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The impact of virtual clinical education during the COVID-19 pandemic on nursing graduates in the hospital setting

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The impact of virtual clinical education during the COVID-19 pandemic on nursing graduates in the hospital setting

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Content The Impact of Virtual Clinical Education during the COVID-19 Pandemic on Nursing
Graduates in the Hospital Setting
by
Debbie L. Jones
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
December 2024

© Copyright by Debbie L. Jones 2024
All Rights Reserved

The Committee for Debbie L. Jones certifies the approval of this Dissertation
Eric A. Canny
Angie Simonson
Kenneth A. Yates, Committee Chair
Rossier School of Education
University of Southern California
2024

iv
Abstract
This study utilized a modified version of Albert Bandura’s social cognitive theory (2002) to
explore the impact of virtual clinical education during the COVID-19 pandemic on nursing
graduates entering the hospital setting. Using a qualitative interview protocol, 14 nursing
administrators across the United States shared their observations on integrating nurses who were
trained in virtual environments for clinical skills during the peak of the COVID-19 pandemic and
subsequently graduated (post-pandemic nurses) critical thinking skills, teamwork, skill set
competencies, and patient empathy into the hospital setting. The findings reveal deficits in postpandemic nursing graduates’ competencies compared to pre-pandemic nursing graduates’
competencies. Nursing administrators agreed that virtual clinical education lacked the dynamic
and reciprocal learning environment in traditional pre-pandemic clinical rotations. Contributing
factors to these deficits may include lack of confidence, generational differences, reliance on
technology and social media, and mental health challenges. Based on the findings and a literature
review, this study recommends a clinical nursing education model that includes patient
observation and hands-on experiences, as required by pre-pandemic clinical education
requirements. Additionally, the study highlights the need for extra training for post-pandemic
nurses while recognizing their need for work-life balance, flexible schedules, and mental health
support.
Keywords: COVID-19 pandemic, virtual clinical education, post-pandemic nurses, social
cognitive theory

v
Dedication
To my friends and family, thank you for standing by me through every high and low on
this long journey. You have been my biggest cheerleaders, and the motivation I needed to keep
going. A special thank you to my sister, Mary Ann Bagley, for everything; and she is the only
person who knows what everything entails.
To my children and grandchildren, this is what I know: Hard things are possible, and
difficult times will pass - there is always something good to be found. Success is yours alone to
define. Strive to be the best version of yourself. Remember that our greatest purpose is to show
up and serve with love, integrity, and gratitude. Stay humble and never give up! You were right
Mom.
A special thank you to my classmates who inspired me and gave me hope. The Saturday
Crew made it all work! A special thanks to Amy Connely and Greg Martinez. When I felt like I
had nothing left to give, they would shine a light on the next step and keep me going.
To all nurses, past, present, and future, who have faced and fought through the
challenges of the COVID-19 pandemic and beyond, your resilience, dedication, and sacrifices
have left an indelible mark on the world.

vi
Acknowledgements
First and foremost, I would like to acknowledge Timothy Lee, who made the dream of
this degree a reality. Tim has been my mentor, supporter, boss, and so much more. He opened
doors along my professional journey that I could not have imagined. I am forever grateful for his
impact on my career.
My colleague, Margaret Pfeiffer, who generously shared her professional network and
guided me in the right direction. She reviewed the data and offered invaluable insight into the
nursing community’s challenges. Her experience and support were crucial to the success of this
research.
The nursing administrators who readily opened space to share their experiences and
perspectives on the state of nursing during and the continuing aftermath of the COVID-19
pandemic. I am grateful that they trusted me with their raw and uncensored view of the current
and future of nursing. Thank you for contributing to this important work.
My dear friend, Kirstie DeBiase, Ed.D., who exemplifies educational excellence and has
been instrumental in shaping my growth as an academic leader. Her thoughtful intelligence
continually inspires me to expand my personal and professional horizons. She has been with me
through every step of this process encouraging and lending insight.
To the incredible staff, professors, and students of the Rossier School of Education who
make the challenging accessible. My sincere gratitude to my dissertation chair, Dr. Yates, who
helped me bring it home. His never-ending support, patience, encouragement, and guidance were
the lifeline I needed when all seemed lost. I also want to thank my committee members, Dr.
Canny and Dr. Simonson, whose invaluable insight helped me stay true to my research.

vii
Table of Contents
Abstract.......................................................................................................................................... iv
TOC................................................................................................Error! Bookmark not defined.
List of Tables .................................................................................................................................. x
List of Figures................................................................................................................................ xi
Chapter One: Introduction to the Study.......................................................................................... 1
Context and Background of the Problem.................................................................................... 2
Purpose of the Project and Research Questions.......................................................................... 3
Importance of the Study.............................................................................................................. 3
Definitions................................................................................................................................... 5
Organization of the Dissertation ................................................................................................. 6
Chapter Two: Literature Review .................................................................................................... 8
History of Nursing Education ..................................................................................................... 8
Board of Nursing Didactic and Clinical Requirements Pre-COIVD-19 Pandemic.................. 13
The COVID-19 Pandemic......................................................................................................... 21
Board of Nursing Response to COVID-19 Pandemic Mandates.............................................. 21
The Impact of Virtual Clinical Education................................................................................. 22
Conceptual Framework............................................................................................................. 31
Summary................................................................................................................................... 35
Chapter Three: Methodology........................................................................................................ 36
Research Questions................................................................................................................... 36
Overview of Design .................................................................................................................. 37
Participants................................................................................................................................ 37

viii
The Researcher.......................................................................................................................... 38
Data Sources ............................................................................................................................. 39
Data Collection Procedures....................................................................................................... 40
Data Analysis............................................................................................................................ 40
Credibility and Trustworthiness................................................................................................ 41
Ethics......................................................................................................................................... 42
Chapter Four: Findings................................................................................................................. 44
Research Questions................................................................................................................... 46
Participants................................................................................................................................ 46
Table 1 ...................................................................................................................................... 48
Roadmap of Chapter 4 Research Findings................................................................................ 48
Research Question 1: What are the Nursing Administrators’ Perceptions of the Impact of
Virtual Clinical Education on Post-Pandemic Nursing Graduates’ Critical Thinking Skills,
Teamwork with other Medical Professionals, Skill Set Competencies, and Demonstration of
Patient Empathy in the Hospital Setting? ................................................................................. 50
Research Question 2: How have Nursing Administrators Adjusted New Nurse Onboarding and
Training Protocols to Accommodate the Needs of Virtually Trained Post-Pandemic Nursing
Graduates Entering the Hospital Setting? ................................................................................. 58
Research Question 3: What are the Nursing Administrator’s Recommendations for Continued
use of Virtual Clinical Education?............................................................................................ 65
Additional Findings Not Represented by the Research Questions........................................... 68

ix
Hospital Actions to Address Post-Pandemic Nurses Needs..................................................... 73
Summary................................................................................................................................... 75
Chapter Five: Recommendations.................................................................................................. 78
Discussion of Findings.............................................................................................................. 78
Discussion of Additional Findings ........................................................................................... 84
Hospital Initiatives to Address Post-Pandemic Nurses Needs.................................................. 87
Discussion Summary ................................................................................................................ 88
Recommendations for Practice ................................................................................................. 90
Implementation and Evaluation ................................................................................................ 93
Limitations and Delimitations................................................................................................... 96
Recommendations for Future Research.................................................................................... 97
Conclusion ................................................................................................................................ 98
References................................................................................................................................... 101
Appendix A................................................................................................................................. 120

x
List of Tables
Table 1: Description of Sample Participants
Table 2: Roadmap of Research Findings

xi
List of Figures
Figure 1: Modified Social Cognitive Theory Concept Map

1
Chapter One: Introduction to the Study
The foundation of nursing education lies in integrating didactic instruction with hands-on
clinical experience to promote critical thinking skills, teamwork, proficiency in essential skills,
and the development of patient empathy necessary for nursing competence (Sharif & Masoumi,
2005). The COVID-19 pandemic was an unprecedented global crisis, resulting in an incredible
loss of life and formidable challenges to maintaining employment, education, and personal
stability worldwide. Most countries adopted mandates that limited human contact to control the
spread of the virus, dramatically changing our day-to-day interactions (Callaway et al., 2020).
Following directives to shelter-in-place, schools quickly transitioned to remote learning
modalities (Chan et al., 2021). Nursing programs nationwide scrambled to develop virtual
clinical education to replace the hands-on clinical training typically conducted at bedside in
hospitals (Park et al., 2023). Depending on the specific nursing program requirements, a prepandemic nursing graduate was required to complete a minimum of 600 clinical hours and 500
didactic hours to sit for the licensure exam (Board of Vocational Nursing and Psychiatric
Technicians, 2024; California Board of Registered Nursing, 2024; National Council of State
Boards of Nursing, 2024). Not surprisingly, many hospitals discontinued student education to
focus on COVID-19 patient care (Park et al., 2023). As such, nursing students who attended
school during the COVID-19 pandemic received virtual clinical activities in place of the
expected hours of bedside clinical training. This study examined hospital nursing administrators’
evaluation of the impact of virtual clinical education on post-pandemic nursing graduates' critical
thinking skills, teamwork with other medical professionals, skill-set competencies, and
demonstration of patient empathy in a hospital setting.

