughout their careers, eventually facilitating student success in landing meaningful internship programs, volunteer opportunities, and ideal workplaces. Contact us to learn more about how we can help you empower your students to make a positive impact on the lives of patients and communities.

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Current Trends and Challenges in Nursing Education

Over the past few years, nursing and healthcare have undergone various changes. Due to these changes, the current trends and challenges in nursing education have been brought to the forefront, reshaping how nurses are trained and prepared for their roles in healthcare. Adapting to the current trends and challenges in nursing education can be overwhelming. Still, the responsibility does not fall on the nurse educator alone but on the healthcare industry as a whole.

Current Trends in Nursing Education

The changing roles and the current trends in nursing research are at the helm of what influences the trends in nursing education. Nursing schools and nurse educators must adapt to new technologies and advancements. The current trends a nurse educator needs to focus on include the following:

• Understanding data collection and analysis : Healthcare is shifting its focus to a preventative style of medicine. To help monitor proper management, researchers collect and analyze data to create quality measures. Nurses must understand this skill to provide quality healthcare to their patients.
• Evolving workplaces : Nurses don’t just work in hospitals anymore . The role is continuously changing, and they are working from home, in research institutes, and on cruise ships. The possibilities are endless!
• Lifelong learning : Nursing and healthcare are constantly evolving. Nurses must be current with the trends in nursing research and base their care on evidence-based practice. So many educational opportunities are available, and nurses are encouraged to participate.
• Telehealth : The pandemic skyrocketed the use of telehealth resources, and virtual care is not slowing down. Nurses must be fluent in this new communication style between healthcare providers and patients.
• Online education : With the lack of nurse educators and the flexibility of online learning, many nursing programs are utilizing virtual and hybrid educational styles. Since the development of more realistic simulation technologies , nursing students can easily transition into a real healthcare environment.
• Global health and disaster preparedness : The pandemic also emphasized the importance of nurses preparing for public health emergencies and community disasters.

The Evolution of Nursing Education Trends Over the Years

The nurse’s role has evolved dramatically since the days of Florence Nightingale. Initially, the nurse focused on patient hygiene and comfort care techniques, so training was informal and often at the bedside. Florence Nightingale understood the importance of the nursing role and was responsible for creating formal nursing instruction. With healthcare advancing, nursing education needed to follow suit to ensure those in the position had the competency necessary to care for patients.

Early nursing education was a diploma program that included instruction in the classroom and a healthcare environment. Advancements in medical technologies meant educational changes for nurses. Diploma programs evolved into associate degree programs and then into bachelor degree programs. The development of medical specialties was also reflected in nursing programs , and nurses were expected to show competency in various specialties before graduating.

The level of nursing education continued to move forward, and advanced practice nursing was born. With the wide variety of patient management that a nurse can hold, nursing education now focuses on professional development and lifelong learning.

Challenges Faced in Nursing Education

With the evolving trends in nursing research and healthcare, many challenges in nursing education impact the quality of education and the readiness of graduate nurses. Some of the critical challenges in nursing education include the following:

• Nurse educator shortage : With a lack of nurses comes a shortage of nurse educators. Many nurses prefer a clinical position due to the higher salary and reduced administrative role. Additionally, many nurse educators are approaching retirement age. The need for educators limits how many students a nursing school can admit, which adds to the overall nursing shortage.
• Web-based programs : Integrating technology into nursing programs can be challenging for a few reasons. New technology is not always affordable, and students may struggle to access these tools. Some nurse educators may need help understanding how to incorporate them into their curriculum fluently.
• Lack of preceptors : Finding adequate clinical placements for nursing students can be challenging. Clinical sites can be limited in the area of the nursing program, and other healthcare programs may compete for those sites as well.
• Updating curriculums : Nursing curriculums must keep up with the constantly changing healthcare environment, including advancing technology, new techniques, and healthcare management models. Keeping the educational programs up to date on current literature is essential for competent graduate nurses.
• Social media use : Over the last decade, social media use has increased, which can be a valuable resource in building a community or developing partnerships. It can also be a dangerous place for misinformation and shortcuts that nurses should not incorporate into practice.

How Can the Healthcare Industry Address These Challenges?

Multiple sources must work together to address the challenges in nursing education. Nursing schools, healthcare organizations, nurses, and policymakers must collaborate for better reimbursement for nurse educators and more affordable resources for nursing programs. Below are some additional interventions:

• Increasing funding for technology: More funding needs to be available for the necessary technologies to teach students, whether it is updated simulation labs or online educational programs. These advancements are no longer a luxury but a necessity. 
• Bridging the wage gap: The salary of a nurse educator should be comparable to that of a clinical nurse. The current wage gap motivates nurses to stay at the bedside or move to other healthcare areas instead of teaching.  
• Decreasing teacher-to-student ratios: Large classroom sizes can negatively affect the learning quality of nursing students and increase the rate of burnout for nurse educators. 
• Reducing administrative work for nurse educators: Nurse educators should be responsible for teaching future nurses. Their focus should not have to be on nursing school admissions and counseling the nursing students—additional staff should be available for those responsibilities. 
• Offering scholarships: Offering scholarships to nurses who want to study nurse education would be a way to spark interest in the specialty and assist in making the program more affordable. 
• Partnering academic centers with healthcare systems: Partnerships between academic centers and healthcare systems would support consistent clinical sites and assist in developing adjunct faculty training programs.  

How Are These Trends and Challenges Affecting the Quality of Nursing Education?

The trends and challenges in nursing education play a direct role in the quality of nursing education . Not only are the trends influencing the curriculum and teaching methods, but also the readiness of graduate nurses. Addressing the challenges in nursing education by continuously revising curriculums to incorporate simulation and real-life learning experiences creates well-prepared graduate nurses. Additionally, healthcare organizations and schools should support nurse educators and faculty to participate in continuing education to provide the best learning experiences for their students.

Nursing education faces various changes and challenges in today’s healthcare world. From a shortage of nurses and educators to incorporating new technology into the curriculums, nursing education is adapting to prepare its students for the complexities of the latest healthcare environment. 

Andrea Mosher, CPNP, PMHS, is a suburban emergency room RN turned primary care pediatric NP. With this drastic evolution in practice, there was a steep learning curve. Now, her daily role is based significantly on educating patients and families, so writing freelance health content seemed to be the perfect fit to share her knowledge with patients and other healthcare workers.

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Current and Future Educational Challenges for the Nurse Educator

Submitted by Skip Morelock PhD, RN, NEA-BC

Tags: critical care education future of nursing graduates Nurse Educator nurse shortage nursing faculty teacher

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The nursing educator of today has at their disposal a veritable goldmine of techniques, curricula, models, and simulators as well as other modern technological advances which make it possible to teach a class and impart clinical knowledge from thousands of miles away. With these advancements come challenges: some which are peculiar to the online world and unknown two decades ago. How does one teach from a distance, how can the nurse educator ensure that the pupil on the other side of the computer is in fact who they say they are, and what about the cost of this education? In order to effectively teach current and future nurses, the modern nurse educator must have a command of not only the clinical facets of the concept being taught, but also must master the various methods of delivery for that information. Lecturing still has a place in nursing education, but this is now being augmented by various knowledge delivery systems to help bring the education experience alive and demonstrate to the student how best to implement new knowledge. Education and educational techniques will continue to advance as new technologies are discovered and implemented.

Historical Perspective

Nursing education has progressed rapidly over the past 100 years. Although the art of caring has its roots far back in history, the immediate post-Nightingale nursing education represents a more formal, modernized, and to some extent standardized approach to nursing education. During the late 19th and early 20th Centuries, the primary focus of nursing education was to enable intelligent and able women of the post-Victorian age to assist physicians. Indeed, the physician and medical leadership of that time period played a dominating role in shaping nursing education and the epistemological development of nursing as a profession (Walker and Holmes, 2008). The expectation at that time was that nursing education would never rival that of physicians and early curriculums included courses to train nurses to suppress their own feelings and thoughts especially if they conflicted with the physicians own plan of care. Dr. K. Watson (1907) writes “it is common knowledge that the more highly qualified the nurse is the less likelihood there is of her attempting to usurp the medical man...” In some ways, vestiges of this anachronistic power imbalance remain today even as nursing educators try to throw off the traditional orders of medical power and knowledge and impart in their students a new sense of responsibility with the patient (and not the physician) as the center of power.

Review of Literature

This literature review will trace the intellectual development of modern nursing education and covering the transition to online delivery of education. Future challenges to not only the nurse educator but the nursing student will also be reviewed. Several themes emerged during the literature review. Nursing education is changing as rapidly as healthcare itself. The Institute of Medicine (IOM) is clearly concerned that nursing education must advance in order to prepare future nurses for effective and collaborative clinical practice. While focusing on need, access, and cost, the nurse of the future will have to balance clinical skills with more advanced skills such as a working knowledge of financial implications and considerations for not only the patient, but also the entity which the nurse is employed. The IOM has suggested that while the Bachelors of Science in nursing would not address all of the future educational and clinical expectations; it would at least expose future practitioners to these fields and would help engender a broader knowledge base of healthcare and its place in society (IOM, 2011). Others, notably Charles Foster (2012) suggest that the Bachelors of Science is important, but also recommends professional specialty certification as evidence that nurses are engaging in lifelong learning. Other studies, notably by Lea, Skirton, Read, and Williams (2011) and Halcomb, Salamonson, Raymond, and Knox (2011) have touched on not only the need to update nursing education, but also to take into account the rapid growth of information regarding the human genome and how nurses can best teach and educate patients in this extremely delicate area of healthcare and to incorporate this knowledge into practice. Williams, Prows, Conley, Eggert, Kirk, and Nichols (2011) have gone as far as saying that genomic education should be permeating all nursing curricula and that current courses be examined carefully for incorporation of genomic content. This is interesting when considering that barely ten years ago, the discussion of genetic issues and implications were left to the physician or counselors with extensive experience. Critical care nurses also are requiring more intense education prior to graduation based on the fact that nurses are frequently working in critical care immediately post graduation. There is a growing expectation that these nurses should be equipped with the basic skills to function in a hospital, but also armed with the ability to rapidly learn and inculcate new information relevant to critical care practice (Lawrence, 2011). A pre-graduation critical care course has been offered as a possible solution. The course would be in the format of a two day workshop and taught by clinical content experts in critical care. A study by Gallagher, Rice, Tierney, and McKinney (2011) found that such a course significantly increased the confidence of a nursing student’s ability to recognize and act to reverse the deterioration of a patient’s clinical status. This type of training is completely relevant even if the student does not plan to specialize in critical care. The sicker hospitalized patients of today combined with the inherent complexities of managing patients with various and sometimes chronic pathologies make the ability to critically think and act especially important. Modern nursing education employs old fashioned and time-tested methods such as lectures blended with either web-based or web-enhanced content. Teaching an online course, contrary to the belief of some, can be a labor- intensive and formidable challenge (Zsohsr and Smith, 2008) and (Weiner, 2010). Yet, the effective transition to this form of education must continue with some sense of urgency as the new realities of healthcare emerge. Nurse educators must be willing to part with ‘sacred cows’ in lieu of more mobile and easily modified courses designed to meet the needs of a more mobile nursing society (Garrett, 2012). Care must also be taken in the regulatory sphere that emerging nursing courses and online schools of nursing as well as nurse educators who teach these courses meet the accepted standards by graduating safe practitioners and by maintaining appropriate accreditations (Murray, Philipsen, Pope, Hart, Wood, Lamm, Tolson, et al, 2012 ; Smyer and Colosimo, 2011). Many gaps were noted in the literature which will provide ample opportunity for further investigation and research. While there are many articles addressing the need for educators to change their methods, there are only a few articles that posit more concrete examples of exactly how that should look and more importantly how these changes can be effectively implemented. There is significant information on web-based information and how online learning compares with a more bricks and mortar approach and also information regarding faculty shortages. The gaps lies in the follow up...where are we with these changes and how are they impacting the bedside nurse or the patient? The literature also seems to be strongly encouraging the rapid adoption of online curricula as well as increasing the pace of approvals of new nursing programs, but there is a lack of information on how to best assess these programs for their utility and effectiveness in the training of new nurses. Also of great concern to this researcher was the lack of information regarding the proliferation of illegitimate nursing programs which threaten not only the student, but also potentially the patient. Part of the reason for the number of gaps noted in the literature is likely the rapidity in which healthcare is advancing which contributes to a research lag which should correct given time.

