Nursing’s Newest Challenge: Closing The Experience-Complexity Gap

Healthcare in the U.S. today is in a dangerous downward spiral, and the state of nursing is the canary in the coal mine. What the media has labeled a ‘nursing shortage’ is actually a far more complex equation with numerous problems and twice as many solutions needed to address them effectively. 

The experience-complexity gap is one variable that has gotten zero press yet may be the greatest danger to patients everywhere and the nursing profession at large. Coined in 2019 by the Nursing Executive Centre of the Advisory Board, the term describes the dangerously widening difference between the average nurse’s knowledge today and the rapidly increasing complexity of the patients they serve and the technology they must oversee. 

Put simply, patients have never been sicker, the technology required to keep them alive has never been more involved, and the nurses overseeing their care have never been less knowledgeable and experienced–through no fault of their own. 

Closing the experience-complexity gap may be the single most pressing issue facing the nursing profession today. We spoke with four experienced nurse educators and advanced practitioners to understand what caused the gap, the impact of rising patient acuity on safety, and the solutions they believe are crucial to solving this pressing nursing challenge. 

What is the Experience-Complexity Gap?

The experience-complexity gap (EC gap) describes the difference between the average knowledge and experience level nurses have today and the knowledge and experience level they need to provide safe nursing care to an increasingly sick and complex population. 

To understand the severity of the issue, it’s essential to understand that nursing has long operated under an apprenticeship model of learning and instruction. 

For most of the 20th century, high-acuity nursing specialties like the ICU and ER were exclusively staffed by highly experienced nurses who had years of professional experience before they were eligible to apply for a position. 

After that nurse has worked for a few years in their new specialty, they may be asked to guide a new nurse through their orientation, called a preceptorship. This involves the new nurse effectively being attached to the more experienced nurse’s hip for months, where they are educated, tested, and guided through learning how to do the job. 

Only after the new graduate nurse has been signed off on all the required skills, proven themselves in clinical practice, and received the blessing of the unit’s leadership do they “graduate” from orientation into independent practice. 

Nursing relies on an apprenticeship model like medicine because it’s impossible to learn even half of the required knowledge in school. Instead, nursing school prepares students to pass their board examination, and the real learning begins on the job. 

However, apprenticeship models rely entirely on highly experienced, knowledgeable expert nurses to guide the new learners from novice to competent. Today, because nursing turnover is so incredibly high and many baby boomer nurses are retiring, it’s not uncommon for an ICU nurse with less than one year of nursing experience to precept a brand-new graduate nurse. 

This net loss of the intangible knowledge required to nurse effectively includes skills such as clinical judgment, time management, and critical thinking. Without these essential skills, nurses are woefully unprepared to provide the complex care that most nursing units in the hospital setting require.

Understanding the Real Nursing Crisis: Retention

While the nursing education and hospital sectors have been laser-focused on producing more nurses, they have failed utterly in creating environments where these new nurses want to work, so much so that 20 percent of new graduate nurses leave the profession within one year.

Lack of Safe Staffing

Because of the sexist way doctors decided to categorize nurses financially over 100 years ago, hospitals today view nurses as a cost. To maximize their profits and yearly bonuses, hospital executives do everything they can to cut nurse staffing despite decades of research showing its negative impact on patient safety and nurse retention. 

Hospital lobbyists have fought tooth and nail to prevent mandatory safe staffing standards, which nurse unions, researchers, and policy experts believe are the single most important change that would save patient lives and nursing careers alike. 

Workplace Violence Against Nurses and other HCWs

In addition to working short-staffed daily, nurses face a pandemic of violence from patients and their family members. From verbal abuse, sexual assault, and physical violence–nurses face a nonstop barrage of vitriol and a total lack of support from hospital administrators who rarely, if ever, address the issues meaningfully. 

Ashley Pianko, DNP, a nurse educator, shares, “The things that happen to nurses in the hospital are not tolerated in any other profession. There’s a huge disconnect in how nurses are expected to tolerate the abuse—and always with a smile.” 

A New Pattern of Prosecution for Mistakes

Today’s nurses work without adequate staffing or resources, increasing their stress and likelihood of making mistakes. Historically, medication errors have been handled with what healthcare calls a just culture. A just culture means utilizing a non-punitive approach to view mistakes as systemic issues and always encouraging clinicians to come forward and admit their mistakes. 

When all clinicians feel safe enough to admit they’ve made an error, it creates a safer environment for patients and results in better care. However, after the criminal prosecution of a registered nurse who made a medication error in 2017, many nurses lost faith that the healthcare system would protect them. 

Dr. Pianko worries greatly about how the criminalization of nurses will affect the profession and, therefore, patients: “Medication errors happen to even the most experienced nurses. So it can happen to you.”

If nurses are forced to work in unsafe environments without adequate resources and know they will be prosecuted personally for any mistakes, far fewer will be willing to take on that thankless responsibility.

The Yelpification of Healthcare

In the modern era, where you can rate anything and find detailed listicles that compare and contrast every feature imaginable, many hospital executives have embraced what some have dubbed ‘The Yelpification of Healthcare.’ 

Yet, doctors and nurses are incredibly alarmed by his growing trend, and it’s not hard to see why. Healthcare is not fast food. It’s highly complex, requires years of study to understand, and often necessitates healthcare professionals to have difficult conversations with their patients.  

The downstream effects of this in the doctor-patient relationship are already documented. Some Urgent Care doctors are being forced to prescribe antibiotics for the common cold to avoid complaints, for example, which could have catastrophic effects on humanity’s future. This trend has contributed to the Antibiotic Stewardship movement, which developed to protect patients from themselves and maintain the efficacy of antibiotics.

