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Do We Have Blinders On?

Updated: Jan 8, 2022

In a recent paper, A Crisis in Competency: A Defining Moment in Nursing Education, Kavanaugh & Sharpnack (2021) discussed their concerns regarding the alarming decline in competency levels of new graduate registered nurses (NGRNs). They documented a decline in competency, an indicator of safe practice, measured by the Performance Based Development System (PBDS, del Bueno, 2005), from 35% in 2005 to 23% in 2017 and 9% in 2020. The April/May 2020 cohort of NGRNs came in at 7% competency, sadly most likely related to the COVID-19 situation and the challenges to nursing education of the first few months of the pandemic. What are we to do?

The authors argued that our focus must be to “adapt and embrace pedagogies relevant to a new generation of learners," including much more integration of technology as well as active learning pedagogies. Certainly, knowledge and innovation are changing at such a rapid pace that it is difficult, at best, to keep up. Critical thinking is a key skill that is needed to understand and determine the relevancy of the masses of information that are confronting students and all of us now. But, pedagogical research showed us decades ago that active learning promotes critical thinking. That is not new. Chickering and Gamson’s Seven Practices for Good Practice in Undergraduate Education (1987), now 35 years old, still guide much of the practice of active learning in education, as does Kolb’s Experiential Learning Theory (Kolb, 1984; 2015). Kavanaugh and Sharpnack (2021) do not discuss learning theories that support their thoughts on nursing education.

I don’t disagree with Kavanaugh and Sharpnack on much of what they discuss about the changes we will see with technology, but I do have concerns about the almost total focus on technology in nursing education as the answer to our NGRN competency problem. The authors discuss robotics, artificial intelligence, virtual and mixed reality, and virtual simulations as the tools needed to solve the competency problem. Technologies such as virtual and augmented reality certainly have their place in nursing education. There are also already many technological advances currently in use in nursing education, most prominently, simulation technology which is arguably central in most nursing programs and curricula today. Many programs also purchase or have their students purchase computer-based virtual simulations too.

So, when most schools have adopted much of this technology, and if that is what is needed to correct the competency problem, why have the trends in competency gone down, not up? Simulation technology has been in use in nursing education since the early 2000s, and in some programs even earlier. At the same time, competency levels have trended down substantially.

This is the problem with seeing technology as the answer and not as a tool. I am all for the use of technology to promote learning, but it must be seen within a bigger picture. High fidelity human patient simulators provide essential learning, especially for nurses learning to identify and deal with crisis situations. However, this is still task training. We need to go beyond that.

Nursing is “caring in the human health experience” (Newman, Smith, et al., 2008). How does a focus on technology REALLY accomplish the work of nursing as caring? How does technology promote the holistic approach that is apparent in our unique identity? We need clinical and simulation experiences that move students in the direction that focuses on the centrality of caring in nursing. We need to look beyond technology to meet the needs of students today, needs that are shaped in many ways by: the scarcity of clinical placements, (a reality in nursing education today), the increasingly observational nature of clinical experiences because of safety and legal factors, increasing restrictions based on COVID-19, the shortage of nurses, and a more novice nursing workforce. Imagine the following scenario:

Patients on a hospital COVID unit are experiencing multiple effects of COVID; some may be experiencing oxygenation issues and needing increasingly more advanced care; some may have GI distress; others may have developed DVT; many of them have co-morbidities that may have influenced their response to SARS CoV2 infection; some are vaccinated; some are not vaccinated; they are all receiving 24 hour/day nursing care. During the day, admissions occur as soon as beds become available. Nurses are busy with discharges, but also with transfers to higher levels of care in the ICU and transfers from the ICU as well. Patients are requiring complex nursing and medical care both on the COVID med-surg unit as well as in the ICU. Many patients are diabetic, and in addition to COVID symptoms, their blood sugar levels may be dangerously unstable, requiring close monitoring and insulin administration. Some patients are on heparin drips as they may have developed DVT as a result of physiological processes related to SARS CoV2 infection. Of course there is close oxygenation monitoring as nurses and physicians strive to keep patients off the ventilator. And, very sadly, there is death and dying, more than is typical on most hospital patient care units.