Current Challenges

The current challenges to nursing students include the continued matriculation from traditional classroom-based educational programs to web-based programs, the academic preparation of adequate numbers of registered nurses to meet the growing healthcare demands, the rapid pace of healthcare changes which demand almost constant re-assessment of nursing curriculums, and the recruitment and retention of qualified nursing faculty to teach students. There is little question that online education is here to stay. The advantage of online nursing education is clear: it allows flexibility to view lectures and course material in an asynchronous format...choosing to view the material at a time convenient to the learner. Online courses are now becoming an integral part of formal nursing education (Zsohar and Smith, 2008). Younger students may possess a definite advantage in utilizing the online format as they have likely grown up with the requisite technology while older learners are more likely to be technologically naïve. This can pose issues and can cause the older students to feel disengaged. Key to diminishing this is a full orientation to the web-learning environment prior to classes with ample opportunities to engage the faculty in more traditional formats if there are specific barriers (Weiner, 2010). According to the Institute of Medicine (IOM), The Affordable Care Act, which passed in 2010, as well as an increasingly complex and technical clinical environment has created the almost immediate need for nurses to fill expanding roles which they may not be prepared for (IOM, 2011). In short, nursing education of the last decade is rapidly devolving into obsolescence and is being replaced by education which is considerably more technically oriented, geared toward evidence-based practice, concept-based instruction and includes other competency expectations such as leadership development, teamwork, informatics and collaboration (Hyrkas, Randall & Meinersmann, 2016; Kalb, O’Conner-Von, Schipper, Watkins, and Yetter, 2012; National League for Nursing, 2015). The challenge for nursing educators is to rapidly reassess and if necessary generate new classes and curricula which address the new recommendations. Faculty shortages in nursing are nothing new. As early as 2002, the journal Nursing Outlook termed the nursing faculty shortage as “a dire situation” (Berlin and Sechrist, 2002). One of the main issues facing nursing educators is that compensation rates are considerably higher in the acute care or clinical setting (Siela, Twibell, and Keller, 2009). Another reason for the faculty shortage is the wave of faculty retirements which are ongoing and are contributing to the 200-300 nursing faculty positions which open up each year (American Association of Colleges of Nursing, 2012). The lack of available faculty impacts the student nurse in several ways. The most obvious of which it limits the number of students that can be accepted into a nursing program. Another impact is that it lessens the availability of required classes resulting in competition for space in classes and possibly delays in graduation. One possible solution which has been proposed to alleviate the faculty shortage is for unit-based clinical nurse specialists and advanced practice nurses to assume some aspects of clinical education. From an operational point of view this makes sense since the instruction would be given by a clinical expert in the field. Connolly and Wilson (2008) studied advance practice nurses and nurse practitioners and found that they were underutilized in the education role. Barriers to implementing this were found to be lack of support from the hospital educators, an increase in responsibility without a concomitant increase in salary, and the existing nurse shortage which made it difficult if not impossible to assume additional responsibilities. The proliferation and influence of social media must be considered as an adjunct to the nursing education process. With all the pitfalls and risks that are associated with social media, it is not going anywhere. As a conduit for disseminating current trends in education as well as serving as a rapid-fire means of assessing new technologies and therapeutic regimens, the nursing student must use extraordinary discretion when consulting social media outlets for current information. The lack of peer-reviewed information and the proclivity for pithy short statements or sound bites, critical or nuanced aspects of the subject may be lost or ignored completely. Nursing information present on social media should be taught as an interesting sidelight, but not to ever replace sound judgment (Carroll, Bruno & Tschudi, 2016).

Future Challenges

Future challenges to nursing education include ensuring that nursing students be instructed in the care of an increasingly non-hospital based patient population, the development of new electronic platforms to enhance the learners’ educational experience, the art and science of collaboration, and finally maintaining integrity of scholarship in the online learning process. While the shift has been subtle from hospital based care to an increasing emphasis on community based care, some nursing educators feel that nursing schools in the future will need to produce graduates that can provide competent care to a diverse patient population. This will require broad education in symptom management, community based point of care testing techniques, and the ability to systematically assess chronically ill patients for system deterioration (Waters, Rochester, and McMillan, 2012). For a hospital based patient, this is a complex task for the new nurse and it can take months to develop this skill, but it can be very challenging for a new nurse to provide this level of expertise to a community based client. Nursing schools will surely feel this pressure to produce graduates that can safely practice in both the hospital and the community setting. There has been an explosion of online or web-based nursing classes in the past ten years. What is the future of this type of learning? Susan Petula (2011) surmises that systems or concept theory will eventually overtake traditional nursing instruction. Systems theory as applied in this circumstance would mean an integration of nursing education programs, boards of nursing, and information technology. The proposed benefits of such an approach to nursing education would be improved interagency communication, improved regulatory compliance, and data generation. The data generation piece is critical since this would provide evidence for future policy creation as well as identifying and disseminating evidence-based practice findings in an expedited manner. The Joint Commission maintains that poor communication is at the root of most patient care incidents in United States hospitals (The Joint Commission, 2014). Nursing education should be playing the key role in cross-professional collaboration. One college of nursing in Texas has modeled and implemented a transformational program in which senior level nurses are teamed with 4th year medical students in a controlled simulation environment (Booth and McMullen-Fix, 2012). Prior to the program, a pre-assessment showed that neither profession even realized the scope or magnitude of their respective positions. This exercise also revealed that new or inexperienced nurses were frequently hesitant when informing the physician was the appropriate course of action. This is valuable information and since it was detected early in the study, prior to the students’ graduation, further education in assertive and effective physician communication could be instituted. Faculty-driven efforts to increase collaboration by nurses with other key members of the healthcare team can only serve to benefit the patient. There has been a proliferation of nursing schools in both the United States and in foreign countries which have not been accredited by a recognized governing body (Morgan, 2012). While most of these programs concentrate of the preparation of the medical assistant, there are an increasing number of programs which are attempting to graduate practical nurses and also some which guarantee eligibility to sit for the board examination for registered nurses. In 2008, the Texas Board of Nursing identified and advised regulators that several nursing programs had opened in Texas without requisite approval from either the National League for Nursing Accrediting Commission (NLNAC) or the Commission on Collegiate Nursing Education (CCNE) (Texas Board of Nursing Quarterly Report, 2008). In the United States, there is a triad approach to governing educational institutions. The three entities are the federal government, state government, and accrediting agencies. In principle, this system should yield protection against an unaccredited nursing program slipping through the cracks. Yet because of gaps inherent in all three entities, this system has failed (Morgan, 2012). Credential evaluation will become even more important in the future as nurses from an array of different countries continue emigrating to the United States and with the expectation that they will be able to immediately practice as registered nurses (Shaffer and Dutka, 2012). In 2008, foreign educated registered nurses comprised 13% of the employed registered nurses in the United States (Schumacher, 2011). While the Philippines have long had a pipeline into United States hospitals, nursing graduates from other countries have recently begun to appear in increasing numbers. Countries such as Ghana, Gambia, Nepal, and Saudi Arabia are now the countries of origin for many new nursing graduates who are immigrating to the United States in search of a more stable political climate and enhanced employment opportunities (Shaffer and Dutka, 2012). Evaluating the nursing curriculums from so many different countries requires painstaking and diligent work, but is critical to ensure that these nurses have had comparable training to the nurses in the United States.

Nursing education is experiencing many changes. From the traditional classroom to web-based clinical instruction, the transition continues. Accompanying the transition come the challenges which nursing educators must identify and remedy. From enabling, encouraging, and coaching the technologically naïve student to success to generating new technological pathways for the more technologically experienced, nursing education continues to be a dynamic field. Themes which were generated during the literature review and the discussions on future and current topics in nursing education, several gaps in research were identified and will provide fertile ground for further nursing research and the acquisition of new nursing knowledge. The end user of course is the patient. It is incumbent upon nursing educators to inspire their charges while challenging them to deliver competent, culturally aware, and evidence-based care.

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• Published: 22 August 2023

Exploring challenges and facilitators to E-learning based Education of nursing students during Covid-19 pandemic: a qualitative study

• Fereshteh Araghian Mojarad 1 ,
• Ali Hesamzadeh 1 , 2 &
• Tahereh Yaghoubi 1  

BMC Nursing volume  22 , Article number:  278 ( 2023 ) Cite this article

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During the COVID-19 pandemic, there was a shift to e-learning and online education in educational and learning processes. Research has shown that nursing students who are satisfied with e-learning tend to have better learning outcomes. Therefore, this qualitative study aimed to explore the challenges and facilitators of e-learning for nursing students during the pandemic.

This qualitative study utilized a content analysis approach. Sixteen participants with nursing education experience were purposively selected and interviewed using a semi-structured format. The data collected were analyzed using the conventional qualitative content analysis approach.

Through data analysis, two main categories were identified: e-learning challenges and facilitators. The e-learning challenges included subcategories such as inexperienced teachers, ineffective learning, academic cheating, system problems, and inappropriate evaluation. The facilitators included subcategories such as improving education, and promoting online exams.

Conclusions

While e-learning was adopted as a substitute for in-person education during the COVID-19 pandemic, its implementation involves both challenges and facilitators. By addressing the challenges and optimizing the facilitators of e-learning, nursing schools can successfully adapt to this new mode of education in the post-pandemic era and provide high-quality education to their students.

Peer Review reports

The COVID-19 pandemic has transformed the healthcare environment and the learning settings of nursing students, resulting in a shift from traditional face-to-face education classes to online courses. This shift has impacted students’ learning opportunities and has required nursing schools to adapt to new modes of education delivery [ 1 ]. The pandemic has forced universities around the world to rapidly improvise and adopt online teaching methods [ 2 ]. Consequently, nursing education underwent many changes, and nursing students inevitably turned to different types of e-learning through various social networks [ 3 ]. E-learning is the use of electronic resources like the internet, computers, and smartphones to acquire and disseminate knowledge [ 4 ]. Iran is among the countries that have adopted various e-learning methods as an alternative to traditional education [ 5 ].

Given the rapid changes in teaching-learning environments, e-learning based education is an alternative or supplement to conventional teaching and it offers new models of learning opportunities for individuals at any time [ 6 ]. Despite the fact that over three and a half million students are estimated to be currently enrolled in e-learning classes, there is limited information available regarding its level of flexibility, distribution, and openness [ 7 ]. E-learning has a positive impact on the academic achievements of students, as it reduces costs, saves time, increases accessibility of education, and enhances academic performance [ 8 ]. However, there are challenges in providing e-learning education in universities, such as the lack of financial and physical resources to supply the necessary computer systems and equipment, which are major obstacles to its development [ 9 , 10 ]. E-learning based education infrastructures encompasses technological tools, systems and structures that facilitate proper access to e-learning services [ 11 ]. Furthermore, the results of various studies have demonstrated that the most significant obstacles to e-learning are unsuitable organizational structures, cultural and environmental challenges, as well as negative public perceptions [ 12 , 13 ]. During the COVID-19 pandemic, several studies have suggested that learners were not adequately prepared for e-learning and expressed dissatisfaction with the method [ 14 , 15 , 16 ]. According to a study, medical students expressed dissatisfaction with the use of e-learning technology when compared to in-person classrooms, citing feelings of isolation and disconnection from their peers and instructors [ 17 ]. García-González et al. (2021) reported that a significant majority of nursing students experienced emotional impacts such as elevated levels of anxiety due to the shift to online learning during the COVID-19 outbreak [ 18 ]. Results from a study of nursing students indicated that 61.6% of students had negative attitudes to e-learning [ 16 ]. However, the results of another study indicated that nursing students had a positive e-learning experience [ 19 ]. Elzainy and colleagues indicated that E-learning was highly beneficial for competent educators as it decreased the need for in-class attendance, compensated for the suspension of face-to-face teaching, and provided more opportunities for open discussions [ 20 ]. E-learning has been shown to be effective and valuable in nursing education, as it actively engages learners in the learning process and facilitates self-directed learning. The continuous presentation of teaching materials can improve student motivation, satisfaction, and enjoyment compared to other methods of instruction [ 21 ].

Nursing students in low-income countries often hold negative attitudes towards online learning, primarily due to the high cost of internet connections and slow internet speeds [ 14 ]. Despite the importance of understanding nursing e-learning based education during the COVID-19 pandemic from a qualitative perspective, the majority of studies conducted have been quantitative, with few qualitative studies exploring this issue [ 15 ]. Qualitative research provides detailed descriptions of participants’ experiences and feelings, emphasizing subjective and diverse perspectives to gain an in-depth understanding of a social issue or problem [ 22 ]. Qualitative content analysis is a widely used method in nursing science that can be applied to a variety of contexts and data sources [ 23 ]. Qualitative content analysis systematically codes and classifies text to uncover patterns and themes, generating knowledge and understanding of the phenomenon being studied beyond simple word counting [ 24 ].

