After seeing a steady increase in numbers since the 1970s, the nursing workforce hit a plateau during the first 15 months of the COVID-19 pandemic. Much of the reversal was due to nurses taking early retirement and leaving the workforce. Approximately 100,000 nurses left the workforce in 2021, including a higher proportion of nurses younger than 35 years compared with older nurses, according to a recent Health Affairs study.

At the same time that hospitals and health care facilities are seeing a decline in nursing numbers, 70% of advanced practice registered nurse (APRN) educators are reporting moderate or extreme concern regarding clinical training site shortages. Nursing school faculty are aging out of academia, entering early retirement, or re-entering clinical practice, experts say.

Together, the two phenomena in the nursing profession are creating the potential for a severe shortage of nurses in the near future; the US Bureau of Labor Statistics predicts that there will be an average of 194,500 openings for registered nurses each year between 2020 and 2030.

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Patty Knecht, PhD, RN, ANEF

Panelists at the ASU+GSV Summit held April 17 to 19, 2023, in San Diego discussed how nursing schools can evolve their education programs to better recruit nurses aides and assistants as well as other adult seeking career changes to fill these gaps in the health care system.

Is the System Broken?

When adults seek to enter the health care field, they are often unsure of the academic rigor involved in education programs, said Patty Knecht, PhD, RN, ANEF, chief nursing officer at ATI Nursing Education. The education industry, including nursing schools, has not yet created seamless pathways to enter the health care workforce, and there is a need for a uniform definition of competency-based education in nursing as well as other medical professions, Knecht noted. 

What is Competency-Based Education?

Competency is an observable ability of a health professional, integrating multiple components such as knowledge, skills, values, and attitudes. Since competencies are observable, they can be measured and assessed to ensure their acquisition.1 It is important to remember that nursing education competencies need to be developed with workforce input and closely aligned with stakeholder prioritized job outcomes/expectations. In addition, these competencies need to be flexible to allow for generalization and applicability across many contexts (ie, job settings).  

As teams prepare to think differently about their approach to nursing education, it can be helpful to understand what does not describe a competency. Competencies are not a checklist, are not stagnant, do not necessarily align with a particular clinical setting, and are not educationally time based (ie, semester driven). Competencies do require a high level of student accountability, regular faculty/facilitator/coach interaction, clarity, and multiple methods of evaluation.    

The Essentials: Core Competencies for Professional Nursing Education identify competencies for baccalaureate and graduate nursing programs, and some might argue foundational work for other registered nurse (RN) program types (ie, diploma, associate degree in nursing) and practical nursing (PN) programs.2 This provides a framework for moving forward competency-based nursing education in a time period when filling the nursing pipeline is a focus.   

Patty Knecht, PhD, RN, ANEF
Chief nursing officer
ATI Nursing Education  

1. Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32(8):638-645. doi:10.3109/0142159X.2010.501190
2. American Association of Colleges of Nursing. The Essentials: Core Competencies for Professional Nursing Education. April 6, 2021. Accessed May 11, 2022.
Jennifer Graebe, MSN, RN, NEA-BC

One of the opportunities for improvement to entering health care professions is that academic programs are “very traditional” in terms of structure (eg, duration of time, start and stop dates), said Jennifer Graebe, MSN, RN, NEA-BC, director of the Nursing Continuing Professional Development (NCPD) & Joint Accreditation Program at American Nurses Credentialing Center. “If we want to diversify health care, we have to be humanistic about the journeys that different people take and provide on- and off ramps for the opportunity to become educated and advance into different health care professions.”

On the industry side, predictive models can be used to identify persons hired in nursing support or allied health support roles who are poised to become health care professionals in the future, said Natalie Jones, MSN, RN, NPD-BC, executive director of Workforce Development at Wellstar Health System. She urged health systems to be broader in thinking and determine how to stack credentials and build on what individuals are learning in support roles to change their career trajectory in the future.

Charla Long, JD

“Time does not equate to competence,” said Charla Long, JD, executive director of Competency-Based Education Network. “Nursing board licensure bodies throughout the country look at how many hours of continuing education an individual has. I could care less how many hours you spent in continuing education. What I really care about is how can you do your job better? Do you have the competencies that are new and cutting edge that I need?”

Graebe agreed and added that leveraging professional development to mean more than “time in the seat” is important. For example, “what is that certified nursing assistant [CNA] are able to articulate and demonstrate in terms of competency in a simulation-like setting and then apply in the practice setting that has similarities in relationship to nursing-related competencies?”

However, nursing educators may consider these new strategies to be too risky given the need to teach to the The Essentials: Core Competencies for Professional Nursing Education established by the American Association of Colleges of Nursing (AACN), Knecht said. Educators are also feeling the stress of the Next Generation NCLEX examination and clinical judgment. She applauded the AACN for providing the essentials as a great starting point for nursing programs, but added that “we also have to reengineer the way in which our nurse educators approach education and they have got to think competency first.”

Creating Stackable Pathways to Nursing Education

Graebe emphasized the need to avoid reteaching information that nursing students know or are competent in by using prior learning assessment. This will help create more seamless and engaged learners in the pipeline, she said.

Jones said that her institution is investigating how they can avoid reteaching what individuals in nursing residency programs already learned in nursing school. One potential strategy is to evaluate competencies in senior practicum programs and apply that knowledge once nurses enter residency programs to allow for shortened orientation and onboarding periods.

“When we think about the CNA [certified nursing assistant] and certified medical assistant (CMA) pathway [into nursing school], it is the same concept,” Jones said. “These allied health care professionals have already learned such competencies as safety and building rapport with patients and don’t need to start those competencies over.” However, documenting those competencies is challenging. WellStar already started automating this documentation process during the COVID-19 pandemic to identify highly trained nurses who were skilled at providing extracorporeal membrane oxygenation (ECMO) and other higher level interventions. The same system could be applied to identify CNAs and CMAs who have competencies that can push them further along the pipeline to becoming a licensed practical nurse (LPN) or registered nurse (RN).

“In Tennessee, we have built a competency-based program for personal care aids and CNAs based on competencies that community colleges are now embedding into entry level nursing credentials as a step,” Long said.

Given that generally time-based credits are the current model for nursing educational advancement (ie, CNA to LPN to RN to APRN) and that a change in the education system is unlikely to occur fast enough to help with the current staffing shortage, Knecht proposed using screen-based simulation aligned with analytics that could assess credit for prior learning as a way to pair educational technology with the traditional learning model to advance learners to the next step faster.

Knecht also discussed administrative tools to assist nurse educators with clinical scheduling and agreements with provider institutions documenting compliance, and integrating evaluations , as well as mapping curriculum and alignment with accreditation bodies. Products such as ATI Program Manager, Exxat, and Typhon help meet this industry need, Knecht said in an interview. This will make current educators more efficient and ultimately improve student/program outcomes, she said.

In addition, Knecht and her colleagues are working with their partners on education technologies that can help adult learners becoming proficient on prerequisites and be ready for the rigor of nursing school. “If you can’t get through your prerequisites and you don’t have basic reading and math skills, you will not make it in either an LPN or an RN program,” Knecht said.

For performance-based assessments, Long suggested the need to make simulation learning more affordable so that assessments of catheter or intravenous needle insertions, for example, do not need to be practiced on other students, professors, or patients.

Together, the key strategies or competency-based education, stackability of professional development credits, credit for prior learning, as well as new education technologies may help build nursing programs that are more inclusive to the population of working adults who wish to pursue a career in nursing, the experts said.


Mitigating the healthcare crisis with increased access to education for working adults. Presented at: ASU + GSV Summit; San Diego, CA: April 6, 2022.