2
Context and Background of the Problem
The COVID-19 pandemic forced many hospitals to discontinue clinical student
education, allowing hospital personnel to concentrate on COVID-19 patients (Chan et al., 2021).
The transition to a virtual learning model posed significant challenges in replicating the clinical
education experience for nursing students (Kells & Jennings Mathis, 2023). Following shelter-inplace mandates, many nursing programs developed virtual clinical teaching models despite
limited evidence of effective learning outcomes (Kells & Jennings Mathis, 2023). Various
concerns are emerging as post-pandemic nursing graduates enter the medical community.
Virtually trained nurses did not experience hands-on patient interactions and thus had limited
opportunities to develop patient empathy and effective communication skills (Choi et al., 2022).
Virtual clinical education also hindered nursing students’ exposure to critical thinking through
procedural and emergency events in collaboration with patients and medical colleagues (Choi et
al., 2022). The National Council of State Boards of Nursing (NCSBN) (2024) reported a national
decline in the first-time pass rate of the National Council Licensure Exam (NCLEX) scores.
NCSBN (2024) reported that in 2019, pre-pandemic, approximately 171,387 nursing graduates
attempted NCLEX, with an 88.18% pass rate. In 2022, post-pandemic, 188,005 nursing
graduates attempted NCLEX with a 79.90% pass rate (NCSBN, 2024). This decline represents a
significant decrease in the expected number of licensed nurses entering the medical community
post-pandemic. Fewer nurses passing NCLEX has reduced the expected number of new nurses
entering the job market, compounding concerns about a long-term nursing shortage (Buerhaus,
2021).

3
Purpose of the Project and Research Questions
Nursing students who attended school during the peak of the COVID-19 pandemic
experienced disruptions to the board of nursing required clinical hours of in-hospital patient
training due to shelter-in-place mandates. This study explored the evaluations of various hospital
nursing administrators of the impact of virtual clinical education on post-pandemic nursing
graduates in a hospital setting. To this end, the study examined the responses of nursing
administrators to the problem of practice and what they learned to improve nursing education in
the future. The questions that guide this study are:
1. What are the nursing administrator’s perceptions of the impact of virtual clinical
education on post-pandemic nursing graduates’ critical thinking skills, teamwork with
other medical professionals, skill set competencies, and demonstration of patient empathy
in the hospital setting?
2. Have nursing administrators adjusted new nurse onboarding and training protocols to
accommodate the needs of virtually trained post-pandemic nursing graduates entering the
hospital setting?
3. What are the nursing administrator's recommendations for continued use of virtual
clinical education?
Importance of the Study
The impact of nurses with inadequate clinical training has severe ramifications for the
medical community. As post-pandemic nursing graduates enter the workforce, the lack of handson clinical experience is taking a toll on nursing operations and hospital efficiencies (Turale &
Nantsupawat, 2021). This study sought a deeper understanding of the virtual education this

4
generation of nurses received by gathering feedback from hospital nursing administrators
assimilation of these graduates into the post-pandemic hospital setting.
Overview of Theoretical Framework and Methodology
This section describes the theoretical frameworks applied to this study, justifies its
appropriateness, and gives an overview of the methodological approach. This study applied a
modified version of Albert Bandura's social cognitive theory (SCT) as its theoretical framework
(Bandura, 1998). A SCT framework focuses on the social context of learning with a three-prong
construct that includes the individual's social learning experience, environmental factors, and the
behaviors that influence a cognitive human experience (Bandura, 1998). Using a modified
version of SCT, this study delineated the first construct, environmental factors, as the virtual
clinical education experience through the height of the COVID-19 pandemic and the hospital
setting that employed these post-pandemic nursing graduates. The second construct of SCT was
the nursing graduates’ virtual clinical education experience during the height of the COVID-19
pandemic from the perspectives of nursing administrators. The research protocol did not include
interviewing the nursing graduates directly to evaluate their self-efficacy, cognitions, or beliefs
in their virtual learning experience; however, the research indirectly assessed the nursing
graduates’ behaviors, efforts, and motivation by surveying the hospital nursing administrators’
perspective by proxy. This study’s final construct of SCT focused on the nursing administrator’s
observations of the behaviors of the post-pandemic nursing graduates on the job in the hospital
setting.
Bandura (1998, 2002) developed SCT with the belief that learning occurs through
dynamic and reciprocal interactions between individuals. This study hypothesized that, from the
perspective of nurse administrators, virtual clinical education’s lack of reciprocal learning

5
interaction has negatively affected post-pandemic nursing graduates skill set competencies,
critical thinking skills, effective teamwork, and patient empathy in the hospital setting. Using
qualitative methodology to interview hospital nursing administrators allowed an in-depth inquiry
into their perception of the impact of post-pandemic virtually trained nurses in the hospital
setting.
Definitions
This section defines significant words and phrases that appear throughout this study.
Board of Vocational Nursing and Psychiatric Technicians refers to the California
Nursing Board that approves nursing curricula, clinical training locations, and compliance
regulations and certifies nursing graduate's licensure examination scores (BVNPT 2024)
Generation Z refers to the generation born in 1997 - 2012. For this study that is the
predominant age range of post-pandemic licensed nurses entering the hospital setting (Turner,
2015).
National Council National Council Licensure Examination (NCLEX) refers to the
licensure exam that assesses the competency of nursing graduates in the United States and
Canada (Authement et al., 2023).
National Council of State Boards of Nursing (NCSBN) is a non-profit organization that
supports nursing regulatory bodies, sets nursing standards and develops and maintains the
NCLEX exam outcomes across the United States, Canada, and other territories (NCSBN, 2024).
Nursing Administrators in this research study refers to chief nursing executives (CNE)
and chief nursing operators (CNO), which are interchangeable in some organizations, chief
executive operators (CEO) of hospitals, nursing department directors (DD), department

6
supervisors (DS), and nursing educators (NE) often seen in University affiliated hospitals
(Branden & Sharts-Hopko, 2017).
Post-Pandemic Nurse in this study, the term 'post-pandemic nurse' refers to the cohort of
nurses who completed their clinical education virtually due to shelter-in-place mandates during
the peak of the COVID-19 pandemic and subsequently obtained their nursing licenses (Weberg
et al., 2021).
Social Cognitive Theory refers to a theory developed by Albert Bandura that states
learning occurs with a reciprocal and dynamic interaction between the environment, and
individual’s self-efficacy and cognition, and observable behaviors (Bandura, 2002). This study
used a modified version of Bandura’s social cognitive theory by exploring the nursing
administrator’s perspective of the post-pandemic nurse’s self-efficacy and cognition by proxy.
Virtual Clinical Nursing Education is a remote simulated nursing education model
involving case studies and other web-based activities instead of traditional hands-on patient
experiences due to shelter-in-place mandates of the COVID-19 pandemic (Martin & Tyndal,
2022).
Organization of the Dissertation
Chapter 1 of this study includes an introduction to the problem of practice, context,
background of nursing education, and pandemic-induced transition to virtual clinical education.
It also articulates the importance of this study and provides an overview of the theoretical
framework, research methodology, and definitions of keywords and phrases.
Chapter 2 is a comprehensive literature review that includes the history of pre-pandemic
nursing education, virtual clinical simulation, and the impact of virtual education on postpandemic licensed nurses in the hospital setting. Chapter 3 outlines the qualitative research

7
methodology, sampling criteria, and interview protocols. Chapter 4 identifies and analyzes the
findings of the research. Chapter 5 reviews recommendations based on the limitations and
delimitations, proposes future study, and presents the conclusion of this study