This study aims to describe challenges and facilitators of e-learning in nursing education during the COVID-19 pandemic from the perspective of those involved, using a qualitative approach.

Study design

The present research is a qualitative study that utilized the content analysis method, employing a conventional approach and following the qualitative analysis steps outlined by Graneheim and Lundman [ 25 ]. Conventional content analysis is the most commonly used method for analysis in studies aimed at describing the properties of a phenomena. It helps the researcher to understand social phenomenon in a subjective yet scientific manner [ 24 ].

The participants and settings

In this study, the participants comprised of students, teachers, and staff of the educational unit at Nasibeh Faculty of Nursing and Midwifery in Sari, Iran. A purposeful sampling method was employed to collect data. The purposeful diversity in the sample selection was intended to facilitate the wider applicability of the research results to its intended audience [ 26 ]. The researchers approached potential participants and invited them to participate in the study. Those who expressed interest were provided with detailed information about the study. The participants were not required to disclose their names and provided written informed consent. The sample consisted of eight nursing students from different semesters, six teachers with varying levels of academic experience, and two educational unit staff members with diverse work positions (Table  1 ).

Data collection

Data was collected through semi-structured interviews, which were conducted in a private room at the faculty to ensure the privacy of the participants, while adhering to health and safety protocols for COVID-19 prevention. The interviews and data collection period commenced from November 2020 and continued until February 2021, with the aim of achieving theoretical saturation. The term “saturation” refers to the point at which the data collected contains sufficient information to address the research questions at hand [ 27 ]. Upon obtaining verbal consent and ensuring confidentiality, face-to-face interviews were conducted using open-ended questions. The interviews were recorded with the participants’ consent. They were asked questions such as: “Would you please tell me your experiences during the providing e-learning in the faculty?“ “Would you like to describe the experiences regarding the problems of e-learning education?“ “What are the supporters of e-learning?“ Throughout the interview, emphasis was placed on eliciting the participant’s personal experiences and perspectives related to their e-learning education. To gain a deeper understanding of the participants’ experiences and perspectives, follow-up and probing questions were asked based on the data provided during the interviews. The English version of interview guide, which contains details related to the interview questions, is provided in the supplementary file. The researcher aimed to be an attentive listener throughout the interview process. The interviews typically lasted between 30 and 50 minutes.

Data analysis

Data analysis involved creating an immediate summary of each interview, followed by a thorough review of the recorded interviews and transcribed recordings. The qualitative approach developed by Granheim and Lundman was employed for data analysis [ 25 ]. The data analysis process involved several steps. First, the researchers read through all the transcripts to gain a comprehensive understanding of the data. Units of meaning, which could be a word, sentence, or an entire paragraph that pertained to the study question (What are the challenges and facilitators of nursing student e-learning during the COVID-19 pandemic?), were identified and marked. These units of meaning were then condensed into a description of their manifest content and an interpretation of their latent content. Subsequently, the researchers abstracted sub-themes from the descriptions and interpretations. Through a process of reflection and discussion, the researchers agreed on a number of sub-themes and identified relevant headings that would unify the sub-themes into themes [ 28 ]. The transcripts were reviewed multiple times to enhance understanding. Semantic units, such as paragraphs, sentences, or words, were identified and summarized based on their meaning. Similar codes were compared and contrasted, and then grouped into more abstract categories labeled with specific headings. Finally, the categories were compared to one another to identify overarching themes that encapsulated the data.

Trustworthiness

To ensure the reliability of the data, an expert with qualitative research experience reviewed all the codes, subcategories, and categories, as recommended by Guba and Lincoln [ 29 ]. The researchers aimed to enhance the credibility of the study by selecting participants with diverse experiences, establishing rapport and engaging in sufficient interaction, collecting valid information, and validating the findings with the participants. Additionally, the researchers maintained continuous engagement with the data throughout the analysis process. The findings were presented to the participants and a group of experts for verification, and any discrepancies were addressed and resolved.

For dependability, the audio recording from the interviews was transcribed verbatim into a text file. The process of the transcribing and coding was done independently by two researchers, and then the results were compared and a final decision was made.

To enhance confirmability of the findings, the research team made a concerted effort to avoid any preconceived notions or biases during the analysis process. The coding process of the interview transcripts was finalized through consultation and consensus among the research team members.

To enhance the transferability of the study findings, the researchers provided a detailed and comprehensive description of the research findings, which may be applicable to other fields. The presentation of the participants’ statements was faithful to their original wording. The use of convenience sampling with maximum diversity contributed to the transferability of the study results. Other researchers may be able to perceive the new concepts and insights that emerged from the study, which could contribute to nursing education and related fields.

The study included 16 participants who had experience with nursing e-learning during the COVID-19 pandemic. The data were categorized into two categories: e-learning challenges and e-learning facilitators. The e-learning challenges category consisted of five subcategories, including inexperienced teachers, Ineffective learning, Academic cheating, System problems, and Inappropriate evaluation (Table  2 ). The e-learning facilitators category included two subcategories, improving education and Promoting online exams (Table  3 ).

Challenges of E-learning Education

The first category that emerged from the analysis of the participants’ statements on their e-learning experience during the COVID-19 pandemic was “E-learning challenges,“ which consisted of the following five subcategories:

Inexperienced teachers

The participants’ statements indicated that some teachers lacked sufficient experience with e-learning during the COVID-19 pandemic. Specifically, the participants noted that these teachers faced challenges with using Camtasia software (an interactive online learning video software [ 30 ]), had limited experience with e-learning-based education, struggled with uploading large files of educational materials, had difficulty uploading several files simultaneously, did not adhere to a schedule for uploading files, and did not utilize the forum session.

Participants shared their experience as follows:

“In the first course of online training, the teachers uploaded a large amount of files close to the exam time…” (Participant 1).

One of the teachers said: “At the beginning, it was very difficult for me, it was all trial and error to record audio and video in Camtasia software.” (Participant 3).

Ineffective learning

According to the participants’ statements, “Ineffective learning,“ particularly in vocational training, was another subcategory of e-learning challenges. Participants identified problems such as the use of English language in educational materials, difficulty in understanding the educational content for some students, high levels of student absenteeism in online classrooms, irregular learning patterns by some students, poor interaction among students and with the teacher, teacher-centered teaching, and a lack of use of teaching aids. Participants shared their experiences in this regard:

“In the Navid system (a software for uploading educational materials), you cannot ask your own questions directly; you can ask the teacher through sending a message, but I prefer not to ask”. (Participant 5)

“I’m not fond of the online classroom because I’m not in contact with the students in person. It’s not enjoyable for me at all. As I can’t see the students’ faces, I can’t get the due feedback from my class.” (Participant 6).

“Lots of the students are from the rural areas and may not have access to the Internet, and some said that they do not have a laptop or a computer, and the Navid system cannot be loaded on their mobile phones.” (Participant 9).

Academic cheating

Another subcategory of e-learning challenges was “Academic cheating.“ Participants noted instances such as copying assignments and submitting them to teachers, the use of various cheating methods in e-learning education, and the formation of cheating groups in online classes. Participants shared their experiences as follows:

“I feel bad when some students cheat during exams or they send us duplicated assignments. “(Participant 11).

“Usually in the online exam, there is room for some students to cheat despite the teachers trying to control it.” (Participant 10).

System problems

Participants also discussed system-related problems, such as issues with internet access, a lack of sufficient hardware and software facilities at the onset of the pandemic, slow internet speeds, difficulties with uploading and downloading large educational files, and challenges with working with Navid software. Participants shared their experiences as follows:

“E-learning education costs a lot to upload and download large files for the teachers and the students” (participant 14).

“Considering that the main server is in the headquarters of the university and we do not access it, we could not solve the problems of disconnections immediately.” (Participant 13).

Inappropriate evaluation

Based on the participants’ experiences, an inappropriate educational evaluation was identified as another e-learning challenge. Although educational evaluation is an important component of the learning process, participants noted that it did not have sufficient credibility in the context of e-learning education. Participants shared their experiences as follows:

“When I find out about students’ cheating, I don’t know what may happen to their educational evaluation matter.” (Participant 16).

“Considering that some students pass the exam by cheating, the rights of the students who painstakingly handwrite and studied the files are violated.” (Participant 2).

E-learning education facilitators

Another main theme that emerged from this study was e-learning facilitators, which included two subcategories: improving education and promoting online exams.

Improving education

To improve Education, participants identified several measures, such as enhancing teachers’ skills in using e-learning facilities, integrating multiple teaching methods, adhering to a specific schedule for uploading files, retraining teachers to work optimally with the software, holding online question-and-answer sessions, encouraging student participation, and increasing teachers’ access to online webcams. Participants shared their experiences as follows:

“I was the advisor of the first semester students, and on a daily routine, I asked them about the study hours through the WhatsApp group, which encouraged competition and increased their studies.” (Participant 15).

“We had a teacher who presented the lesson to us through files, both audio and video in the Navid system, and he solved our course related problems through WhatsApp.” (participant 12).

From the teachers’ perspective, online courses were considered more effective for learning because they were similar to in-person classes. The active presence of the students, the question asking and answering potential, the possibility of seeing the teacher while presenting the material, creating more motivation and attention in learning are some of the merits of online education.

Participant number eight stated that:” In online education, seeing the teacher in person can be an encouragement for the student to study.“

Or participant number two said:” In online class, the communication problem with the student is somewhat solved.”

Participant number four stated so:” For online classes, it is better if the teachers hold the classes after five pm to have better interaction with the students.”

Improving online exam

Participants discussed potential solutions to ensure more valid exams. They suggested improving infrastructure, increasing the number of online examinations, having teachers upload more assignments, and conducting standardized tests under appropriate conditions. The participants provided the following accounts of their experiences:

Participant number seven said:” At the end of the class, I usually asked three to four questions from the lesson so that to come up with good assessment “.

Participant number three also stated: “It’s better to adjust the exam time and the answering duration.”

Participant number 13 said: “we predicted all the possible solutions for online exam, for instance we determined a specific time for each question and the exam questions their answer were randomly presented to reach more desirable evaluation.”

In the present study, the students mentioned some advantages accrued through e-learning based education, such as the lack of attendance in the physical classroom, being free to choose the time and type of the course for studying, easy access to the educational material which had been saved in the software system, saving time and money, not requiring to hold compensatory.

The study aimed to identify the challenges and facilitators of e-learning in the nursing faculty, as well as to explore potential solutions to improve the effectiveness of e-learning. The participants’ insights and experiences provided valuable insights into the practical aspects of e-learning and highlighted the importance of adapting to new modes of education during a crisis.

Inexperienced Teachers

The findings showed that some teachers had insufficient experience with e-learning based education. Leigh and colleagues (2020), reported that nursing schools used unfamiliar technology of e-learning to present theoretical lessons and the COVID-19 pandemic has forced educators to rapidly adapt to digital technologies in order to continue to provide high-quality nursing education remotely. This has been a challenging process for many educators who may have been less familiar with e-learning platforms and digital tools [ 31 ]. In the study by Nabolsi and others (2021), the majority of the participants had their first experience in e-learning and they lack of technical skills to manage e-learning effectively, and they suggested that ongoing training and support can help faculty feel more comfortable with online teaching and improve the quality of their instruction [ 32 ]. Additionally, a study by Shafiei and colleagues (2019) identified teachers’ incapability to apply e-learning, negative attitudes towards e-learning, and a lack of desirable interaction between teachers and students as challenges of e-learning in Iran [ 7 ].

Another challenge of e-learning was ineffective learning, which was associated with poor interaction and communication between teachers and students, a lack of opportunities to discuss and resolve ambiguity during teaching sessions, teacher-centered education, and a lack of use of educational aids.

While e-learning can be effective in improving nursing knowledge and skills, it may not be suitable for all types of learning or all learners. Some learners may prefer more traditional forms of education, such as classroom-based instruction, or may struggle with the technology or lack of personal interaction. Therefore, it is important for educators and institutions to carefully consider the use of e-learning and to provide support and resources to ensure that learners can fully engage with the learning experience [ 33 ]. Magner and others (2014), also noted that providing educational feedback to the students can increase the quality of learning by creating motivation and situational interest [ 34 ]. Nursing educators should provide clear guidance and support for online learning, and that they prioritize opportunities for social interaction and support to combat feelings of isolation and disconnection [ 35 ]. Besides, Inability to concentrate and to avoid e-learning activities can negatively affect academic progress [ 36 ]. It is necessary that educators and institutions prioritize the provision of resources and support to enable students to fully engage with e-learning, while also exploring hybrid models of education to meet the diverse needs and preferences of students [ 4 ]. In addition, the findings of a systematic review study suggested that e-learning tools may become increasingly important in medical education even after the pandemic subsides. Students should have access to high-quality online resources and interactive digital platforms to support their learning needs [ 37 ]. However, the transition to e-learning required students and faculty members to adapt to new teaching methods and strategies, which required time and effort [ 20 ].

