1. DiMattio, Mary Jane K. PhD, RN
  2. Hudacek, Sharon EdD, RN, ACNS-BC


Academia and nursing practice are at a crossroads.


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News stories abound about the hospital nurse staffing crisis. Hospital nurses who turned to agencies during the height of the COVID-19 pandemic are leaving hospitals altogether; many health systems are responding by preparing their own nurses. These developments may present safety concerns for patients given the potential hazards related to nurse turnover as well as strong evidence of the positive impact of baccalaureate nurse education on patient safety outcomes. Nursing faces a conundrum: how best to prepare nurses for the future while simultaneously preparing them for the present. We propose that it is time to reframe hospital nursing as a specialty instead of as an entry-level position.


The influential Future of Nursing 2020-2030 report focuses almost exclusively on advanced practice and community nursing. Despite innovations such as hospital at home and baccalaureate nurses in primary care, health systems are still building hospitals, most RNs still work in hospitals, and the pandemic has demonstrated a continued need for hospitals. The Essentials: Core Competencies for Professional Nursing Education (2021) from the American Association of Colleges of Nursing (AACN) urges academia to place greater value on primary care as a career choice, yet the projected oversupply of NPs described in Health Affairs by Auerbach and colleagues (2020) suggests we may already be doing this.


Both the academic and practice sectors of nursing share the blame for the current shortage of hospital nurses. Hospitals have begun operating as businesses and offer few avenues for nurse career advancement. Setting unrealistic expectations for new nurses, the practice sector has glossed over the reality that caregiving does not comport with speed and efficiency and largely failed to act on the mountain of evidence implicating the work environment as a key driver of nurse turnover. For its part, academia has responded to the hierarchical and oppressive hospital atmosphere by setting its sights on advanced practice and community nursing while tacitly downplaying fundamental and acute nursing care. Both sides seem to have embraced the notion that distance from the patient is desirable while refusing to tackle the economic reality that hospitals treat nursing as a cost center instead of as a revenue generator, thus reinforcing nursing's lack of power in the setting.


On a positive note, the AACN Essentials also provides a road map forward by proposing academic-practice partnerships and four spheres of care: wellness and disease prevention, chronic disease management, hospice/palliative care, and regenerative/restorative care. Within these spheres, hospital nursing should be recast as the specialty of regenerative/restorative care and lead an overhaul of nursing education, particularly clinical experiences. Currently the quality of clinical education in acute care is variable and heavily dependent on adjunct faculty. Students care for one or two patients in isolation from the activities of the hospital in a private-duty model. They graduate with an unrealistic view of how hospital nursing is practiced, which contributes to moral distress, burnout, and turnover. Regenerative/restorative care as a specialty would require students' immersion in what the AACN Essentials calls "mega-acute" hospital environments, which focus on giving care within complex health care systems.


One way to achieve immersion would be to incorporate what we envision as a fourth-year fellowship (4YF) in BSN programs. This fellowship year would immerse senior nursing students in a clinical practice placement of their choice, under the supervision of an experienced nurse mentor. Our research found that a nurse mentor model promoted reciprocal learning between mentors and students. Students who built relationships with their mentors had increased enthusiasm and felt safer in the practice setting. Nurse mentors in turn experienced reinvigoration of their own practices.


The 4YF model has mutual benefits for nursing practice and academia. Hospitals would benefit by gaining new nurses who are better prepared. Academia would benefit from having to procure fewer clinical faculty and placements. Certainly, there would be logistical hurdles. Nursing is not unique, and should look to other professional programs, such as physical therapy and architecture, that have found ways to include practicing professionals in preparing graduates for licensure and the workforce.