8
Chapter Two: Literature Review
This literature review begins with a brief section on the foundation of nursing education,
its progression from on-the-job patient training programs to formal academic nursing programs,
and an overview of the evolution of the nursing profession. It includes a summary of each state’s
legislative Board of Nursing (BON) implementation and licensure requirements. This review
then transitions into a discussion of the importance of didactic and clinical experience
partnership in nursing education, addressing the crucial part played by observing nursing
educators demonstrate patient empathy, clinical skill-set competency, effective teamwork, and
critical thinking skills. This chapter also examines the BON didactic and clinical hour
requirements before the height of the COVID-19 pandemic and how those requirements adapted
to shelter-in-place mandates.This section covers emerging research on virtual clinical education,
examining its effects on hospital operations and its implications for the forecasted nursing
shortage. Chapter two concludes with a review of Bandura’s conceptual framework and his SCT
as it applies to the problem of practice.
History of Nursing Education
Nursing profession standards evolved from the practices developed by the pioneer of
nursing, Florence Nightingale (Hanes, 2020). Nightingale is historically credited with organizing
a team of nursing volunteers to care for British soldiers during the Crimean War of 1853 and
introducing standards of hygiene, wound treatment, and patient care (Bakewell, 2011; Ellis,
2008). The Nightingale Principals were at the foundation of nursing programs developed in
various British hospitals after the war (Whelan & Buhler-Wilderson, 2011). In 1872, the first
nursing school in the United States was established at the New England Hospital for Women and
Children (Davis, 1991). Over the next few years, various hospital-affiliated nursing programs

9
arose across Europe and North America, solidifying a new era of formal nursing education
(Hanes, 2020; Whelan & Buhler-Wilderson, 2011).
By the turn of the century, there were over 400 hospital-affiliated nursing programs
globally (Whelan & Buhler-Wilderson, 2011). These newly formed nursing programs focused on
apprentice-type training, including janitorial and laundry duties, with limited theory instruction
(Whelan & Buhler-Wilderson, 2011). D’Antonio and Clark (2022) noted that these early nursing
programs often exploited young students, primarily women, requiring 2 to 3 years of hard labor
in exchange for a nursing diploma. These nursing programs created a revolving student nursing
pool, limiting the hospital’s need to hire many nurses. Hospitals commonly hired a trained nurse
in a supervisory role to manage the unpaid pool of student nurses (Whelan & Buhler-Wilderson,
2011). As the nursing profession continued to develop and fill essential functions in the medical
community, it highlighted the need for standardization of education and equitable working
conditions.
Standardization of the Nursing Profession
In 1893, a group of nursing educators gathered at the Chicago World’s Fair to lay the
groundwork for the first nursing association to promote education standardization, curriculum
development, and teacher training: the American Society of Superintendents of Training Schools
of Nursing (Tagliareni, 2019). This society progressed into the current National League of
Nursing Education (NLN), which has been instrumental in introducing accreditation
requirements, nursing education reform, and professional standards in the field of nursing
(Tagliareni, 2019). Along with NLN is the notable professional nursing organization, American
Nurses Association (ANA), which promotes nurses’ rights, professional development, and
nursing excellence (ANA, 2024).

10
As the nursing profession began to establish itself as a vital part of the medical
community, the focus turned to academic expectations. The American Society of
Superintendents of Training Schools of Nursing began to take steps to standardize and regulate
nursing education (Tagliareni, 2019). These initial ventures into education standardization
evolved into nursing education accrediting organizations that set guidelines for curriculum, skill
competencies, and examination requirements. Today, organizations such as the Accreditation
Commission for Education in Nursing (ACEN), the American Association of Colleges of
Nursing (AACN), among others, regulate nursing education standards. Nursing programs that
ACEN or AACN accredit are required to maintain strict licensure pass rates. AACN, for
example, requires an 80% first-time NCLEX pass rate, while ACEN requires a 100% overall
NCLEX pass rate for all nursing graduates (AACN, 2024; ACEN, 2024; Foreman, 2017). The
strict requirements of licensure pass rates required by accrediting bodies such as ACEN or
AACN ensure that an academic institution delivers a high-quality nursing program (AACN,
2024; ACEN, 2024; Foreman, 2017).
Implementation of State Legislative Boards of Nursing
World War I (WWI) was a turning point in establishing the importance of nursing in the
20th century. Approximately 23,000 American nurses enlisted and served on the front lines and
in the United States, delivering critical care to the wounded military (Whelan & BuhlerWilderson, 2011). By the end of WWI, medical science, technology, and treatment
advancements aligned with America’s shift from predominantly home-based healthcare to
hospital-based healthcare (Moseley, 2008). The need for skilled nurses increased as hospitals
expanded patient capacity and delivered increasingly complex treatment options (Walker &
Holmes, 2008).

11
Moseley (2008) noted that specialized medical treatments propelled the advancement of
complex nursing skill sets and broadened the scope of nursing, intensifying the need for
professional and education standardization. Over time, each state legislature created its own
nursing board to govern specific nursing requirements. As the nursing profession evolved, the
scope of practice and education requirements delineated the nursing profession into registered
and licensed status. Today, registered nurses must have a college degree defining the scope of
practice: associate degree nurse (ADN), bachelor’s degree nurse (BSN), or master’s degree nurse
(MSN) (NCSBN, 2024). The scope of nursing continued to develop. Today a licensed vocational
nurse (LVN) or practical licensed nurse (LPN) is defined as a nurse who is not required to have a
college degree (NCSBN, 2024). Various nurses also function under specialized degrees, such as
nurse anesthetists, nurse practitioners, and midwives; however, registered nurses (RN) and
licensed vocational nurses (LVN) are the most common.
While each state has its own BON, its objectives remain consistent: to protect public
safety and regulate nursing education and licensure standards (Spector et al., 2018). Today’s
nursing field is highly regulated by accrediting bodies such as ACEN and AACN, the
Department of Education, and each state’s BON. Each level of nursing requires successful
completion of a didactic curriculum, clinical hands-on experiences, and licensure examination
success as determined by each nursing regulatory organization (Spector et al., 2018). Regulatory
oversight by the BON maintains strict adherence to rules and guidelines to ensure that a nursing
graduate meets the required standards of education, competence, and ethical policies within their
scope of practice.
Each state’s BON maintains specific requirements, including but not limited to
curriculum standards, delivery methods, and content assessment. By the 1960s, nursing

12
education was moving away from hospital-based programs and trending toward higher education
institutions (Whelan & Buhler-Wilderson, 2011). Although removing nursing training from
predominantly bedside care initially faced some resistance, the concept that higher education
institutes could deliver a more comprehensive learning model to support the complex medical
needs of the 21st century eventually prevailed (Whelan & Buhler-Wilderson, 2011). Today, most
nursing programs are associated with colleges or universities, and clinical education is a
partnership between medical facilities, preceptors, and clinical instructors (Spector et al., 2018).
All nursing programs must meet various requirements, including accreditation standards,
and state BON expectations. Approved nursing program accreditation includes leadership
development, sufficient facilities, equipment, and supplies, fiscal viability, adequate clinical
learning experiences, and required curriculum with appropriate evaluation plans for ongoing
quality improvement (Spector et al., 2018). Curriculum topics incorporated into most nursing
programs consist of pediatrics, geriatrics, basic life support, pharmacology, obstetrics, public
health, mental health, medical-surgical, human growth, and development (BVNPT, 2024;
CBRN, 2024).
Board of Nursing Licensure Standards
The NLN was instrumental in the state-specific adoption of nursing licensure
examinations. By the 1950s, the State Board Test Pool Examination (SBTPE) was implemented
across the United States and all examination results were reported to the NLN to evaluate
nursing programs’ effectiveness based on examination results (American Journal of Nursing,
1952). Eventually the SBTPE was phased out and replaced by the National Council Licensure
Examination (NCLEX), the current nursing licensure examination requirement in the United

13
States (Davis & Marrow, 2021). The BON requires that a licensed vocational or practical
licensed nursing graduate have the following qualifications:
● Be at least 17 years of age.
● Proof of High School Diploma or equivalent.
● A clean record from the Department of Justice and Federal Bureau of
Investigation.
● A graduate of an approved school of vocational or practical nursing school.
● Pay the required application fee.
With qualifications met, the nursing graduate qualifies to sit for the NCLEX exam. The nursing
graduate has 5 hours to answer 85 out of 150 possible questions successfully.
The BON requires that a registered nursing graduate have the following qualifications:
● Be at least 18 years of age.
● Proof of graduation from an accredited nursing program.
● A clean record from the Department of Justice and Federal Bureau of
Investigation.
● There is an optional on-the-job experience track.
● Pay the required application fee.
With qualifications met, the nursing graduate qualifies to sit for the NCLEX exam. The nursing
graduate has 5 hours to answer 85 out of 150 possible questions successfully.
Board of Nursing Didactic and Clinical Requirements Pre-COIVD-19 Pandemic
The BON in each state has specific didactic and clinical requirements for nursing
graduates to qualify for the NCLEX exam. Some states require the completion of specific hours
for clinical and didactic competencies, while others require completion of credit hours per
regulations of the academic institution (Bowling et al., 2018). Clock hours or credit hours are the

14
most common time-keeping systems used in nursing programs; however, some programs are
hybrid and use a combination of clock hours and credit hours and a lesser-used competencybased education model (Bowling et al., 2018). In a clock hour nursing program, students must
make up any missed time to meet the hourly requirements of the program (BVNPT, 2024;
CBRN, 2024; NCSBN, 2024).
Before the height of the COVID-19 pandemic, California, for example, required a
nursing graduate to complete specific credit hours or 600-1000 clocked clinical hours and
complete specific credit hours or 500-800 clocked didactic hours, depending on the nursing
degree, the approved BON curriculum, and accreditation agency requirements to sit for the
licensure exam (BVNPT, 2024; CBRN, 2024). The didactic requirements included instructional
comprehension in the following topics: legal and ethical nursing standards, anatomy and
physiology, pediatrics, geriatrics, basic life support, pharmacology, obstetrics, public health,
mental health, medical-surgical, leadership and professional development, human growth, and
development (BVNPT, 2024; CBRN, 2024).
Most BONs require clinical rotations that partner with didactic curriculum competencies
augmenting the clinical experience. The clinical requirements for each nursing program will vary
based on the BON’s approved curriculum, accreditation guidelines, and academic institution
requirements; however, the clinical practicum for all nursing programs is vital ensuring nursing
fundamental comprehension and competent bedside patient care (Bowling et al., 2018). A robust
and effective clinical experience allows nursing students to observe, assess, and care for patients
at all life cycle stages, and in diverse settings (Bowling et al., 2018).