Another finding mentioned by the participants was academic cheating, which can prevent individuals from fully engaging in the learning process and developing necessary knowledge and skills. Therefore, universities need to develop solutions to ensure the security of online tests and prevent academic dishonesty [ 38 ]. The lack of direct supervision and monitoring of students in online exams can make it easier for students to cheat by accessing unauthorized resources or collaborating with others. Some strategies such as using plagiarism detection software, designing exams that require critical thinking and application of knowledge, and implementing remote proctoring to monitor students during online exams, can be used to address this issue. These strategies can help promote academic integrity and ensure that students are evaluated fairly and accurately [ 39 ]. Holden and colleagues (2021) emphasized in their systematic review study that the application of artificial intelligence in developing online tests was helpful in reducing cheating during exams [ 40 ].

System problems was a subcategory of e-learning challenges. As the study of Koohpayehzadeh and others (2017) suggested, the development of the technological factors such as the infrastructure, network, software and hardware are essential for e-learning based education [ 41 ]. The need for access to appropriate technology and internet connectivity, can be a barrier for some students [ 42 ]. Currently, more than 26% universities of medical sciences in Iran lack the necessary hardware and software infrastructures to implement e-learning based education [ 43 ]. Additionally, research by Özkan and colleagues (2021) identified poor internet speed and frequent power outages in rural areas as the biggest obstacle against distance learning for nursing students [ 44 ].

Inappropriate evaluation was another finding of the study. Sadeghi Mahali and colleagues (2022) also emphasized that one of the most significant challenges of e-learning education was the problem of educational evaluation [ 45 ]. Similarly, in a study by Yassini (2015), the evaluation of e-learning courses was reported as ineffective from the students’ perspective [ 46 ]. Other research findings have also revealed that student evaluation was a challenge in online medical education during the COVID-19 pandemic in Saudi Arabia [ 47 ]. The emergence of the COVID-19 pandemic has brought about changes in how learners are evaluated in relation to their level of learning [ 48 ]. Furthermore, just like with all educational activities, ensuring the quality of e-learning programs is crucial and considered an integral part of e-learning [ 47 ]. According to a study, students who regularly participated in online discussion forums performed significantly better than those who did not. Furthermore, there is a positive correlation between the amount of time spent on the e-learning platform and student performance [ 49 ]. This information can be used to improve the evaluation of students’ academic progress.

In addition to the challenges, this study also identified facilitators for promoting e-learning education, which included two subcategories: Improving education and promoting online exams.

According to the participants, enhancing teacher skills through retraining, integrating multiple teaching methods, and organizing question-and-answer sessions are essential to improve e-learning based education. E-learning technologies have been found to enhance interactive teaching and learning processes [ 50 ], providing a high-quality and sustainable educational infrastructure that fosters student participation and cooperation with teachers. Furthermore, the change in the teaching process during the COVID-19 pandemic has provided an opportunity for teachers to develop their skills in using e-learning facilities [ 1 , 51 ]. Despite the benefits of e-learning based education, it is generally not a substitute for traditional education methods, but can be used as a complementary method [ 52 ]. To encourage group discussions and critical thinking, teachers may use the Socratic Method in e-learning classrooms. This method involves purposefully asking and answering questions consecutively [ 31 ]. However, as students and teachers had limited e-learning experience before the COVID-19 pandemic, they generally preferred face-to-face sessions, and the mandatory shift to e-learning education occurred suddenly, causing pressure, uncertainty, and anxiety [ 52 ]. Amidst the COVID-19 outbreak, teachers faced numerous challenges while working with educational technologies, such as a lack of awareness of new e-learning educational methods and ways to minimize student distractions [ 53 ]. The main concerns of faculty teachers and students during the COVID-19 pandemic in e-learning education were the inability to deliver practical courses and internships, ensuring accurate exams and preventing cheating during online tests, and reducing social interactions [ 54 ]. However, e-learning technology has provided an environment for independent and self-directed learning, the ability to learn anywhere at any time, collaborative teaching and learning, and efficient evaluation and feedback provision for lessons [ 55 ].

Promoting online exam

Over the past three years, the practice of online evaluation has significantly increased, especially since the COVID-19 pandemic [ 56 ]. Online exams have become an integral part of e-learning solutions for true and fair assessment of student achievement [ 57 ]. Online exams offer potential benefits, such as increased accessibility and cost-effectiveness, leading to greater student engagement. They can also provide objective evaluation, timely feedback, and comprehensive assessment. However, challenges such as technical issues, cheating, and infrastructure require further research to optimize online exams for promoting student learning and performance [ 57 ].

Study limitations

The small sample size and recruitment of participants from a single nursing school limit the generalizability of the results to other nursing schools and settings.

During the COVID-19 pandemic, the use of e-learning became a necessity in most nursing schools worldwide due to the suspension of in-person teaching. However, this shift to e-learning brought its own set of challenges and opportunities. Nursing schools that adopt e-learning need to be aware of the potential challenges and find ways to address them. They should also strengthen the facilitators who use this method of education. To improve e-learning education in nursing faculties, programs that increase the knowledge of nursing teachers to work with e-learning related software and hardware should be developed. This can provide a more effective learning environment for nursing students and lead to better evaluation and testing of their progress. Furthermore, providing the necessary infrastructure and equipment, such as appropriate systems and high-speed internet, is essential to ensure that students have a seamless e-learning experience. By addressing the challenges and optimizing the facilitators of e-learning, nursing schools can successfully adapt to this new mode of education in the post-pandemic era.

Data availability

The data supporting the findings of this study are available upon reasonable request from the corresponding author, [T.Y.]. However, the data cannot be made publicly available due to concerns regarding the compromise of participants’ privacy.

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Acknowledgements

We would like to express our sincere appreciation to all the participants who generously shared their valuable experiences and insights during this research work.

This research project was approved and supported by the Deputy of Research and Technology of Mazandaran University of Medical Sciences, Sari, Iran. with a registration code of 7988.

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Conceptualization: TY and FAM. Study design: TY, FAM and AH. Data gathering: TY, FAM and AH. Formal analysis: TY, FAM and AH. Writing manuscript-original draft: TY, FAM and AH. Writing manuscript-revision: TY, FAM and AH. Supervision: TY and FAM. All authors approved the final version of the manuscript.

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Mojarad, F.A., Hesamzadeh, A. & Yaghoubi, T. Exploring challenges and facilitators to E-learning based Education of nursing students during Covid-19 pandemic: a qualitative study. BMC Nurs 22 , 278 (2023). https://doi.org/10.1186/s12912-023-01430-6

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Challenges in Nursing and Tips for Overcoming Them

Nursing challenges have existed since the field began. From social disparities faced by the first nurses to modern-day staff shortages, challenges in nursing continue to evolve.

Today, nurses have gained respect as the most trusted roles in society and maintain the top ethics rating in the U.S., according to a 2022 Gallup poll. Though difficult, nursing is rewarding work that impacts countless lives.

In the following article, we’ll discuss past and present challenges in nursing. We’ll dive into the origin of nursing, then discuss how challenges in the field have progressed with the introduction of modern medicine, technology and more rigorous standards of education.

We’ll also take a look at how one can navigate daily challenges in nursing while delivering quality patient care.

Challenges in Nursing: In the Beginning

Professional nursing started with Florence Nightingale, a visionary who saw beyond the social norms of her time.

In the mid-1800s, the act of nursing consisted of women taking care of family members in their homes, and establishing nursing as a legitimate profession was a challenge. However, Nightingale saw the value of extending this type of care beyond the home, which would serve as an opportunity for both women and the profession to gain notice.

During the Crimean War, the British government assigned Nightingale and her small band of nurses to one of their military hospitals. They sanitized walls, let fresh air in, prepared healthy food and dispensed medicine. Not only were these changes made, Florence also used the scientific methods of observation and data analysis to determine their effects. In a matter of weeks, death rates dropped and countless soldiers regained health.

Challenges in Nursing: 20th Century

In the 20th century, nursing care became more common in public facilities than in homes. However, the quality of care was inconsistent and depended on the hospital.

As time went on, more standards were put into place to combat these inconsistencies and nursing challenges. Hospitals began providing their own training schools for nurses. This required nurses to learn on the job rather than at a university.

Inadvertently, this led to gender segregation in the field and promoted the stereotype that nursing was “women’s work.” These challenges in nursing were the norm until the latter half of the 20th century.

With the evolution of technology and industrialization, the nursing profession began to expand beyond hospital walls. In 1965 the American Nurses Association (ANA) released a position statement calling for nursing education to move to the higher educational setting in an attempt to professionalize the role. Programs in community colleges, technical colleges and universities replaced hospital training programs.

By the 1970s, universities also started offering doctoral programs, with a focus on science and research.

Challenges in Nursing: Today 

Problems in nursing have changed over time, but the career itself is still a rewarding path for those who are motivated to serve others. Today, nursing is a vast and varied field, with a multitude of opportunities for those considering it as a career.

Advanced degree programs, such as Master of Science in Nursing (MSN) programs, have expanded the offerings and reach for modern-day nurses, equipping them with the skills they need to meet evolving challenges.

Nurses work hard to ensure that patients receive quality care. To avoid burnout, it’s important to be aware of today’s nursing challenges and understand their impact. This will help you find ways to cope and use self-care.

Long Hours 

Long hours have been one of many consistent challenges for nurses. They typically have demanding schedules because nursing is a 24/7, round-the-clock job. These long hours can also mean working overtime, several 12-hour shifts in a row or being on-call. Because nurses’ schedules are demanding, working over 40 hours a week is not uncommon.

Over time, this can leave nurses feeling drained. Stress and exhaustion (both mental and physical) can present secondary challenges in nursing, leading to the potential for costly medical mistakes.

Physicality 

Nurses are on their feet most of the time. Nursing duties can be physically demanding, as in the case of helping to lift patients (from a wheelchair to a bed, for instance, or from the bed to the bathroom).

They do have access to equipment that can make these physical aspects less strenuous, such as slide sheets or mechanical lifts. However, nurses experience a high rate of work-related injuries — one of the most chronic being back injuries. Shoulder injuries and leg pain are also common ailments.

Safety on the Job

Nurses face additional challenges through workplace hazards in a hospital or clinical environment. Because nurses work with sick people, their risk of exposure to someone with an infectious illness is much higher than that of the general population.

The risk of exposure to and contraction of infectious diseases is one of the most serious challenges of nursing. A necessary measure to combat this challenge is for nurses to turn to preventative and self-care. 

Workplace Violence 

Workplace violence and bullying are serious issues, and the nursing field is not immune to these challenges. The American Nurses Association (ANA) defines bullying as “repeated, unwanted harmful actions intended to humiliate, offend and cause distress in the recipient.”

This is one of the more dangerous challenges nurses face, and it’s a prominent concern. According to a 2022 survey crafted by the healthcare performance company Press Ganey, more than two nursing personnel were assaulted every hour during Q2 of 2022. 

According to a 2022 analysis conducted by McKinsey & Company, the United States may experience a registered nursing (RN) shortage of between 200,000 and 450,000 by 2025 without industry and government intervention. 

A continued shortage of nurses is an ongoing challenge. This contributes to nurses being stretched thin and overworked. For a nurse who takes the care of patients seriously, it can be frustrating to not have enough time to devote to each individual patient or interact compassionately with their families. 

Technological Advancements

Technological advancements have impacted the healthcare profession in positive and exciting ways, but technology has also created one of the newest challenges in nursing.

Technology moves at a very fast pace, and new advances can have an immediate impact on the way nurses work, requiring nurses to continually learn new skills. New software or equipment can seem overwhelming, especially if one doesn’t have a natural aptitude for technology.

Patient Death 

Due to the nature of the job, nurses in certain clinical settings can be exposed to dying patients. Their death can evoke a wide range of emotions, such as sadness, compassion and helplessness. 

It’s important for nurses to develop strong coping strategies that can help them prevent compassion fatigue from overwhelming them in the wake of patient death. Doing so can help them focus on delivering consistent care to every patient they encounter.