This illustrates the highly complex nursing and medical care needed for patients with COVID. And as the pandemic continues, and even as new pandemics become a reality, new graduates need these experiences to prepare for nursing practice. Nevertheless, this care and these clinical learning experiences are currently not available to most nursing students as part of their clinical experiences because of hospital and/or nursing school restrictions. But wait. I have described a continuous 48-hour SIMULATION. And, we have designed other simulated patient care units (med-surg; primarily 72-hour continuous) to provide the complex nursing experiences students need in today’s restrictive clinical atmosphere.

Students in our sims care for a multi-patient assignment of simulated patients (student patient actors); they prioritize their care; they assess, plan, and implement care for these patients; they work with an interprofessional team; they call and communicate with the provider; they admit, transfer, and discharge patients. It is a holistic, learning rich, integrated environment.

Our process is human centered and uses the technology that students encounter in the clinical setting—the EHR, smart IV pumps, cardiac monitors, etc., while also integrating current high-fidelity simulators for crisis events (codes, etc.), and low fidelity mannikins for IV starts, blood draws, injections, etc. We are focused on critical thinking and clinical judgment, communication, and nursing process (we start with our objectives); we also know that nurses must start or restart IVs, administer meds, do dressing changes, and that becomes a part of overall time management and patient care, and must be a part of our patient care experience. It is a totally integrated nursing educational experience in which communication with patients and the relational aspect of care is central.

For those that say that this will soon be able to be accomplished through virtual reality, I get that. Let’s consider that in detail. In our simulation and in the real world, the care scenario is very complex, especially during a 48-72 hour interval with all the interactions from and with patients that are needed (i.e., all the lab work that might be needed, meds, blood transfusions, interactions with providers, family members and others). Additionally, there is interaction with the EHR for the entire time period to which all members of the health care team contribute.

Even with AI, the software coding and necessary script development needed to support a single sim will be extremely complex, expensive to develop, and inflexible. Additionally, the server and networking needs to support a VR sim of this magnitude, especially when individual students will have to be interlinked with all the other resources, will also be expensive and require considerable IT support. The costs and timeline of IT support, software and scenario development, must all be examined and are all TBD. I am not seeing any discussion of how to maintain this level of support and whether it’s both economically and technologically sustainable for most nursing schools.

Also, there seems to be no consideration of human factors. Will the wearing of VR gear for hours at a time be invisible so that physical discomfort does not interfere with active learning? Currently, nausea sometimes accompanies the use of VR headsets and is an individual restriction that won’t be apparent until the user participates in the experience. These are all additional factors which must be considered before even the initial investment and this technology is undertaken. It is not uncommon to find nursing schools that have committed to even today’s technology to find after they have committed to it that it is underutilized and sometimes unfit for their purposes. There must be an honest evaluation of whether the technology meets the needs of nursing education.

We are at a crossroads in nursing education. There are forces that are making it more and more difficult to prepare students for practice in the real world. We must pay attention to the declining competency levels of NGRNs; current 9% competency is truly alarming. This decline has happened while there has been increased use of high-tech nursing experiences. We are not advocating throwing the baby out with the bathwater, but we also don’t advocate continuing down a road with blinders on. We take a different path. Nursing is relational. Our integrated, 48 and 72-hour sims focus on nursing care, critical thinking, and clinical judgment, and offer a solution to the competency issue today. Admittedly designing our simulations take some time and expense, but they are adaptable to individual real-world, real-time issues, and the results are truly amazing. To read more about our approach to simulation, please visit


Chickering, A. F., & Gamson, Z. (1987). Principles for good practice in undergraduate education. AAHE Bulletin, March, p. 3-7.

Kavanaugh, J., & Sharpnack, P. (2021). A crisis in competency: A defining moment in nursing education. OJIN, 26(1).

Kolb. D. (1984; 2015). Experiential learning: Experience as the source of learning and development. Pearson Press.

Newman, M., Smith, M., Harris, M.D., & Jones, D. The focus of the discipline revisited. Advances in Nursing Science, 31(1): E16-E27.

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