15
The Importance of Connecting Didactic and Clinical Competencies
By the turn of the century, nursing programs began transitioning from hands-on bed-side
training models to programs that incorporated theory-based curricula (Moseley, 2008). In 1910,
American educator Abraham Flexner presented research on the process of medical education and
advocated for higher standards and more thorough didactic requirements, which are at the crux
of excellent patient care (National Library of Medicine [NLM], 2024). Although Flexner’s report
highlighted physician education models, the concept of advancing didactic requirements to
improve patient outcomes was noted across the field of medical education, including nursing
(NLM, 2024). To this day the foundation of nursing education is partnering didactic
comprehension with hands-on clinical experience to promote critical thinking skills necessary for
competent nursing (Sharif & Masoumi, 2005).
A competent and skilled nursing pool is at the core of patient care and safety in the
hospital setting. Delivering capable patient care goes beyond demonstrating excellent
psychomotor skills or muscle memory for tasks (Fero et al., 2010; Van Horn & Lewallen, 2023).
Theoretical knowledge provides a foundation for critically evaluating patient needs and acting
quickly to make informed choices. For example, a female patient may present with nausea and
back pain, while a male patient may present with severe chest pain. A nurse focusing only on
clinical training may assess the male patient as the more significant risk for a myocardial
infarction and initiate medical intervention. However, with theoretical knowledge of
cardiovascular disease, the nurse would also know that the female patient may be just as likely as
the male patient to be having a significant cardiac event (Sharaf et al., 2013). A nurse’s ability to
understand the “why” behind a symptom or medical event can make all the difference in
initiating the correct medical intervention (Sharif & Masoumi, 2005).

16
The Importance of Developing Critical Thinking Skills in Clinical Education
The foundation of nursing education is partnering didactic comprehension with hands-on
clinical experience to promote the critical thinking skills necessary for competent nursing (Sharif
& Masoumi, 2005). The world of medicine is a fast-paced, ever-changing complex environment.
Nursing students need exposure to various clinical experiences to develop their skill set in a
structured learning environment (Mlinar Reljić et al., 2019). Nursing students must see what a
medical event, such as a seizure, looks like in person to develop the critical thinking skills
needed for competent nursing. Understanding the theory behind the seizure, and the appropriate
nursing skills required such as maintaining the airway and protecting the patient from further
injury and being equipped to critically evaluate the patient’s response to treatment are how
critical competency develops (Holland et al., 2017). How will the nursing student adapt and
make the quick medical decisions necessary if the theory version of the patient’s medical needs
goes beyond the textbook or video presentation? If the patient’s initial medical event, the seizure,
progresses into cardiac arrest, the nurse’s critical thinking skill set will kick into action and
initiate cardiopulmonary resuscitation (CPR) (Gazarian et al., 2010). A textbook or video will
not deliver the same impact as being present for the hands-on experience.
To develop critical thinking skills, clinical education also uses problem-based learning
(PBL) (Schmidt et al., 2011). PBL, often referred to as a case-study review, plays a prominent
role in many nursing programs, with evidence that this learning technique promotes critical
thinking skills as well as teamwork, good communication, and self-evaluation (Maharjan et al.,
2021; Schmidt et al., 2011). PBL is often used in group settings to encourage activation of prior
knowledge, collaborative research beyond prior knowledge, and the opportunity to consider new
concepts to promote long-term information retention (Schmidt et al., 2011). A 2007 study

17
tracked 147 nursing students; one group engaged in PBL activities, and the other participated in
traditional education delivery models (Ozturk et al., 2008). The nursing students who
participated in PBL activities scored significantly higher on the California Critical Thinking
Disposition Inventory (CCTDI) than the students who received traditional education modalities
(Ozturk et al., 2008). The PBL process of self-evaluation and consideration of different outcomes
supports the development of a nursing student’s critical thinking.
The social interaction at the foundation of PBL supports Bandura’s SCT, which
maintains that learning occurs through dynamic and reciprocal interaction between individuals,
their environment, and behavior (Bandura, 1998, 2002). Under the BON’s strict guidelines,
nursing programs are challenged to create the next generation of competent and skilled nurses.
Methods like PBL encourage critical thinking skills and teamwork, the foundation of patient
safety, and effective hospital interactions (Maharjan et al., 2021). The dynamic and reciprocal
interactions between nursing students, clinical opportunities, and skilled instructors supports
Bandura’s SCT, PBL, and the development of critically thinking nursing students (Bandura,
1998, 2002).
The Importance of Developing Teamwork Skills in Clinical Education
Patient safety and efficient hospital operations rely on successful multidisciplinary
teamwork. The World Health Organization (WHO) (2023) has determined that the foremost
cause of adverse medical events related to hospitalized patients is poor teamwork and
communication among medical personnel. Interpreting multiple perspectives requires a dynamic
synthesis of knowledge, critical thinking skills, and collaborative interaction, which is necessary
when making clinically sound decisions (Bandura, 1998; Endacott et al., 2015; Facione &
Facione, 1996; Gazarian et al., 2010; Horlait et al., 2021). Numerous research studies have found

18
that nursing staff working efficiently with physicians has the greatest impact on patient outcomes
(Aiken et al., 2002; Needleman et al., 2002; Tourangeau et al., 2007). During clinical education,
nursing students must experience and understand the impact of adherence to hospital nursing
protocols on effective teamwork (Ballangrud et al., 2017; Sochalski, 2004). Understanding and
functioning effectively in the medical team environment is crucial for competent nursing and
patient safety (Gazarian et al., 2010; Sochalski, 2004).
Effective teamwork in a medical facility is more than developing the capability to
complete tasks in a group setting. Eduardo Salas’ (2005) research identifies five elements to
effective nursing teamwork: leadership skills, mutual performance monitoring, backup,
adaptability, and a strong team mentality. These five elements are realized through
communication, a shared mental mindset, and trust. The Nursing Teamwork Survey (NTS)
results, administered to over 1,700 nurses, solidified much of Salas’s research (Kalisch et al.,
2010). The NTS findings supported Salas’s previous teamwork research, reporting that trust,
team orientation, backing up one another, having a shared mental mindset, and team leadership
are critical factors (Bragadóttir et al., 2019; Kalisch et al., 2010). Didactic education alone does
not allow for the replication of observable nursing teamwork in a hospital setting, which is
crucial to learning per STC (Bandura, 2002). Effective teamwork is a vital part of clinical
nursing education experienced through observation, and practice in a hospital setting (Endacott
et al., 2015; Gazarian et al., 2010; Kelly et al., 2014).
The Importance of Developing Skill-Set Competencies in Clinical Education
Most nursing programs establish the foundation of skill competency by introducing the
theory behind the skill, practicing the skill in a lab setting, and performing clinical observation
with faculty instruction before the nursing student participates in hands-on patient care (Perry et