How to Cope with Challenges in Nursing

Nurses are a resilient, proactive group, and dealing with and overcoming the challenges of nursing is part of what makes them so amazing at their jobs and how they care for their patients.

The following tips can help nurses function optimally.

1. Practice Regular Self-Care

Providing high-quality care requires you to be healthy and feeling at your best. When you’re at work, take regular breaks, don’t skip meals and pace yourself.

When you leave work, leave work issues behind. Eat nutritiously, get adequate rest and take well-earned time for yourself.

Even a short walk can refresh your perspective. Don’t shortchange your own health and well-being — you and your patients will thank you.

2. Put Safety First

As a nurse, you are used to putting the safety of your patients first — but don’t do this if it puts yourself at risk.

Don’t be afraid to ask for assistance with moving or lifting a patient who might be too heavy for you. 

Form positive relationships with those you work with and be collaborative. Be proactive and make your voice heard if you see or experience something that poses a safety risk — either to a patient or to the medical staff.

Finally, if you do experience an injury on the job, take the time you need for healing; don’t continue to push yourself when you’re in pain.

3. Practice Good Hygiene

Practicing good hygiene, such as washing your hands thoroughly and frequently, covering your mouth and nose when you cough or sneeze and avoiding touching your face are all simple but surprisingly effective ways you can protect yourself from disease.

In the hospital setting, nurses can make sure they wear personal protective equipment, commonly known as PPE. This includes wearing gloves to protect their hands, masks to protect their mouths and noses, goggles to protect their eyes and gowns to protect their skin and other clothing.

4. Prioritize Workplace Wellness

If you’re a nurse leader, you can develop an organizational culture that emphasizes workplace wellness. 

There are several tactics that can be used to bring this wellness mindset to fruition, and they can also help encourage nurse self-care . Designating a free room or rooms as quiet zones where nurses can go for a few minutes can allow them to alleviate stress and recharge their batteries. Having healthy snacks readily available can also help nurses maintain energy and keep them nourished, which could also help keep negative feelings at bay. 

Engaging with nurses and seeking insight into the state of the current work environment can help nurses feel more included in the flow of the work environment, which could reduce frustrations that lead to nurse burnout or, in some cases, bullying or violent behaviors.

5. Be Mindful of Staff Shortages

If you find yourself working in a place that is short-staffed, you can attempt to negotiate with your supervisors to make sure your schedule is not negatively affecting your ability to function productively.

If there seems to be no way around an overly taxing schedule, be proactive and explore other nursing options. Remember, putting yourself at risk is counterproductive, both to your own health and that of your patients.

6. Build Technology Skills

Your main concern is caring for your patients, but the reality is that technology can help you do your job more efficiently. So it’s important to stay up to speed on nursing technology. Keep in mind that technology is meant to make your life easier, and because of this, the learning curve is more than worth it.

If you want to stay ahead of technology’s ever-evolving curve, consider proactively learning new tech skills. If you have long-term career ambitions in the nursing field, upskilling may also improve your chances for advancement, as you may have more tools to offer than the competition.

Build a Supportive Environment

Compassion fatigue is a big challenge in nursing and can lead nurses to withdraw from social interactions or isolate themselves from healthy relationships. These behaviors can make a nurse feel like they’re alone. If you’re a nurse leader, it’s important to minimize these behaviors by building a supportive environment. 

Reassure your staff that they aren’t alone if they feel emotional after interacting with dying patients. Make them feel like they can share these emotions in a safe, inclusive environment.

There may be times when your staff needs additional support. In these instances, it’s important to encourage the use of a facility’s external support system, such as an Employee Assistance Program (EAP). These programs allow nurses to gain professional help and care regarding not only the driving factors behind compassion fatigue but other issues that may contribute to concerns such as nurse burnout.

How a Faith-Based Education Can Help

Nurses face plenty of challenges as the field requires stamina, perseverance and commitment. Earning a faith-based nursing degree can help provide the foundational elements needed to overcome these challenges. By integrating the knowledge and skills of a nursing program with a community that supports growth in faith and academics, you can cultivate a sense of support that can keep you centered as your career grows.

This sense of support can also help you maintain focus on the numerous benefits of being a nurse, including the profession’s ultimate goal of providing care that can improve patient lives. You can realize your God-given potential while impacting society as a whole for good. Meeting the challenges of nursing takes a special individual, one who is committed to providing the highest level of care to patients while also continuing to grow professionally and personally.

Overcoming Challenges in Nursing with an MSN

Advanced degrees offer more options, especially for nurses. If you’re interested in a more autonomous role, consider an online Master of Science in Nursing (MSN) degree.

In Spring Arbor University’s online MSN program, students can choose from the following tracks:

• MSN- Nurse Practitioner ( Family Nurse Practitioner , Psychiatric Mental Health Nurse Practitioner , Primary Care Pediatric Nurse Practitione r or Adult-Gerontology Nurse Practitioner )
• MSN/ MBA Dual Degree
• MSN Ed.- Nurse Educator

There are also bridge programs available for students who do not yet hold a bachelor’s in nursing but want to pursue a master’s degree.

Spring Arbor University’s enriching curriculum combines the knowledge of medical and diagnostic practices with cultivating compassion that stems from the Christian faith.

Nursing students will become proficient in applying a holistic approach to treating patients as whole persons, not merely an impersonal mass of unrelated symptoms.

Spring Arbor’s online nursing programs are uniquely designed for working nurses to help you better cope with the challenges of nursing while you earn your degree.

With a flexible online format and an engaged network of faculty and staff, you’ll have the support that you need. Our graduates often emerge as nurse leaders who deliver quality patient care and are prepared to help others overcome challenges in nursing.

Explore Spring Arbor University’s programs and see which one is right for you.

Recommended Readings

4 Problems Nurses Face in the Hospital Nurses’ Guide to Medical Missions Trips - Serving Those in Need What Can You Do With an MSN in Nursing Education? 10 Tips for Nursing Safety Why Become a Nurse Practitioner?

American Association of Colleges of Nursing, Nursing Shortage The American Journal for Nursing , “American Nurses’ Association’s First Position on Education for Nursing” American Nurses Association, Violence, Incivility, & Bullying Encyclopedia Britannica, Nursing Encyclopedia Britannica, The Practice of Nursing Gallup, “Nurses Retain Top Ethics Rating in U.S., but Below 2020 High” Indeed, 8 Challenges as a Nurse and Tips for Overcoming Them The Joint Commission, Quick Safety 24: Bullying Has No Place in Health Care (Updated June 2021) Journal of Education and Health Promotion , “Challenges Faced by Nurses While Caring for COVID-19 Patients: A Qualitative Study” McKinsey & Company, “Assessing the Lingering Impact of COVID-19 on the Nursing Workforce” Press Ganey, On Average, Two Nurses are Assaulted Every Hour, New Press Ganey Analysis Finds Psychology Research and Behavior Management , “Feelings and Emotions of Nurses Related to Dying and Death of Patients - a Pilot Study” Relias, “Increased Nurse Work Hours & Patient Safety Effects” Springer Publishing , “Florence Nightingale, Nursing, and Healthcare Today” WebMD, “Compassion Fatigue: Symptoms to Look For” WellRight, How Your Wellness Program Can Improve Nursing Retention

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2023: Challenges in Nursing Education

This May a short walk across the stage of institutions across Illinois marked the end of another school year, and another year spent preparing young nurses to step into the workforce. The Class of 2023 were freshmen in 2020 when COVID-19 sent our world into chaos – students were forced to navigate the brunt of the pandemic along with its accompanying challenges as educational institutions across the nation grappled with how to shift a curriculum that relies profoundly on hands-on learning online. 

Looking back, as a community of educators we have learned some things. The pandemic saw nurses — both in practice and in education — rally together for the good of our country in ways that were inspiring, exhausting, and every feeling in between. Looking back, we cannot say enough thanks to our partners in nursing practice for the sacrifices they made during the pandemic. Looking forward, we also, unfortunately, cannot say that we believe the need for those sacrifices has met its end.  

On May 5, the World Health Organization (WHO) Director-General Tedros Adhanom Ghebreyesus announced the end to the international public health emergency as worldwide cases of COVID-19 infection, hospitalizations, and deaths continued downward. However, we at the Illinois Association of Colleges of Nursing (IACN) see continued challenges on the horizon. 

This piece marks the first in a series of pieces that will explore the challenges affecting nursing education in Illinois. Our goal is not only to provide quality nursing education but also to serve as a reliable source of information about the most pressing issues facing students, institutions of higher education, and nursing educators. 

IACN’s View on the Top Challenges in Nursing Education in 2023

Many of the things we believe are the top challenges nursing education faces in 2023 are not new — in fact, we have written about some of them before (linked below). However, they have been exacerbated by the pandemic and without intervention, we believe may become even larger issues than they are now. 

These challenges include: 

• The faculty shortage
• Nurse burnout
• Student resiliency
• Accessibility issues 
• NCLEX 

Why do we believe these are Illinois’ top challenges?

First, and perhaps most importantly, many of them are linked together in ways that make it extremely difficult to find solutions. Take, for example, the faculty shortage. 

Finding faculty has long been a challenge in Illinois. Because there are national shortages for both practicing nurses and nurse educators, nurses across the board are asked to take on more, contributing to burnout. In Illinois, nurses are retiring at a faster rate than new nurses are entering the workforce, further exacerbating the issue of burnout. Regardless of industry, people who are burned out largely do not take on additional challenges (like going back to school and earning the required credentials to teach). 

Compounding this is pay; educator salaries in Illinois are largely not competitive. This makes it hard to pull nurse educators from other states or inspire practicing nurses to pivot to being educators. Suddenly, (in a very simplified version of this vicious circle), we find ourselves in a situation where because there are not enough nurses there are not enough nurse educators, and because there are not enough nurse educators, we struggle to graduate enough nurses.  

Resiliency, accessibility, and NCLEX relate to students and are again closely linked. Advisors across higher education recognize that GenZ is different than previous generations, with unique challenges that put pressure on both educational institutions and healthcare facilities. Institutions of higher education are grappling with how to provide enhanced student support services and accommodations at a scale not seen before. Generational challenges, compounded by challenges faced by students during the pandemic, are contributing to sliding NCLEX pass rates across the state (and nation). And then, students struggle with resiliency upon entering the workforce, leading to the need for enhanced support for early career nurses from healthcare institutions that are already strapped for bandwidth.  

What comes next?

As stated earlier, in the coming pieces we will dive deep into these challenges, unraveling the “why” and proposing solutions where possible. Stay tuned!

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• Nursing, Patient Safety, Team Training

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 [email protected] .

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Examining and mitigating racism in nursing using the socio-ecological model

Affiliations.

• 1 School of Rehabilitation and Medical Sciences, The Herbert H. and Grace A. Dow College of Health Professions, Central Michigan University, Mount Pleasant, MI, USA.
• 2 Georgetown University School of Nursing, Washington, DC, USA.
• 3 Trudy Busch Valentine School of Nursing, Saint Louis University, Saint Louis, MI, USA.
• PMID: 38567694
• DOI: 10.1111/nin.12639

Racism in nursing is multifaceted, ranging from internalized racism and interpersonal racism to institutional and systemic (or structural) elements that perpetuate inequities in the nursing profession. Employing the socio-ecological model, this study dissects the underlying challenges across various levels and proposes targeted mitigation strategies to foster an inclusive and equitable environment for nursing education. It advances clear, context-specific mitigation strategies to cultivate inclusivity and equity within nursing education. Effectively addressing racism within this context necessitates a tailored, multistakeholder approach, impacting nursing students, faculty, administration, professional organizations, and licensing and accrediting bodies. This all-encompassing strategy recognizes that the interplay of interpersonal dynamics, community culture, institutional policies, and broader societal structures intricately shapes individual experiences. Nurses, nurse leaders, educators, organizations, and policymakers can work together to create a more equitable and inclusive nursing profession by targeting each of these levels. This transformational process can yield positive outcomes across various environments where nurses learn, work, and serve people and enable the demographic composition of nurses to better match the populations served.

Keywords: academic environment; diversity; equity; inclusion; mitigation strategies; nursing education; racism; socio‐ecological model.

© 2024 John Wiley & Sons Ltd.

Top 5 most challenging requirements for 2023

The Joint Commission regularly analyzes standards compliance data to identify trends and tailor education related to challenging standards and National Patient Safety Goals (NPSGs).

Below are the Top 5 Joint Commission requirements and corresponding elements of performance (EPs) identified most frequently as “not compliant” (in the higher Survey Analysis for Evaluating Risk ® or SAFER ® categories) during surveys and reviews from Jan. 1 through Dec. 31, 2023. For more information, see the April issue of Perspectives .