Nurses are at the forefront of this rising conflict as they are often the face of healthcare—a system that most Americans do not like or trust–and the person who spends the most time with the patient and their family. Routinely, they are put in the impossible position of delivering healthcare in a collapsing system to patients with the customer service expectations of a five-star resort, and the nurses always lose.

Sky-High Education Costs & Diminishing Interest

The cost of pursuing higher education has never been higher. Additionally, with the advent of social media platforms like TikTok, which have made it easy for nurses to share their unfiltered experiences with the world, many prospective nurses choose different career paths that cost less and aren’t as hard.

Lack of Adequate Preparation in Nursing School

Tiffany Gibson, MSN, RN is an experienced nurse leader and educator who has worked as a clinical instructor and in professional nursing development throughout her career. She firmly believes the Covid-19 pandemic has worsened the effectiveness of nursing education: “Many of these new graduate nurses are not getting nearly enough clinical preparation with real patients before graduating, and what we’re seeing is them experiencing shock when entering their first nursing job,” Gibson says. 

Jesse Martinovich, MSN, RN, a nurse educator at the Karmanos Cancer Institute, agrees: “I feel like since the pandemic, we’ve been dealing with a double-edged sword of new graduates who were forced to do online clinicals during and who don’t have the strongest skills coming in, and a loss of many experienced nurses to retirement. It’s a really tricky thing.”

In combination, this lack of preparation from nurses coming out of school and relatively inexperienced nurses precepting them has led to more stress for both groups of nurses and a worse experience for everyone involved. 

While this list is far from comprehensive, it provides some nuance to this often grossly oversimplified healthcare issue. For Gibson, the ultimate betrayal of nurses is not one issue but how they have been treated when bringing up these endemic issues for years: “The reason for this mass exodus is because the healthcare system does not care for the nurse. Stop telling me about burnout and your wellness program if you’re not working to fix the system that is traumatizing nurses. Fix the systems that are causing burnout and trauma in the first place.”

How Do We Close the Experience-Complexity Gap?

The nursing staffing crisis and the resulting experience-complexity gap pose a major threat to the nursing profession and the health and safety of the public. So, how do we close the gap? According to the nurse educators and leaders we spoke to, with a multi-pronged approach.

Pour Into Preceptors

According to Dr. Pianko, Gibson, and Martinovich, revolutionizing the preceptor role is crucial to closing the EC gap. As with so many other aspects of nursing, the support that preceptors receive varies wildly, with some receiving additional education on how to teach new graduate nurses effectively and others none at all. 

Similarly, many nurse preceptors are forced into the role and are not offered any additional compensation despite the huge increase in cognitive load and responsibility. 

Overhauling this system will require preceptors to be uniformly educated, supported, and compensated–three things they often aren’t. Martinovich shares other aspects of her precepting system, which she helped create at the Karmanos Cancer Institute, which has been highly effective at increasing recruitment and nurse retention. 

At her hospital, preceptors are compensated and apply for and take on a new job title as their unit’s dedicated preceptor. This title change rewards nurses who are interested and passionate about teaching.

More Nurse Residencies

Another critical evidence-based professional development intervention that has been shown to increase new nurses’ confidence and competency is nurse residencies. Nurse residencies are structured periods of additional education and training offered to new nurse graduates in some hospitals. They can help meaningfully address gaps in clinical skills that some new graduates may have and learn hospital-specific and unit-specific policies.

Graduates who complete accredited nurse residency programs report higher confidence, their preceptors rate them higher on skills competency assessment skills, and they commit fewer errors than their counterparts.

Provide Adequate & Meaningful Clinical Experiences for Nursing Students

Tiffany Gibson firmly believes that nursing schools and hospitals need to develop a much closer relationship to provide a more rigorous and thorough educational experience that prepares students for the realities of nursing. 

As a clinical instructor, she felt torn between providing adequate hands-on clinical experiences that her students needed to be truly prepared for the job and feeling restricted by the syllabus she had to adhere to. 

“I think we would see a shift if schools and hospitals collaborated from the beginning to integrate the students cooperatively. I had that experience in nursing school, and it was phenomenal. In addition to my clinicals, I worked full-time as a patient care technician in the hospital for six months, then returned for my final semesters. While it takes longer, the nurses who graduate from these programs are much better prepared for the modern hospital environment,” Gibson says. 

Gibson says, “I also believe that nursing students should get much more exposure to community health. Understanding the social determinants of health will change their view of their patients and provide crucial context on how and why they ended up in the hospital. This knowledge will help them provide more compassionate, culturally informed nursing care.”

Truly Address Workplace Violence

Dr. Ashely Pianko believes that addressing workplace violence is crucial to addressing the nurse retention crisis and the EC gap. “Hospitals need to do a much better job following through on evidence-based interventions that will address the workplace violence problem. Every nurse I know—myself included—has been assaulted at work. Physically, sexually, or both. Groping, throwing things, verbal assault. It’s endless,” Dr. Pianko says. 

In addition to patient screening and the use of metal detectors, Dr. Pianko recommends hiring more sitters and providing more comprehensive training to prepare them for their role. Other effective strategies include regular debriefings, staff education, and de-escalation training. 

Robust Retention Efforts

Finally, these changes will be in vain if hospitals cannot create environments that attract and retain nursing talent. What each nursing unit needs will vary, but nurses across the board have asked for the following for decades:

• Higher wages with raises that match inflation
• Safe staffing 
• Flexible scheduling 
• Career Advancement
• Respect