19
al., 2018). The clinical procedural skills (CPS) executed depend on the scope of nursing practice
as determined by the level of education and licensure (BVNPT, 2024; CBRN, 2024). As stated
previously, many studies have highlighted the need for didactic, hands-on practice in a labsetting, and observable interactions in patient care; before a nursing student attempts to complete
CPS on a patient (Ewertsson et al., 2017). SCT also emphasizes the social construct of learning
through observation and teamwork (Bandura, 2002). As the steps of nursing competency become
interlayered with didactic learning, lab practice, and hands-on observation, the nursing student
must perform CPS accurately in patient care (Ewertsson et al., 2017).
The medical field is a dynamic, rapidly evolving, and often high-pressure environment in
which patient safety and effective care are the goal. There is no room for error when a nurse is
required to deliver a CPS (Papp et al., 2003). The clinical learning experience is vital in
developing a competent nurse prepared to critically react during stressful and complicated
medical events (Ewertsson et al., 2017; McGregor, 2005). Though nurses may apply didactic
knowledge in addressing a clinical event, accurately delivering CPS can be the difference
between a poor patient outcome and a successful patient outcome (Admi, 1997; O’Mara et al.,
2014).
Many factors determine a nurse’s ability to deliver accurate clinical skills. The field of
medicine uses a myriad of equipment and supplies that requires both knowledge, and physical
training (Ewertsson et al., 2017). Nursing students must learn how to operate intricate and
complex pieces of equipment that require nimble actions. Clinical nursing education relies on a
certain level of manual dexterity, physical agility, and eye-hand coordination (Kuzgun & Denat,
2020; Papp et al., 2003). Kuzgun and Denat’s 2020 study showed that a student’s attitude toward
and motivation in their education played a large part in overcoming any issues with manual

20
dexterity and physical ability to complete successful nursing skills. SCT also supports Kuzgun
and Denat’s study and other research indicating that executing successful nursing skills hinge on
a student’s ability to mimic observed skills and receive feedback from instructors and peers
(Ewertsson et al., 2017; O’Mara et al., 2014). Precise and accurate nursing CPS performance is a
critical component of effective hospital operations and patient outcomes.
The Importance of Developing Patient Empathy in Clinical Education
The Oxford English Dictionary (2024) refers to a nurse as one who cares for the sick,
soothes the infirm, and shows empathy and compassion. Empathy in nursing goes beyond
recognizing a patient’s pain and suffering; it compromises the capacity to listen, validate,
support, and enhance therapeutic communication (Edstrom, 2023; Levett-Jones et al., 2020). As
the nursing profession has expanded its scope of practice over time, the mission of a nurse
remains consistent to deliver competent patient care while demonstrating the humanistic quality
of empathy (Gillespie, 2002). Research shows that demonstrating empathy can improve a
patient’s psychological well-being and medical outcomes (Durkin et al., 2022; Edstrom, 2023;
Nourallah et al., 2020). To nurture these qualities, nursing students must receive didactic and
clinical training.
According to Bandura’s (1998) social cognitive theory, learning happens through the
dynamic and reciprocal observation of actions, a model that raises concern for nursing students
who received a virtual clinical education. Such students had decreased opportunities to observe
clinical instructors and other medical professionals interacting with patients during medical
events. Even with the most advanced, interactive, and high-fidelity simulated learning
environments, virtual education can not replace the reality of patient care: the sounds, smells,
emotions, and complexities of the human experience (Cunico et al., 2012; Edstrom, 2023; Mlinar

21
Reljić et al., 2019). Didactic learning is essential to creating a foundation of nursing knowledge.
Virtual clinical education, PBL, and lab competency skill-based training can augment a student
nurse’s knowledge; however, the ability to think critically, perform competently, work in a team
environment, and demonstrate patient empathy requires observable and practiced bedside care
(Durkin et al., 2022; Edstrom, 2023).
The COVID-19 Pandemic
The Centers for Disease Control (CDC) (2024) reported a viral outbreak in late 2019 in
Wuhan, China, noting patients exhibiting atypical pneumonia-like symptoms that did not
respond to standard treatments. By January 2020, the outbreak in Wuhan had spread, and public
health officials in China identified the virus as a novel coronavirus (CDC, 2024). The virus
spread quickly. With more than 100,000 confirmed cases and over 4,000 deaths, on March 11,
2020, the World Health Organization (WHO) declared COVID-19, a severe and acute respiratory
virus, a global pandemic (WHO, 2024). On March 13, 2020, the United States declared a
nationwide emergency (CDC, 2024). Most countries adopted mandates that limited human
contact and dramatically changed our day-to-day interactions to control the spread of the virus
(Callaway et al., 2020). The COVID-19 pandemic resulted in an incredible loss of life, economic
challenges, and employment, education, social, and personal trials worldwide. The United States
reached the peak of the COVID-19 crises in the winter of 2020/2021, with the death toll reaching
approximately 1.1 million by 2024 (CDC, 2024).
Board of Nursing Response to COVID-19 Pandemic Mandates
During the shelter-in-place mandates of the COVID-19 pandemic, numerous nursing
programs transitioned to a virtual education model for both didactic and clinical education (Chan
et al., 2021). Many hospitals discontinued student education programs so they could prioritize

22
hospital personnel’s efforts in caring for COVID-19 patients (Park et al., 2023). Using California
as an example, Governor Gavin Newsom’s executive order, the Department of Consumer Affairs
(DCA) notified the CBRN and BVNPT that all nursing programs in California would follow the
“DCA-20-03 Nursing Students Clinical Hours” order which waived previous clinical hour
licensure requirements for nursing students (DCA, 2024). The DCA 20-03 order was initiated to
keep California nursing programs operating during the height of the COVID-19 pandemic in
alignment with the shelter-in-place mandates, to ensure a future nursing workforce.
Effective April 3, 2020, through August 31, 2021, the DCA waived hands-on clinical
requirements for nursing students (DCA, 2024). However, the CBRN and BVNPT did not
specify or monitor what qualified as virtual clinical replacement activities (BVNPT, 2024;
CBRN, 2024). Nursing programs scrambled to develop virtual clinical simulation to replace the
hands-on clinical training typically conducted at the bedside in hospitals (Park et al., 2023). Most
nursing programs used a combination of skills labs, virtual simulation, interactive software,
telehealth observations, and videos in an effort to maintain the educational rigor necessary for
licensure success (Dewart et al., 2020; Kawasaki et al., 2021). As the COVID-19 pandemic
subsided, hospitals slowly reintroduced student nursing education options. By the beginning of
2023, the BVNPT and CBRN required all nursing programs to return to pre-pandemic clinical
requirements; however, there has been some flexibility on a case-by-case basis due to local
clinical accessibility limitations (BVNPT, 2024; CBRN, 2024).
The Impact of Virtual Clinical Education
Education delivery is an ever-evolving process. In 1728, Caleb Phillips introduced
remote education in the form of a shorthand correspondence course through the United States
Postal Service (Pregowska et al., 2021). As technology advanced, phonographic correspondence

23
courses emerged, followed by radio and television broadcasting educational programs, which
offered flexibility and access to a broader range of learning opportunities (Pregowska et al.,
2021). These initial forays into remote learning eventually progressed into virtual universities
offering degrees using a variety of e-learning platforms (Pregowska et al., 2021). The COVID-19
pandemic accelerated global research and prompted significant investment into the digital
learning tools and platforms necessary to continue education modalities, including nursing
education (Pregowska et al., 2021; Suliman et al., 2021).
Although the shelter-in-place restrictions of the COVID-19 pandemic have been lifted,
the lessons learned from remote education have been the catalyst of research and investment into
adopting and normalizing distance learning (Ameri et al., 2023). The Accrediting Bureau of
Health Education Schools (ABHES) accredits over 200 allied health care programs, including
nursing programs from associate’s level to master’s level, nationwide, and has a vested interest
in regulating the highest standards of education, including hybrid and online learning modalities
(ABHES, 2024). Specifically, the ABHES 2024 conference focused on distance education,
emerging innovative teaching methods in didactic and clinical applications, software, legal
ramifications, accreditation standards, and Department of Education (DOE) requirements
(Hunsinger & Johnson, 2024). The COVID-19 pandemic has ushered in a new era of distance
education evolution, including nursing clinical education.
Pre-COVID-19 Pandemic Virtual Clinical Education
Before the COVID-19 pandemic, nursing programs adopted both didactic and clinical
virtual education modalities, referred to as Digital Nursing Technology (DNT). A nursing
education study in 2015 examined the results of 31 separate studies on the effectiveness of DNT
compared to traditional face-to-face learning (McCutheon et al., 2015). The results noted that 28

24
out of 31 nursing programs demonstrated similar, if not better, learning outcomes in a DNT
platform compared to a traditional in-person learning environment (McCutheon et al., 2015).
Pre-pandemic research reported the benefits of allowing nursing students to transfer didactic
knowledge into a safe environment of virtual clinical scenarios repeatedly, increasing selfefficacy during hands-on clinical practice (Bambini et al., 2009; MacLean et al., 2019). Bandura
(2002) posited that an individual’s level of self-efficacy is a critical factor in their determination
to overcome obstacles to complete a task. Research showing increased nursing students’ selfefficacy, flexible learning opportunities, and patient safety indicated that DNT partnered with
hands-on lab skills offers an excellent learning tool for augmenting traditional nursing education
(Lewis et al., 2016; Ward et al., 2018).
Pre-pandemic research evinced positive and developing opportunities in utilizing virtual
clinical education; however, it also noted weaknesses. Even with the implementation of highfidelity manikins and repeated virtual scenarios, virtual clinical education can not replace the
human experience (Bambini et al., 2009; Lewis et al., 2016). A 2009 study of 112 nursing
students during a postpartum and newborn hospital rotation showed increased knowledge and
procedural competency after completing virtual clinical simulation scenarios, compared to
students who did not participate in virtual clinical simulation (Bambini et al., 2009). Although
the study showed increased self-efficacy and procedural knowledge, the nursing students could
not transfer didactic knowledge into a contextual experience in scenarios with postpartum
patients presenting with signs and symptoms of a hemorrhagic crisis (Bambini et al., 2009;
Mlinar Reljić et al., 2019). Identifying the nuances and cues of human interaction may have
limitations in virtual clinical education.