Ambulatory Care

• IC.02.02.01, EP 2: The organization implements infection prevention and control activities while doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.
• IC.02.01.01, EP 2: The organization uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection.
• MM.01.01.03, EP 2: The organization follows a process for managing high-alert and hazardous medications.
• MM.01.02.01, EP 2: The organization takes action to avoid errors involving the interchange of medications on its list of look-alike/sound-alike medication.
• EC.02.05.01, EP 7: In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, relative humidity, and temperature. For new health care facilities or altered, renovated, or modernized portions of existing ventilation systems or individual components (constructed or plans approved on or after July 5, 2016), heating, cooling, and ventilation are in accordance with NFPA 99-2012, which includes 2008 ASHRAE 170, or state design requirements if more stringent. Existing systems are in compliance with the ventilation standards that were in effect at the time the facility was constructed or last modified.

Behavioral Health Care and Human Services

• Training and competence assessment of staff who care for individuals served at risk for suicide.
• Guidelines for reassessment.
• Monitoring individuals served who are at high risk for suicide.
• NPSG.15.01.01, EP 1: The organization conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide and takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging).
• NPSG.15.01.01, EP 2: Screen all individuals served for suicidal ideation using a validated screening tool.
• HRM.01.06.01, EP 3: The organization conducts an initial assessment of staff competence. This assessment is documented.
• NPSG.15.01.01, EP 4: Document individuals’ overall level of risk for suicide and the plan to mitigate the risk for suicide.

Critical Access Hospital

• IC.02.02.01, EP 2: The critical access hospital implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.
• Verifies that the medication selected matches the medication order and product label.
• Visually inspects the medication for particulates, discoloration, or other loss of integrity.
• Verifies that the medication has not expired.
• Verifies that no contraindications exist.
• Verifies that the medication is being administered at the proper time, in the prescribed dose, and by the correct route.
• Discusses any unresolved concerns about the medication with the patient’s physician or other licensed practitioner, prescriber (if different from the physician or licensed practitioner), and/or staff involved with the patient’s care, treatment, and services.
• EC.02.05.01, EP 15: In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, temperature, and humidity. For new and existing health care facilities, or altered, renovated, or modernized portions of existing systems or individual components (constructed or plans approved on or after July 5, 2016), heating, cooling, and ventilation are in accordance with NFPA 99-2012, which includes 2008 ASHRAE 170, or state design requirements if more stringent.
• PC.02.01.11, EP 2: Resuscitation equipment is available for use based on the needs of the population served.
• EC.02.02.01, EP 5: The critical access hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals.
• Any medications administered, including dose.
• Any activity restrictions.
• Any changes in the patient’s condition.
• Any summaries of the patient’s care, treatment, or services furnished to the patient’s physician or allowed practitioner.
• The patient’s medical history.
• Any allergies to medications.
• Any adverse drug reactions.
• The patient’s functional status.
• Any diet information or any dietary restrictions.
• Diagnostic and therapeutic tests, procedures, and treatments, and their results.
• Any specific notes on care, treatment, or services.
• The patient’s response to care, treatment, or services.
• Any assessments relevant to care, treatment, or services.
• Physician or allowed practitioner orders.
• Any information required by organization policy, in accordance with law and regulation.
• A list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient’s care, treatment, or services.
• The plan(s) of care.
• For DMEPOS suppliers serving Medicare beneficiaries: The DMEPOS prescription, any certificates of medical necessity (CMN), and pertinent documentation from the beneficiary’s prescribing physician or allowed practitioner.
• All pertinent diagnoses.
• Mental, psychosocial, and cognitive status.
• Types of services, supplies, and equipment required.
• The frequency and duration of visits.
• The patient’s prognosis.
• The patient’s potential for rehabilitation.
• The patient’s functional limitations.
• The patient’s permitted activities.
• The patient’s nutritional requirements.
• All medications and treatments.
• Safety measures to protect against injury.
• A description of the patient’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors.
• Patient-specific interventions and education.
• Measurable outcomes and goals identified by the organization and patient as a result of implementing and coordinating the plan of care.
• Patient and caregiver education and training to facilitate timely discharge.
• Information related to any advance directives.
• Identification of the disciplines involved in providing care.
• Any other relevant items, including additions, revisions, and deletions that the home health agency, physician, or allowed practitioner may choose to include.
• LD.04.01.07, EP 1: Leaders review, approve, and manage the implementation of policies and procedures that guide and support patient care, treatment, or services.
• PC.01.03.01, EP 5: The written plan of care is based on the patient’s goals and the time frames, settings, and services required to meet those goals.
• IC.02.02.01, EP 2: The hospital implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.
• Discusses any unresolved concerns about the medication with the patient’s physician or other licensed practitioner, prescriber (if different from the physician or other licensed practitioner), and/or staff involved with the patient’s care, treatment, and services.
• NPSG.15.01.01, EP 1: For psychiatric hospitals and psychiatric units in general hospitals: The hospital conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide; the hospital takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging). For nonpsychiatric units in general hospitals: The organization implements procedures to mitigate the risk of suicide for patients at high risk for suicide, such as one-to-one monitoring, removing objects that pose a risk for self-harm if they can be removed without adversely affecting the patient’s medical care, assessing objects brought into a room by visitors, and using safe transportation procedures when moving patients to other parts of the hospital.
• EC.02.05.01, EP 15: In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air exchange rates, filtration efficiencies, temperature, and humidity. For new and existing health care facilities, or altered, renovated, or modernized portions of existing systems or individual components (constructed or plans approved on or after July 5, 2016), heating, cooling, and ventilation are in accordance with NFPA 99-2012, which includes 2008 ASHRAE 170, or state design requirements if more stringent.
• EC.02.06.01, EP 1: Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided.

Laboratory and Point-of-Care Testing

• QSA.02.08.01, EP 2: The laboratory performs correlations at least once every six months. The correlations are documented.
• Individual unacceptable proficiency testing results.
• Late submission of proficiency testing results (score is zero).
• Nonparticipation in the proficiency testing event (score is zero).
• Lack of consensus among all laboratories participating in the proficiency testing event (score is ungradable). These actions are documented.
• QSA.02.11.01, EP 7: The laboratory performs review of other records (for example, work records, equipment records, quality control summaries) at a frequency defined by the laboratory, but at least monthly. The review is documented.
• EC.02.04.03, EP 7: The laboratory performs preventive maintenance, periodic inspection, and performance testing of each instrument of piece of equipment. These activities are documented.
• Direct observations of routine patient test performance, including patient preparation, if applicable, and specimen collection, handling, processing, and testing.
• Monitoring, recording, and reporting of test results.
• Review of intermediate test results or worksheets, quality control, proficiency testing, and preventive maintenance performance.
• Direct observation of performance of instrument maintenance function checks and calibration.
• Test performance as defined by laboratory policy (for example, testing previously analyzed specimens, internal blind testing samples, external proficiency, or testing samples).
• Problem-solving skills as appropriate to the job.

Nursing Care Center

• EC.02.02.01, EP 5: The organization minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals.
• IC.02.02.01, EP 4: The organization implements infection prevention and control activities when doing the following: Storing medical equipment, devices, and supplies.
• Documents current licensure and any disciplinary actions against the license available through the primary source.
• Verifies the identity of the individual by viewing a valid state or federal government-issued picture identification (for example, a driver’s license or passport).
• Obtains and documents information from the National Practitioner Data Bank (NPDB). The medical director evaluates this information.
• Determines and documents that the practitioner is currently privileged at a Joint Commission-accredited organization; this determination is verified through the accredited organization. If the organization cannot verify that the practitioner is currently privileged at a Joint Commission-accredited organization, the medical director oversees the monitoring of the practitioner’s performance and reviews the results of the monitoring. This monitoring continues until it is determined that the practitioner is able to provide the care, treatment, and services that they are being permitted to provide.
• Performance of a test on a blind specimen.
• Periodic observation of routine work by the supervisor or qualified designee.
• Monitoring of each user’s quality control performance.
• Use of a written test specific to the test assessed.
• PC.02.02.03, EP 11: The organization stores food and nutrition products, including those brought in by patients and residents or their families, under proper conditions of sanitation, temperature, light, moisture, ventilation, and security.

Office-Based Surgery

• IC.02.02.01, EP 2: The practice implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.
• IC.02.01.01, EP 2: The practice uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection.
• EC.02.04.03, EP 4: The practice conducts performance testing of and maintains all sterilizers. These activities are documented.
• HR.01.06.01, EP 5: Staff competence is initially assessed and documented as part of orientation.

Nursing Home Basics: Who Qualifies, Who Pays, and Other Helpful Facts

Why it matters.

Understanding how nursing homes work can be confusing because standards for eligibility, insurance coverage, etc. vary from state to state in the US.

In this second article in our series on nursing homes ( read Part I here ), we answer some commonly asked questions about nursing home structures and functions.

Who Is Eligible to Enter a Nursing Home?

People qualify for nursing home/facility level of care (NFLOC) if they are unable to live alone safely in the community. There is no federal definition of NFLOC and the exact rules governing level of care vary from state to state. Despite this lack of consistency, the following four areas are commonly considered when a state determines a person’s level of care need: physical functional ability; health issues/medical needs; cognitive impairment; and behavioral issues. In many states, there has been significant rebalancing toward home and community-based services and away from nursing home care. Check state websites for updated information on specific eligibility requirements.

Who Pays for Nursing Home Care?

Medicare is the federal health insurance program for people in the US who are 65 or older, some younger people with disabilities, people with End-Stage Renal Disease. A common misconception is that Medicare will pay for all nursing home costs. This is not true.

Post-acute care (PAC) or skilled nursing facility (SNF) care is usually covered by Medicare or private insurance up to 100 days (100 percent for 20 days and then 80 percent for 80 days based on certain criteria). Long-term care (meals, room and board, and basic health services) is often paid for privately until funds are spent down. A “ spend down ” is how someone with Medicare may qualify for Medicaid — a joint federal and state program that provides health coverage to some people with limited income and resources — even if their income is higher than a state's Medicaid limit. Under a spend down, a state lets the person subtract their non-covered medical expenses and cost sharing (like Medicare premiums and deductibles) from their available income. Each state’s Medicaid program covers approximately 70 percent of nursing home care.  Long-term care insurance can also pay for nursing home care, but relatively few people have it.

The average cost of a nursing home is over $90,000 per year but this varies state to state. Multiple organizations provide information about nursing home costs and Medicaid daily rates online, including the  American Council on Aging .

Who Oversees and Regulates Nursing Home Quality and Safety?

The Centers for Medicare and Medicaid Services (CMS) oversees nursing home quality and safety at the federal level. Several divisions have regulations that pertain to nursing homes. 

The CMS Division of Nursing Homes develops and oversees most nursing home regulations. CMS delegates nursing home surveys and inspections to a designated organization in each state, usually the State Survey Agency (SSA). SSAs conduct annual, recertification, and complaint surveys and assess compliance with regulations. There is also a Special Focus Facility program for a small number of low-performing nursing homes that receive more intensive oversight and guidance on quality improvement in each state.

How Do We Measure Nursing Home Quality?

Because definitions of quality may vary, there are different methods used by federal, state, or private organizations to collect and analyze quality data. Here are a few examples:

• Minimum Data Set (MDS) is a standardized assessment tool required by CMS that measures health status in nursing home residents. All nursing homes that accept Medicare or Medicaid must submit the MDS regularly for each resident to receive payment.
• National Healthcare Safety Network is an electronic system for infection reporting, including COVID and other data that goes to CDC.
• CMS Five Star Quality Rating System gathers information from inspections (surveys), quality measures, and staffing from each nursing home and makes this information publicly available on the CMS website.
• Medicare’s Care Compare   allows users to locate and compare data from nursing homes.

What are Quality Innovation Networks-Quality Improvement Organizations (QIN-QIOs)?

QIN-QIOs focus on working with nursing homes, states, and regions to improve quality of life and quality of care across settings, including nursing homes. QIN-QIOs have their own separate line item in the US federal budget to support the national program which covers  all 50 states and US territories . QIN-QIOs are not part of state survey agencies or the survey process. Their focus is on quality improvement, support, education, and training, which are often provided free or at very low cost.

Who Works in Nursing Homes?

Women make up most of the nursing home workforce, particularly direct care workers such as certified nursing assistants (CNAs). ( Almost 90 percent of nursing assistants are female). Many are single parents.  People of color comprise most of the US nursing assistant workforce.

