There is evidence that new registered nurses (RNs) are lacking proper clinical judgment and reasoning skills. A report in The Online Journal of Issues in Nursing revealed that new nurses scoring within the “acceptable” range on the Performance-Based Development System (PBDS) test — which evaluates a nurse’s ability to communicate effectively, think critically, and respond safely when providing patient care — fell from 23% in 2015 to 9% in 2020. Notably, in 2015 when scores were 23% (2.5 times higher than they are today), the nursing industry was calling it a “crisis in competency.”

The preparedness of nursing graduates entering the healthcare field has been on the decline for years, which has only been further exacerbated by the pandemic. As seasoned nurses continue retiring in droves, nurses fresh out of school are finding themselves with a steep learning curve and without any preceptors or mentors to guide them.

Underprepared nursing graduates also put patient safety and quality of care at risk. Since the start of the pandemic, patient experience and perception have taken a hard hit across all healthcare settings in the United States. Hospitals are now left with the costly and time-consuming responsibility of retraining these nurses or requiring continuing education, which pulls much-needed help from active service.

While the current state of affairs seems grim, the nursing industry can turn this downward trend around by making two important changes. At the education level, set the next generation of nurses up for success by deploying competency-based nursing programs that account for modern healthcare challenges. At the hospital level, provide new nurses with virtual learning tools that allow them to meaningfully upskill while remaining an active part of the team.

Outdated academic methods create hurdles in healthcare

With the release of the new “Essentials” last year, the American Association of Colleges of Nursing (AACN) has already provided the framework for a re-envisioned nursing education system. Rather than aligning with an academic degree (i.e. baccalaureate, master’s, doctorate) that requires students to “pass a class” in order to advance, the new model uses a competency-based approach that requires nursing students to demonstrate their mastery of skills before moving on to the next level. Competency-based learning is directly anchored to the outputs of an educational experience and accounts for the role of education throughout a nurse’s entire professional career.

However, academia is notoriously slow to implement changes, and most nursing programs are using an outdated education approach. In the old learning model, students are expected to develop clinical judgment and reasoning skills by completing in-person clinical hours. Depending on one’s location and/or preceptor, though, there can be wide variability in the quality of a student’s clinical experience and resulting aptitude in the unit.

Some students may work with an incredibly invested preceptor during their rounds that truly teaches them the ropes. Others may find themselves shadowing a nurse that does not have the time to be a proper preceptor. Depending on their location, a student may only be exposed to a limited sample of the patient population as opposed to the wider demographic range that is found in actual practice. Sometimes students cannot even secure in-person clinical hours due to accessibility or availability issues. In fact, 92,000 qualified applications were turned away from nursing schools in 2021 partially due to insufficient clinical placement sites and preceptor shortages, according to AACN’s annual survey.

While the challenges with in-person clinical hours are plentiful, there is no evidence that shows they equate to greater learning outcomes (Leighton, Kim, et al., 2021), as has been reflected in the decline of new nurses PBDS test scores. We must explore new ways for nursing students to develop the skills most important to patient care in the 21st century.

Upskilling the nursing workforce requires industry participation

The issues arising from unprepared nursing graduates is being exacerbated by the nursing shortage as hospitals hire LPNs or ADNs to do jobs that normally only higher-level nurses (i.e. BSNs, APRNs) would take on. Making matters worse, nurses are being asked to look after increasingly sicker patients as care within hospitals grows more complex.

Virtual clinical simulations may be able to provide hospitals a pathway to remedy the skills gap while filling short-term labor demands. By using competency-based clinical simulations with their staff, hospitals can give new nurses a chance to pursue more advanced skill sets in a risk-free environment during their employment. After demonstrating mastery of a particular skill in the simulation, nurses can then put those skills directly into practice with real patients.

The theoretical underpinning for virtual clinical simulations are based on increasing order of difficulty, requiring nurses to demonstrate competency of specific skills prior to advancing onto the next level rather than just asking them to “pass a class.” They can also help new nurses gain a better understanding of how to prioritize care based on health concerns and evidence. Learners can repeat an experience within virtual simulation, which encourages deliberate practice for mastery (McGaghie, et al.,2015, Gonzalez & Kardong-Edgren, 2017). Deliberate practice under the right conditions can help the learner improve skill performance and retention, and repeated performance results in optimal performance (Foronda, 2020).

Sentinel City® v.5 is an example of an immersive, virtual simulation for community and population health providing nursing students a way to earn simulated clinical hours. The platform maps to modern nursing objectives, competencies, industry standards and best practices to ensure students are exposed to challenges and scenarios found in modern healthcare settings. Their results are driven by 100 comprehensive, real-world datasets and a wide demographic range of patients – from geriatric to pediatric – from different socio-economic levels.

For nursing professionals, Sentinel U’s Professional Nursing Series™ is a virtual simulation that provides training opportunities for licensed nurses to enhance their skills or learn new areas of practice. The program offers nurse residency programs, nurses transitioning into practice, and practicing nurses a standardized, realistic, and immersive experience covering several specialty areas, including surgical inpatient, surgical outpatient, medical care, critical care, medical surgical care, and intensive care. The virtual simulation series helps train future nurse leaders with the best practice while providing hospital systems with powerful ways to enhance professional development and improve their staff’s clinical judgment. Its authentic patient scenarios challenge nurses to determine patient care priorities while identifying appropriate patient interventions. After completing each patient group, activity reports give users valuable feedback and insight into their progress through detailed performance analysis, including care rationale.

This “working while learning” approach offers employers a way to ensure quality control with their new nurses, and also provides a buffer between now and the time it will take academia to implement a competency-based education model. Using clinical simulations, hospitals can simultaneously employ and train the next generation of nurses, while reinvesting the time and money that is currently being spent retraining unprepared graduates. Such programs would transform the healthcare industry forever, and for the better.

The future of nursing competency needs simulation

Whether used as part of the academic path or as skills reinforcement in the field, clinical simulations can provide new nurses the chance to develop advanced observation techniques, cultivate critical thinking skills, and practice professional patient care within contemporary healthcare scenarios that they will actually encounter in the field – all directly from their personal device, on their own time.

An award-winning industry disruptor building digital learning resources and virtual simulations for academic/professional settings since 2015, Sentinel U was named 2022 “EdTech Company of the Year” by the Global Business Tech Awards. The company also was recognized by The Stevie® Awards as a 2022 Gold winner for Best Virtual Learning Solution and received the 2022 APEX Award for “Publication Excellence” for its rebrand campaign.

To learn more about Sentinel U’s products, visit


By Dr. Laura Gonzalez, PhD, APRN, CNE, CHSE-A, ANEF, FAAN, Vice President, Clinical Learning Resources, Sentinel U®