25
Honing accurate nursing skills is crucial to hands-on patient care and positive patient
outcomes. Escalating complexities in healthcare, nursing shortages, and limited resources
decreased the availability of hands-on training programs for nursing students before and after the
height of the COVID-19 pandemic (Bragadóttir et al., 2019; Oermann & Gaberson, 2013; Ross,
2012). With some hospitals limiting student nursing education opportunities, nursing programs
have incorporated virtual clinical simulation to compensate for limited hands-on clinical practice
(Bragadóttir et al., 2019; Ross, 2012). A 2011 study evaluated the growing trend in nursing
programs using virtual clinical simulation and the impact on nursing skill performance in the
clinical setting (Ewertsson et al., 2017; Ross, 2012; Salyers, 2007). The 2011 research findings
aligned with other studies at that time indicating concerns with psychomotor skill-set
development when relying exclusively on virtual clinical education for nursing skill
development; however, all studies showed that virtual skill simulation along with traditional
hands-on training resulted in improved student self-efficacy and skill competency (Bandura,
2002; Bloomfield et al., 2008; Ross, 2012; Salyers, 2007).
Other pre-COVID-19 pandemic DNT research found limitations in developing a nursing
student’s communication and teamwork skill set (Cant & Cooper, 2009). Communication skills
and effective teamwork are critical in the hospital setting to maximize patient outcomes
(Bragadóttir et al., 2019: Gazarian et al., 2010; Perry et al., 2018). The requisite skills for
interacting with other healthcare professionals are often learned through observation and
engagement in clinical patient care (Bandura, 2002; Liaw et al., 2020; Weaver et al., 2014).
Between 2011 and 2012, 13 studies reported that implementing virtual simulation and
classroom-based team training activities improved healthcare teamwork behaviors (Weaver et
al., 2014). Although research supports virtual clinical activities as a valuable supplement for

26
developing communication skills essential for effective teamwork, virtual clinical activities
cannot replace hands-on patient care learning experiences.
Another pre-pandemic limitation noted in the virtual clinical education literature is the
lack of patient empathy development. The foundation of nursing is competent patient care,
compassion, and empathy, which is difficult to replicate in a virtual scenario (Krick et al., 2020).
Medical staff caring for specialized populations, such as geriatrics, require specific training in
empathy and compassion for dealing with multimorbidities, frailty, lack of mobility, and often
cognitive deterioration (Eide et al., 2020). Although DNT is an excellent tool for augmenting
nursing education, witnessing patient care, compassion, and empathy in patient interaction is
most effective when performed in a real-world setting (Bandura, 2002; Eide et al., 2020; Krick et
al., 2020).
Virtual Clinical Education During the Height of the COVID-19 Pandemic
Following directives to shelter in place, schools abruptly transitioned to remote learning
modalities (Chan et al., 2021). Although there was pre-pandemic implementation of DNT in
various formats, several institutions found themselves lacking the required IT infrastructure,
curriculum software products, staff with experienced e-literacy, and technical support, disrupting
approximately 1.5 million nursing students worldwide (Dziurka et al., 2022; Jokar et al., 2023;
Ramos-Morcillo et al., 2020). Disruption to nursing program’s modalities was evident in remote
and under-resourced locations, leading many nursing institutions to suspend education entirely
(Ramos-Morcillo et al., 2020). Some students who enrolled in face-to-face traditional nursing
programs struggled to adapt to online formats or noted a lack of educational support during the
pandemic (Suliman et al., 2021).

27
Nursing programs nationwide scrambled to implement DNT and, specifically, to develop
virtual clinical simulation to replace the hands-on clinical training typically conducted at the
bedside in hospitals (Park et al., 2023; Warren et al., 2022). Various platforms, including
telehealth observations, training videos, YouTube videos, high-fidelity manikins, online lab
simulations, interactive patient scenario software, virtual reality products, and other e-learning
modalities, were implemented (Dziuka et al., 2022; Kawasaki et al., 2021). Unfortunately, with
little time for comprehensive research, many virtual simulation products were hastily
incorporated into nursing programs with little or no evidence of product effectiveness (Warren et
al., 2022). Emergent research is documenting the outcomes for new graduates who received
clinical virtual simulation in lieu of hands-on clinical education (Dziurka et al., 2022; Warren et
al., 2022). Some of the concerns being revealed include the lack of reciprocal observation in
patient care, dearth of clinical instructors and mentors, gaps in didactic and practical application,
lowered NCLEX pass rates, errors in patient care, and mental stress and fear associated with the
field of nursing education limitations during a global pandemic (Bandura, 2001; BVNPT, 2024;
CBRN, 2024; Dziuka et al., 2022, NCSBN, 2024; Warren et al., 2022).
Other evidence indicates that virtual clinical education has positively impacted nursing
education. Virtual clinical education allows the student to repeat clinical scenarios without
causing harm to patients (Choi et al., 2022). Self-efficacy improved in students who used virtual
simulation formats before engaging in patient care (Bandura, 2002; Choi et al., 2022; Kim et al.,
2020). The flexibility of online education meets the needs of students’ schedules and life
disruptions during the shelter-in-place mandates. Clinical rotations at hospitals have limited
capacity for nursing students exposure to medical conditions; however, virtual clinical

28
applications have the capacity to deliver a wide range of complex and varied clinical experiences
(Choi et al., 2022).
Qualitative research on student perspectives of remote education had mixed outcomes.
Some students felt that virtual simulation and interactive patient scenarios kept them engaged
and motivated to continue their education journey, while others felt demotivated due to lack of
instructor support and struggles with their mental health (Choi et al., 2022; Dziurka et al., 2022;
Kawasaki et al., 2021). The crisis-response adoption of on-line education precluded student
support mechanisms, proper planning designs, and development of effective instructional
strategies that address the objectives of specific nursing curricula, and evidence-based
implementation of didactic and clinical competencies (Adedoyin & Soykan, 2023). The COVID19 pandemic created a “learn-as-we-go experience” on many levels. However, as the pandemic
has subsided, continued research and assessment into virtual education, outcomes, and the
nursing student experience will fortify the future of nursing education.
The Decline in NCLEX Pass Rates Compounds Predicted Nursing Shortage
The NCSBN (2024) reported a national decline in first-time pass rates on the NCLEX.
NCSBN (2024) reported that, in 2019, approximately 171,387 nursing graduates attempted
NCLEX, with an 88.18% pass rate. In 2022, 188,005 nursing graduates attempted NCLEX with
a 79.90% pass rate (NCSBN, 2024). This decline represents a significant decrease in the
expected number of licensed nurses entering the medical field post-height of the COVID-19
pandemic. This unexpected decline in licensed nurses compounds concerns about a long-term
nursing shortage (Buerhaus, 2021).
Before the COVID-19 pandemic, the WHO predicted a 7.6 million nursing shortage by
2030 due to retiring baby boomers (Bagwell et al., 2024; Buerhaus, 2021; Sommers, 2024;

29
WHO, 2023). Baby boomers are also an aging population requiring increased healthcare
services. The United States currently has 3.1 million RNs; given the increased aging population,
the projected need for RNs is 3.3 million by 2031 (Anthony, 2024). Pandemic-induced factors,
such as COVID-19 burnout or pandemic fatigue, have exacerbated predictions of nursing
shortage. (Anthony, 2024; Bagwell et al., 2024; Donnelly, 2022). A substantial body of literature
describes COVID-19 burnout or pandemic fatigue in nursing as a combination of factors: fear of
infecting loved ones, fear for their own health, life disruptions such as child-care problems, job
stress due to short-staffed hospitals, job dissatisfaction, and mental health concerns due to the
severity of illness and volume of death nurses witnessed during the pandemic (Anthony, 2024;
Bagwell et al., 2024; Buerhaus, 2021; Ménard et al., 2023). Increased nursing turnover rates, not
just leaving a particular hospital but the nursing profession altogether, have also been attributed
to COVID-19 burnout (Anthony, 2024; Bagwell et al., 2024). A study in 2021 showed a decline
in the RN population by over 100,000, primarily nurses under 35 leaving the profession, the most
significant drop in the last 40 years (Auerbach et al., 2022). The stressors of pandemic-related
factors and the anticipated population of baby boomers retiring compound the predicted nursing
shortage pre-pandemic.
In addition to the challenges such as retiring baby boomers and COVID-19 burnout, the
declining NCLEX pass rates among nursing graduates have significantly reduced the projected
number of new nurses entering the medical field, further contributing to the anticipated longterm nursing shortage (Buerhaus, 2021). Concerns about the quality of remote education,
specifically virtual clinical pedagogy, is a significant consideration in the literature addressing
declining NCLEX pass rates post height of the COVID-19 pandemic (Abuhammad et al., 2024;
Jokar et al., 2023; Sommers, 2024). As hospitals discontinued student nursing education to allow