Most nursing assistants are low-income wage earners. Many live at or near the federal poverty level and almost half receive some type of public assistance. Nursing homes typically pay CNAs the minimum wage, but this is not necessarily a livable wage depending on where they live. For this reason, CNAs often work in multiple settings and have multiple jobs. For many CNAs, English is not their first language, and they may have limited English proficiency. Many are immigrants.

What Are Some Challenges Faced by the Nursing Home Workforce?

There are many issues facing nursing home CNAs today and some new opportunities. The National Association of Health Care Assistants (NAHCA) conducted a survey of 1,420 CNAs in July 2023. When asked about their jobs, many CNAs reported that low wages and benefits would be the primary reasons they intend to seek another type of employment. They also cited unstable or inadequate hours, lack of supervisor’s/manager’s support, lack of career advancement or professional development, and feeling under-valued.

High rates of turnover (in some cases over 100 percent in a year) and the need for stronger, stable leadership are important reasons to better support CNAs and other direct care workers. Creating and testing standardized career ladders or lattices and providing more training and education on topics of interest to CNAs represent opportunities to promote better retention and reduce turnover. Another way to respond to CNA concerns is by becoming an  Age-Friendly Health Systems Nursing Home .

Alice Bonner, PhD, RN, is IHI’s Senior Advisor for Aging. Amanda Meier, BSW, MA, is IHI’s Project Manager, Age-Friendly Health Systems. If you have any questions or ideas about nursing homes or related policy issues, please feel free to reach out to Alice Bonner ( [email protected] ) or Amanda Meier ( [email protected] ).

You may also be interested in:

The Basics We (and Policymakers) Should Know about Nursing Homes

Centering What Matters: The Core of Age-Friendly Care

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Biden has approved $143 billion in student loan forgiveness and is set to unveil new plan.

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WASHINGTON, DC - APRIL 04: U.S. President Joe Biden delivers remarks in the East Room of the White ... [+] House on April 04, 2024 in Washington, DC. Biden is set to unveil a new student loan forgiveness plan. (Photo by Chip Somodevilla/Getty Images)

President Joe Biden will formally unveil a new student loan forgiveness plan next week, even as the Education Department continues to implement billions in debt relief approved so far.

The Biden administration has approved more than $143 billion in student loan forgiveness since 2021, according to the latest Education Department data. Despite the Supreme Court knocking out Biden’s signature debt relief plan last year (which would have eliminated up to $20,000 in federal student loans for millions of borrowers), the administration has nevertheless been able to provide unprecedented relief by streamlining and reforming key loan forgiveness programs already authorized by Congress. And according to the Wall Street Journal , Biden is set to formally announce a new debt relief plan in a speech next week.

Here’s what borrowers should know.

More Than $143 Billion In Student Loan Forgiveness Approved Under Biden So Far

Through executive actions, temporary initiatives, and regulatory reforms, the Biden administration has managed to enact billions in student loan forgiveness already. The success is due to improvements made to existing loan forgiveness programs, rather than reliance on a new plan (like the one struck down by the Supreme Court last summer). This relief includes:

• $45.6 billion in student loan forgiveness for more than 900,000 borrowers through the IDR Account Adjustment initiative and other fixes to income-driven repayment.
• $62.5 billion in loan forgiveness for more than 870,000 borrowers through fixes to Public Service Loan Forgiveness.
• Over $22.5 billion in debt relief for more than 1.2 million borrowers who were subject to harmful practices or actions by their school such as misrepresentations, fraud, or closure.
• Nearly $12 billion in discharges for half a million borrowers with disabling medical conditions.

The Biden administration also established a new income-driven repayment plan called SAVE, which has resulted in low payments and accelerated student loan forgiveness for certain borrowers. More than 7 million people have enrolled in SAVE so far.

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The Biden administration is developing a new student loan forgiveness plan under the Higher Education Act. This plan will be provide targeted relief to several groups of borrowers including those who have experienced negative amortization (balance increases due to interest accrual, even while in repayment), borrowers who have had loans for more than two decades, and those unable to repay their student loans due to hardship .

The Education Department completed key steps of the negotiated rulemaking process earlier this spring to create regulations governing the new program. A rulemaking committee reached consensus on core elements of the student loan forgiveness plan, particularly for hardship-based forgiveness, which increases the chances that these features will make it into the final plan.

Biden is set to formally announce the plan next week, according to reports. The plan must then go through one more round of public comments before the regulations become finalized. Some observers believe the loan forgiveness plan could become available to borrowers by this summer or fall.

Legal Challenges Expected For Biden’s Next Student Loan Forgiveness Plan

Biden’s next student loan forgiveness plan is widely expected to be challenged in court. His first debt relief program never got off the ground, as litigation resulted in temporary injunctions which blocked relief. The legal dispute eventually made its way to the Supreme Court, where the conservative majority struck down the program as an overreach that exceeded Congressional authorization.

Administration officials hope that Biden’s latest loan forgiveness effort will have a better chance of success. The new program is being established under a completely different legal authority which expressly authorizes the Education Department to cancel student debt. However, the challengers are expected to argue that this authority is narrow, and does not authorize mass student loan forgiveness.

Last month, a coalition of Republican-led states filed a lawsuit in Kansas seeking to block the new SAVE plan . A court has not issued any ruling at this time.

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Investigating the challenges of clinical education from the viewpoint of nursing educators and students: A cross-sectional study

Associated data.

Supplemental material, sj-docx-1-smo-10.1177_20503121221143578 for Investigating the challenges of clinical education from the viewpoint of nursing educators and students: A cross-sectional study by Ashrafalsadat Hakim in SAGE Open Medicine

Nursing clinical education is an important part of education in nursing in which students obtain the necessary skills to care for patients. The aim of this study was to investigate the challenges of clinical education from the viewpoint of nursing educators and students.

In this cross-sectional study, the required information was collected in the form of a census from nursing educators and students. Based on the census method, the research samples consisted of 163 nursing educators and students. The data collection tool is a researcher-made questionnaire. The data were analyzed using descriptive statistics and an independent t -test.

The findings showed in the view of students the factors such as incongruity between educator’s expertise and internship, lack of qualified educators, student’s disinclination to study, lack of cooperation of health professionals, students’ unawareness of their strengths and weaknesses. Lack of skilled clinical educators in the educational planning section.

Conclusion:

According to the current challenges, identifying and then modifying clinical education challenges lead to achieving the educational goals and consequently, educating skillful personnel and supplying high-quality care services.

Introduction

Training is the process and result of mastering systematic knowledge and skills, a prerequisite for preparing a person for life and work. The purpose of training is to form a personality that is able to adapt to life through characteristics such as independence, activity, creativity, etc. 1 Since today’s emphasis is on the ability to apply knowledge to practice. 2 Clinical education is an essential element in the education of legal, medical and psychological professionals. There are some commonalities in the education of these professionals that support an understanding of the importance of clinical education in helping students apply academic education to the “real world” of clients and patients. 3

Most clinical training involves immersion of the student in the workplace for varying periods of time and is therefore similar to the broader constructs of work-based learning or work-integrated learning. 4 The goals of clinical education are to develop critical thinking, professional knowledge and skills, and decision-making skills, and to increase the experience and self-confidence of students. 5 – 8

Clinical education can have different meanings for different disciplines. This requires a different approach in each field. In summary, clinical education has evolved into multifaceted educational models that have been adopted by various disciplines to create and implement experiential learning opportunities for students. 3 In this regard, clinical education is one of the most important parts of nursing education. For personal growth and improving practical skills is very important. 9 The fundamental principle of clinical education is that it prepares nursing students for their professional nursing careers with real practice and to guide their learning and research in national and international contexts and their socialization in their professional roles to provide appropriate and effective patient care. 5 , 10

Considering that learning in clinical environments is an important part of the professional development of nursing students. 11 Learning of nursing students in a clinical education environment is considered a major factor in nursing education programs and helps students to integrate theoretical training with clinical practice and eliminate the theory-practice gap in nursing, therefore reforming of the educational environment should be attended by those involved in the education in order to standardize it in providing educational facilities. 12

Researchers believe that instructive moments that are directly related to optimal patient care can potentially have an impact and develop a positive learning culture in clinical settings. 13

According to the results of a study, nursing students stated that nurses in the clinical environment have many positive and negative direct effects on the clinical learning of nursing students. 7 On the other hand, learning in crowded and complex situations where patient care is a priority can be challenging. 14

The important point is that nursing students have a concern about their clinical education that must be effectively and efficiently implemented, and if this doesn’t succeed correctly, these students will not have a major goal; because the continuity of their activities in the future is somehow influenced by the clinical education process. 15

Also, based on the studies, the development and promotion of teaching-learning quality in clinical education requires explaining the current situation and identifying its challenges, problems and strengths. 16 In this regard, the research findings on the challenges of clinical nursing education revealed that the many problems of clinical education were related to factors associated with clinical educators (78%), learners (73%), clinical environment (71%), educational program (66%), clinical evaluation (60%) and related problems (43%). 17 Also, the result of another study which was carried out with the aim of investigating the barriers to clinical education in nursing, barriers to clinical education were identified as follows: barriers to clinical education in individual contexts related to students (lack of motivation in students), professors (lack of experienced and highly educated professors) and nurses (lack of staff cooperation), managerial (lack of time), facilities (lack of facilities and working conditions), structures and other aspects. 18 The research results of Hakim et al. also showed that 51.9% of the students were not satisfied with the evaluation method and assessed this area as undesirable in the field of monitoring and evaluation. 15 Considering the importance of the viewpoints of educators and students in the educational process (theoretical and clinical) and the differences in the provision of educational services in related institutions as well as performing limited studies in this field, the author performed research with the aim of investigating the challenges of clinical education from the viewpoint of nursing educators and student; so that we can improve the quality of care and ultimately the satisfaction of the health system’s clients by identifying the challenges in this regard, especially the clinical environment, and then taking steps to overcome these barriers.

Materials and methods

Study design.

This descriptive study was conducted in 2020 from April to June on nursing students and instructors.

The research samples consisted of 163 nursing students and educators who are equal to the research community. In other words, in this research, all nursing educators and students of the nursing and midwifery faculty were selected. Therefore, power analysis for sample size calculation was not done.

A total of 163 subjects included the second semester of junior students ( n  = 58), the second semester of senior students ( n  = 82), and nursing educators ( n  = 23, who have more than 1 year of clinical education experience) of the School of Nursing and Midwifery. The inclusion criteria in the present study included being in education and being satisfied with participating in the study, as well as completion of the questionnaire. Exclusion criteria included unwillingness to participate in the study or having a study leave at the time of the research.

Ethical consideration

The author then distributed the questionnaire after receiving the code of ethical consideration (U-95107 research project) from the vice chancellor for research of the university and obtaining oral and written consent from the samples. In addition, participants in the research were assured that the data were completely confidential.

Instrumentation

The author considered a time to fill in the questionnaires so that the research samples had more opportunity to do it. In order to determine the validity, the questionnaire was given to 10 members of the nursing and midwifery faculty and their opinions were examined.

The reliability of the questionnaire was determined using the results of a preliminary study on 24 people from the samples for the entire questionnaire using Cronbach’s alpha coefficient, which was 0.92.

Data collection

In this research, a researcher-made questionnaire was used to collect the data using a literature review, articles, and a survey of experts. After determining the reliability of the questionnaire, questionnaires were distributed among students and educators.

The questionnaire consists of two parts: the demographic information of the educators from questions (1–8) and the demographic information of the students from questions (1–6) and the challenges of clinical education from questions (1–36). The challenges of clinical education comprise six domains, including educators from questions (1–7), students (questions 8–14), clinical education environments from questions (15–19), educational planning from questions (20–25), welfare-educational facilities from questions (26–30) and clinical evaluation from questions (31–36).

The method of the score is in a way that a zero score does not affect the response at all, the score of 1 has a low impact on the response, the score of 2 has a high impact on the response and the score of 3 has a very high impact on the response. The minimum score for the total number of questions was zero and the maximum was 108. The division of responses is in a way that 0–26 scores do not affect the responses at all, 27–54 have a low impact, 55–81 have a high impact and 82–108 have a very high impact on the responses.

In the domain of educators, 0–5 do not affect at all, 6–10 have a low impact, 11–15 have a high impact and 16–21 have very effective. In the domain of clinical education, the score of 0–3 do not affect at all, 4–7 have a low impact, 8–11 have a high impact and 12–15 have a very effective. In the domain of educational planning, the score of 0–4 does not really affect at all, 5–9 have a low impact, 10–14 have a high impact and 15–18 have a very high impact. In the domain of welfare educational facilities the score of 0–3 does not affect at all, 4–7 has a low impact, 8–11 has a high impact and 12–15 have a very high impact. In the domain of clinical evaluation, the score of 0–4 does not affect at all, 5–9 have a low impact, 10–14 have a high impact and 15–18 have a very high impact.

Statistical analysis

After collecting questionnaires, SPSS 20 software was used in order to analyze the data, and descriptive statistics such as mean and standard deviation and frequency percentage were used for the description of demographic data and inferential was used to compare mean and standard deviation between two independent groups. The findings were presented as frequency distribution tables and numerical sizes such as mean and standard deviation. The significance level used in statistical tests was considered as p  < 0.05.

The results showed that most of the research samples were women. The student’s age mean was 23.60 and the educator’s age mean was 45.75. Most of the educators have master’s degrees and most of them have work experience from 11 to 20 years ( Table 1 ).

Frequency distribution of the demographic characteristics.

Students’ opinions about nursing clinical education challenges

In general, students (nursing students) believe that incongruity between educators’ skills and related apprenticeship has the most impact on clinical education challenges in the educators’ section (86%). In students’ idea, the lack of skilled clinical educators (82%) has the greatest impact on challenges in the educational planning section. In students’ opinion, the lack of interest in studying among students caused by unawareness of nursing duties (89%) has the most effects on challenge creation. In their idea, medical sanitary members (Doctors and Nurses) in education centers refuse to cooperate with students which causes problems in clinical education challenges (93%). Overall, 79% of these challenges are related to students’ unawareness of their strengths and weakness even after completing an apprenticeship. In general, 94% lack of education facilities and amenities for students and educators and inaccessibility to a conference hall in the clinic have the greatest impact on creating clinical education challenges ( Table 2 ).

Students’ opinions about nursing clinical education challenges.

Educators’ opinions about nursing clinical education challenges

In educators’ idea, (78%) inadequate scientific information and clinical experiences of educators have the most effect in clinical education challenges. In the students’ section, from the viewpoint of educators, (91%) students’ reluctance to clinical activities has the greatest effect on clinical education challenges. In clinical assessment, from educators’ idea, inadequate opportunity to identify educational targets and assessment process of nursing students (83%) has a significant effect on clinical education challenges. In the educational planning section, educators believe that (96%) incongruity between clinical education goals and theoretical targets are reasons for clinical education challenges. In the educational welfare facilities section, in educators’ opinion (87%), the lack of education facilities in hospital has the most influence on clinical education challenges. In the clinical education section, educators believe that in hospitals, staff doesn’t have enough motivation to help nursing students (91%) ( Table 3 ). The mean of educators’ and students’ opinions on the clinical education challenges in all sections are compared by T -test and only in the educators’ section, do we observe a significant difference between the two groups ( p  < 0.05). In other words, the mean of students’ ideas in the educators’ section was more than the mean of educators’ ideas.

Educators’ opinions about nursing clinical education challenges.

Clinical education is a vital and essential part of nursing education. 19 This paper showed that in spite of efforts, there are many challenges that nursing education would be faced with. Researchers consider it very important to identify the challenges of clinical education in nursing. 20 With regard to the challenges of clinical education, the results showed that in the educator’s section, 86% of students pointed to incongruity between educators’ skills and related job, as the key factor that influences clinical challenges. On the other hand, researchers say identifying the best teaching strategies to maintain and enhance the engagement of nursing students in academic and clinical environments has always been a challenge for nursing educators. 21 In their report, the researchers listed poor school infrastructure and insufficient number of educators as problems for students. 22 Paying attention to the coach as the most effective factor in clinical education and understanding the challenges associated with the agent for improvement of clinical education is very important and effective. In this regard, the use of a safe and effective evaluation system is very important. 23

The researchers stated that based on the barriers identified in different dimensions, appropriate programs and strategies should be designed and implemented with each of the existing barriers in order to improve the quality of clinical education. 18 Also, according to the results of another study, the largest obstacle in clinical training is the lack of motivation and interest of students. 24 In the nursing students section, 89% of students believe that being unaware of nursing duties and inclination to study the subjects are the main reasons for problems and challenges in clinical education. Based on the study results, prevalence of challenge of nursing students in their practical training was reasonable. 25 Nursing education is an ever-changing discipline, and as soon as it shifts from regular classes to web-based clinical guidelines, educators are required to guide, motivate, and coach students to gain a more technologically advanced experience in their field of study. 26 According to the results of the present study and other studies, for attracting the cooperation of the medical team it is necessary to provide better research facilities for their cooperation.

In the educational planning section, 82% of students believe that the lack of experienced educators in the clinical setting is the main reason for clinical challenges. In this regard, researchers express that determining the basic effective features in clinical education of nursing faculty members is necessary to improve the quality of education and ultimately improve the efficiency and effectiveness of the educational system. 23 On the other hand, according to the results of another study, nursing students stated that they face challenges due to the absence of educators during essential hours. 25 Since learning and getting experience in the clinic have a direct relationship with clinical educators’ characteristics, the education-learning process through experienced educators would encourage students to use their capacity.

In the educational welfare facilities section, lack of conference room in clinical setting and lack of rest room for trainer and student are main problems that 94% of students pointed to. In this regard, Dağ et al. 22 say the physical and educational opportunities of organizations should be considered in order to increase the efficiency of clinical education. Also, areas of clinical activity should be selected from institutions that have a suitable physical infrastructure to create positive learning environments. So that, Hakim et al. 15 in their study stated the improvement of facilities and equipment in the clinical environment, the review of tools and evaluation processes is recommended. Hence, managers and planners are included as part of the designers of educational and apprenticeship programs and this ensures that all students have the opportunities to learn. Also equipping the hospital with educational facilities in different parts for controlling and supervising the behavior of students by educators and college and hospitals administrators to avoid following incorrect routines and promoting safety procedures in clinical practice is from constructive steps to improve the quantity and quality of clinical education because the educational content and clinical settings are effective in motivating students for applying information and solving problems and elevating the power of judgment in students. According to the results, it is necessary to take some strategies for providing appropriate welfare facilities such as the use of hospital self-service, a suitable place to change clothes and rest, especially on the night shift at the hospital, and an educational center for students.

In the clinical assessment section, 79% of students discussed that disappointment in weaknesses and strengths after an education course is the main cause of clinical challenges. On the other hand, in the study of Antohe et al., 27 most students rated their clinical learning environment positively. Of course, it can be acknowledged that perhaps one of the reasons for the difference between the results of the study of Antohe et al. and the results of other studies, implementation of individual supervision by students has been in training courses and in clinical environments. Also, the most satisfied students had the experience of individual supervision. Regarding clinical education challenges that is related to the above-mentioned section, 78% of educators believe that inadequate clinical experience and scientific knowledge have the most effects on clinical challenges. Learning and getting information in clinical contexts have direct relation with clinical educators’ characteristics.

In this regard, research results confirm that educators experience various problems, including problems related to having a heavy workload, providing a suitable clinical environment, having too many students, implementing nursing care programs, and having a poor physical environment in clinics and enlisting the support of health-care team members. In addition, educators stated that these problems negatively affect the teaching of some nursing practices and effective learning and education. 22 This process, done by efficient teachers, has huge effect on maximum usage of their capabilities. The identified challenges in clinical education reflect the need to support from clinical educators and helping them in order to prepare for their role through educational programs or change the policy. 28

In students’ section (students assessment), 91% of educators stated that the reluctance of students to do clinical exercises is the main reason for clinical education challenge. Perhaps, in this regard, it can be stated that one of the reasons for the reluctance of nursing students to do clinical exercises is the inappropriateness of the educational structures of the clinical environment. In the clinical education section, 85% of educators argued that hospitals, which have stressful contexts, can cause clinical education challenges. In this regard, in a study, students stated that the first 2 months of clinical placement were stressful for them. 29

Also, based on the results of a study, some students stated that the field of clinical practice was stressful for us, because it was related to human life. 25

Therefore, it can be said that all students experience stress when they enter the clinical environment because it is an unfamiliar environment for them. So, by considering this issue and providing necessary solutions, including establishing proper communication with students upon entering the clinical environment, nursing educators should facilitate this stressful situation for them so that they do not get confused and lack of motivation.

Clinical education is related to the application of nursing education and provides an opportunity for students to learn in actual conditions. However, lack of control over the conditions that make up clinical environments can affect learning. 22 In the education planning section, 96% of educators believe that incongruity between theoretical and clinical education targets effect clinical education challenges. In this regard, researchers suggest adapting to rapidly changing and advancing healthcare adjustments; nurse educators should regularly review and evaluate the training curricula, strategies, and education-learning programs adopted to prepare new professional nurses. 26 On the other hand, in order to solve this problem (inconsistency between theoretical and practical goals), clinical educators should improve the practical skills of nursing students by providing appropriate and up-to-date scientific and practical training in the clinical environment to increase their professional competence.

In the welfare facilities section, 87% of educators stated that lack of educational instruments has the biggest effect in clinical challenges. In this regard, the results of the study showed that the lack of role model, educators responsibilities, insufficient support structure, lack of equipment, conditions related to the challenge of the faculty responsibility were the issues that nursing students faced in the clinical environment. 25 Therefore, the use of educational aids can be useful for better understanding educational materials. In particular, in the cases in which prevalence of a specific disease is low, educational goals of student will not be achieved; therefore, using educational aids can improve learning and accessibility to educational goals.

In the clinical assessment section, 83% of educators stated that inadequate opportunity for identifying targets and method of students’ evaluation are the most important reasons for clinical challenges. In a study by Hakim, 31.1% of these samples had low satisfaction about method of evaluating used by educators. 30 On the other hand, the results of the study by Antohe et al. 27 indicate that the individual monitoring model is an important factor in the overall satisfaction of students in their clinical education courses. One of the most important parts for educators is evaluation (assessing process). If it is done correctly, it can cause students’ improvement and examine the success of apprenticeship courses and it is one of the most basic actions for improving the quality of educational services. It was suggested, before assessing the process, that it’s better to have concordance between lessons taught theoretically and clinical lessons and the use of skilled educators for each part of lesson. Kim et al. stated in their study that nursing educators may need to develop more confidence in their knowledge and increase control over their teaching strategies. Nursing schools and hospitals may need more support and educational opportunities for clinical nurse educators. 8

Of course, to improve the quality of nursing education, it is very important for students to know their duties, roles, nursing duties, numbers of courses, and kinds of procedures.

This motivates and encourages students. So it is essential that the authorities regulate the clinical booklet and give them to the students during their registration. As well as reloading the evaluation forms and adjusting them based on educational goals and existing facilities, and informing the strengths and weaknesses of students after the end of each course can lead to providing better service quality. As a result, this action can also improve the health of the community. It should be noted that the limitation of this study is the lack of power analysis to calculate the sample size, because in this research, all nursing educators and students of the nursing and midwifery faculty were selected. Therefore, it is necessary to consider this important issue in all nursing schools in order to identify and finally solve all the challenges of nursing students. Because by implementing this, the motivation of nursing students in the clinical environment increases and they gain the necessary ability to provide care to the patient.

In general, identifying the challenges of clinical education and then solving and correcting them leads to achieving high educational goals (effective and efficient education), training capable and creative people, providing quality and optimal care, improving the health of clients and finally, the productivity of the health system becomes. To achieve these goals, further investigation and continuous clinical evaluation is needed. Also, by considering the results of this research to solve the mentioned challenges, the relevant planners and managers can witness more coordination between theoretical learning and clinical services, training capable students and providing appropriate services by nursing personnel.

Conclusions

Due to the existence of many challenges in clinical education and according to the results of this study, students and teachers have also mentioned this issue in clinical environments.

Therefore, nursing managers should provide better conditions, so that more motivation and enthusiasm is created in the students, educators and other personnel. Finally, the author suggests using experienced and efficient educators to teach theory courses and clinical courses. Also, the activities of educators and students should be continuously evaluated with accurate and objective tools.

Supplemental Material

Author contributions: A. H: writing – original draft, data collection, data analysis and reviewing the final edition.

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics approval: Ethical approval for this study was obtained from * Ahvaz Jundishapur University of Medical Sciences (U-95107)*.

Funding: The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: I would like to acknowledge the research deputy of Ahvaz Jundishapur University of Medical Sciences for their support of the U-95107 research project that was so important for the completion of this study.

Informed consent: The researcher for the implementation of this study got oral and written consent from the samples.

Supplemental material: Supplemental material for this article is available online.