30
staff to focus on patient care (Park et al., 2023), many nursing programs turned away students
due to lack of clinical resources (Anthony, 2024; Lim, 2024). A 2022 report noted that, due to a
lack of clinical sites and faculty over 70,000 qualified nursing students were not accepted into
nursing programs (Lim, 2024).
The nursing shortage is not confined to the United States; it is a pressing global crisis,
significantly straining already understaffed healthcare systems (Bagwell et al., 2024). The
implications are far-reaching, as inadequate staffing ratios could compromise patient care and
increase error rates (Bagwell et al., 2024). Considering all the contributing factors in the nursing
shortage crisis: COVID-19 burnout, job dissatisfaction, retiring baby boomers and the concurrent
increase in an aging population requiring healthcare, lowered NCLEX pass rates, and restrictions
on student enrollments at some nursing programs due to an inability to support the education
requirements, particularly around clinical activities and faculty, we are clearly facing what
Donnelly (2022) has referred to as the Perfect Storm.
Future of Virtual Clinical Education
The lessons learned through the crisis-induced remote education modalities will shape the
future of nursing education. The distribution of content found in traditional face-to-face nursing
education has evolved through pandemic required DNT, to facilitators of learning, and evaluators
of competency (Podder & Bhardwaj, 2020). DNT is a critical component of nursing education
pedagogy and is instrumental in preparing the contemporary nurse with the skills necessary to
meet the evolving demands of healthcare technology (Bassi et al., 2023). Emerging postpandemic nursing literature highlights continued research and development of evidence-based
virtual education modalities (Cant & Cooper, 2009; Kawasaki et al., 2021; Ramos-Morcillo et
al., 2020). Virtual clinical education has a place in the future of nursing education; however, due

31
to virtual clinical education limitations, research-based recommendations seek to enhance
hospital orientations, training, and mentorship programs so that post-pandemic nursing graduates
receive the extra support they need to ensure patient safety (Suliman et al., 2021).
Conceptual Framework
This study applied a modified version of Albert Bandura's social cognitive theory (SCT)
as its theoretical framework (Bandura, 1998). A SCT framework focuses on the social context of
learning with a three-prong construct that includes the individual's social learning experience,
environmental factors, and the behaviors that influence a cognitive human experience (Bandura,
1998). Using a modified version of SCT, this study delineated the first construct, identifying
environmental factors as both the virtual clinical education experience during the peak of the
COVID-19 pandemic and the hospital setting in which these nursing graduates are employed.
The second construct of SCT is the post-pandemic nursing graduates’ virtual education
experience during the height of the COVID-19 pandemic from the perspective of nurse
administrators. The research protocol does not include interviewing the nursing graduates
directly to evaluate their self-efficacy, cognitions, or beliefs in their virtual learning experience;
rather, it indirectly assesses the nursing graduates’ behaviors, efforts, and motivation by
surveying the hospital nursing administrators’ perspective by proxy. This study’s final construct
of SCT focused on the nursing administrator’s observations of the behaviors of post-pandemic
nursing graduates on the job in the hospital setting.
Bandura (1998, 2002) developed SCT, with the belief that learning occurs through
dynamic and reciprocal interaction between individuals. This study hypothesized that from the
perspective of the nursing administrators, virtual clinical education’s lack of reciprocal
interaction has negatively affected post-pandemic nursing graduates’ skill set competencies,

32
critical thinking skills, ability to collaborate effectively with other medical personnel, and
capacity to demonstrate patient empathy in a hospital setting. Using a qualitative methodology to
interview nursing hospital administrators allowed an in-depth inquiry into the impact of virtually
trained nurses in the post-pandemic hospital setting.
Bandura's initial work focused on the belief that learning happens through observational
and social interaction, with behavioral reinforcement for social learning theory (Boone et al.,
1977). These concepts originated in Bandura's well-known Bobo Doll experiments, in which
preschoolers observed an adult aggressively attacking an inflatable doll and being rewarded,
punished, or ignored (Boone et al., 1977). The study results showed that the preschoolers who
observed the adult rewarded or ignored were likelier to engage in aggressive behavior with the
doll. This experiment reinforced Bandura's thesis that observable behavior encourages learning
more quickly than individual didactic study (Schunk & DiBenedetto, 2020). As social learning
theory evolved, Bandura adopted a more holistic understanding of learning and developed what
we know today as social cognitive theory (Schunk & DiBendetto, 2020).
SCT expands upon the assumptions of social learning theory to include environmental
factors that will affect learning (Schunk & DiBendetto, 2020). For this study, the environmental
factors were the virtual clinical education experience during the height of the COVID-19
pandemic and the hospital setting where the post-pandemic licensed nurse was employed.
According to the logic of Bandura’s (2001) scholarship,the environment will impact a virtually
trained post-pandemic licensed nurse as they navigate hospital procedures, standards, culture,
and patient interaction for the first time.
The second construct in SCT (Bandura, 2001) is the person: that is, the thoughts, beliefs,
cognitions, and self-efficacy that influence an individual’s behavior in a given environment.

33
While one can best assess a person’s cognition directly with and from the individual, such an
evaluation can also occur by indirectly observing behavioral responses and analyzing the
context. These indirect methods serve as proxies for the individual’s underlying beliefs and
cognition. For example, a nursing administrator’s observation of a post-pandemic licensed
nurse’s hesitancy and awkwardness during patient interactions could reflect the limitations of
virtual training and insufficient direct patient clinical experience, resulting in a lack of selfefficacy.
Emerging research has acknowledged behavior differences between pre-pandemic
nursing graduates participating in traditional hands-on patient interactions during clinical
education and post-pandemic nursing graduates receiving virtual clinical education (Alasagheirin
et al., 2023). This study explored these comparisons, expectations, and attributes associated with
a newly licensed nursing graduate (Schunk & DiBendetto, 2020). An individual’s self-efficacy in
reaching a goal is crucial to Bandura’s social cognitive theory. In this spirit the study explored
how the second construct of SCT, the nursing administrator’s perception of the post-pandemic
nursing graduates’ self-efficacy, cognition, effort, and beliefs as proxies, integrated into
Bandura’s triadic reciprocal causation model (Bandura, 2001).
In Bandura’s reciprocal dynamic model (Bandura, 2001), the final construct involves the
nursing administrator’s perception of the behavior of the post-pandemic nursing graduates who
received virtual training and are engaging with patients in a hospital setting. Given that many
newly licensed nurses have yet to experience patient interaction post-pandemic (Choi et al.,
2022), this study explored the impact of virtual clinical education on critical thinking skills,
teamwork, nursing skill sets, and patient empathy behaviors, as demonstrated by newly licensed

34
post-pandemic nurses during patient interactions in a hospital setting (Schunk & DiBenedetto,
2020).
Figure 1
Modified Social Cognitive Theory Map for the Study
Individual by proxy:
Hospital Nursing Administrator’s
perception of Post-Pandemic
Licensed Nurses’ self-efficacy,
cognition, and beliefs in their
virtual clinical learning
experiences.
Triadic Reciprocal
Causation
Social Cognitive Theory
Environmental Factors:
Virtual Training that occurred
during the COVID-19 pandemic
and the
Hospital Setting post-pandemic
Behaviors:
Nursing Administrators’ Observations of
Post-Pandemic Nursing Graduates’
Motivation and Effort Interacting in
Hospital Settings.

35
Summary
This literature review presented a brief overview of the foundation of nursing education
and the standardization of the nursing profession in the United States. As the nursing profession
evolved, each state’s legislature initiated a Board of Nursing, which regulates education and
licensure requirements. BONs in all 50 states align nursing education as a partnership of didactic
and clinical experiences to develop critical thinking skills, teamwork, patient empathy, and
clinical procedure skill competency. This review aligned the tenets of nursing education through
the three constructs of Bandura’s social cognitive theory.
The remainder of Chapter 2 focused on the changes that occurred in nursing education
due to the shelter-in-place mandate at the height of the COVID-19 pandemic. The COVID-19
pandemic required most US academic institutes, including nursing programs, to transition to a
virtual clinical and didactic learning modality. Although clinical virtual education is an emerging
field, limited research exists on its impact on post-pandemic nursing graduates in the hospital
setting. This study explored hospital nursing administration’s perceptions of the effects of virtual
clinical education on post-pandemic licensed nurses as they transitioned into the medical
community.

36
Chapter Three: Methodology
During the height of the COVID-19 pandemic, shelter-in-place mandates meant that
nursing students did not receive the required clinical training in the hospital setting (Callaway et
al., 2020; Chan et al., 2021). Following directives to shelter in place, schools quickly transitioned
to remote learning modalities (Chan et al., 2021). Nursing programs nationwide hastily
developed virtual clinical simulation to replace the hands-on clinical training typically conducted
at bedside in hospitals (Park et al., 2023). This study reviewed hospital nursing administrator's
perceptions of the impact of virtual clinical education on post-pandemic nursing graduates in a
hospital setting. Chapter three specifically explicates the overall research methodology design,
including research questions, research setting, researcher positionality, data-collection protocols,
description of sample participants, participant recruitment, and data analysis. This chapter also
explores the strategies used to maximize the validity and reliability of this study, as well as the
ethical responsibility and any limitations of this research.
Research Questions
The following research questions guided this study:
1. What are the nursing administrator’s perceptions of the impact of virtual clinical
education on post-pandemic nursing graduates’ critical thinking skills, teamwork with
other medical professionals, skill set competencies, and demonstration of patient empathy
in the hospital setting?
2. Have nursing administrators adjusted new nurse onboarding and training protocols to
accommodate the needs of virtually trained post-pandemic nursing graduates entering the
hospital setting?

37
3. What are the nursing administrator's recommendations for continued use of virtual
clinical education?
Overview of Design
This study applied a qualitative design methodology to interview sample participants.
The interview protocol utilized a semi-structured questioning format with open-ended questions
(Bogdan & Biklen, 1982; Morgan, 2013). A semi-structured approach with open-ended questions
allowed follow-up questions to expand and capture valuable data from the participant's
experiences, observations, and opinions of virtually trained nurses in a hospital setting (Merriam
& Tisdell, 2015). The flexibility of semi-structured qualitative questioning enabled the research
to grow and evolve as new information was revealed.
Participants
This study interviewed 14 hospital nursing administrators as research sample participants.
The researcher used a purposeful sampling method, focusing on hospitals in the United States
that employ at least 200 nurses (Merriam & Tisdell, 2015). The initial participant recruitment
focused on nursing administrators familiar with the researcher’s professional network to increase
interview opportunities. However, Merriam and Tisdell (2015) cautioned of potential bias from
convenience sampling by only focusing on participants familiar to the researcher, which may
limit the data-rich information required in a well-rounded study. Cognizant of eliminating bias,
recruitment outreach included hospitals unfamiliar to the researcher and referrals from sample
participants, eliminating potential bias (Merriam & Tisdell, 2015).
The interview participants were nurses who had advanced in their careers into varied
levels of nursing administration. Hospital nursing administrators are responsible for adequate
nursing staffing, onboarding, training, supervising, quality and safety control, and performance

38
evaluation (Branden & Sharts-Hopko, 2017). This study included nursing administrators with
various titles, including chief nursing operators (CNO) and chief nursing executives (CNE),
whose titles are interchangeable in some organizations. One interview participant was recently
promoted from CNO to a hospital chief executive operator (CEO). Other sample participants
included department directors (DD) and department supervisors (DS) and nurse educators (NE)
commonly associated with university-affiliated hospitals. The variety of nursing administrator
titles - from executive nursing leadership to direct nursing supervisors reflects the study’s wide
range of perspectives, which led to rich, well-rounded data. The sample participants averaged
approximately 22.4 years as a nurse and 16.4 years in nursing administration.
This study collected data from 14 interviews with nursing administrators whose
organizations employ at least 200 nurses. Focusing on facilities that employ a minimum of 200
nurses promotes purposeful data saturation (Merriam & Tisdell, 2015). The facilities associated
with the sample participants averaged approximately 1,825 nurses.
The Researcher
As a nursing college administrator required to deliver virtual clinical education through
the height of the COVID-19 pandemic, I have a vested interest in the data collected in this study.
It was crucial that I stayed cognizant of the potential bias, and remained objective through data
collection and analysis, and stayed focused on my role as a researcher (Small & Calarco, 2022).
As a researcher, my interest in the outcomes of this study has the potential to create a unique
power dynamic between the problem of practice, the sample participant, and my position as a
nursing college administrator (Crosschild et al., 2021). There was a concern that sample
participants may withhold information considered negative regarding post-pandemic nursing
graduates, especially nurses who may have graduated from my institution. To avoid any bias the

39
participants may have had with regard to my positionality, I stressed the importance of my role
as a researcher collecting transparent, raw, and accurate data, which is vital to this project’s
findings (Kuzmanic, 2009; Randall & Phoenix, 2009).
Data Sources
This study applied a qualitative interview method using 14 open-ended questions. The
sample population consisted of 14 nursing administrators who were interviewed individually,
lasting anywhere from 30 to 60 minutes.
Interviews
This study implemented an interview protocol consisting of 14 qualitative questions.
Instrumentation
The interview protocol (Appendix A) focused on 14 questions completed in
approximately 30 to 60 minutes. After introductions, reiterating the purpose of the study, and
explaining the interview protocol, the first question was designed to put the sample participant at
ease with a non-threatening and personal narrative asking how they got into the field of nursing
and, eventually, nursing administration (Castillo-Montoya, 2016). The interviews were
conducted using a conversational tone to build rapport between the researcher and the sample
participants (Castillo-Montoya, 2016). Attention to the question sequencing was essential in
developing an effective interview protocol (Patton, 2002). Interview questions two and three set
the foundation of the research by delving into the nursing administrator’s perspective of the
differences between pre-and post-pandemic nursing graduates. Introducing the concept that there
are differences between pre- and post-pandemic nursing graduates, the questions moved toward
specific observations of nursing interactions. Questions four through eight considered the
individual nurse’s performance with patients and other hospital personnel.

40
The depth of the questions gradually increased to extract as much rich data as possible
from the interview participant (Patton, 2002). Questions nine through 13 elicited the nursing
administrator’s perspective on how virtual clinical education has affected hospital operations,
which is at the heart of this study. The final question prompted opinions and recommendations
on effective virtual clinical education in the future.
Data Collection Procedures
The data collection process utilized the Zoom platform, a cloud-based interactive
program that recorded the interview and translated the recordings into a written format. Zooming
allowed the interview participant to remain in a familiar environment and reduce travel
inconvenience to maximize interview time. Each interview took approximately 30 to 60 minutes.
Face-to-face interaction is essential for effective interviewing (Merriam & Tisdell, 2015). Faceto-face interviews allowed the researcher to read body language and the subtleties of facial
expressions, which supported probing questions in a semi-structured interview protocol
(Merriam & Tisdell, 2015). Along with recording the interviews and creating written transcripts,
the researcher took written notes to highlight emerging themes, comments needing clarification,
and ideas for follow-up questions.
Data Analysis
The research findings went through an eight-phase process to review the raw data. The
first phase of the data review was to create a written transcript from the Zoom recording, assign
each interview an identifying number, and remove identifying features that could potentially lead
to analysis bias (Merriam & Tisdell, 2015). The second phase of the data review compared the
recorded interview to the transcript to ensure the written transcript accurately captured the
dialogue. The third phase included removing personal stories or off-topic dialogue to isolate each

41
interview question and participant response (Hagens et al., 2009; Merriam & Tisdell, 2015). The
fourth phase corrected spelling and grammatical errors while maintaining the integrity of the
response (Hagens et al., 2009; Mero-Jaffe, 2011).
At this point, the data were refined and deemed as accurate as possible. The data analysis
then transitioned to the fifth phase, initiating a comprehensive evaluation of the collected data
and synthesization of the researcher’s interview notes (Lester et al., 2020). As the data analysis
evolved, the sixth phase noted emerging topics and began coding bits of data into similar
groupings (Merriam & Tisdell, 2015). The seventh phase evaluated the coded data and created
themes for similar and repetitive data as the study moved to its final phase (Lester et al., 2020;
Merriam & Tisdell, 2015). The eighth phase began the intense scrutiny of research data,
incorporating the literature review, and theoretical framework to deliver comprehensive research
findings.
Credibility and Trustworthiness
Research findings are only as good as the validity and reliability of the data collection
protocol and data sources (O’Leary, 2014). This study used member checking, peer review, and
secondary data to support the credibility and trustworthiness of the data collection and analysis.
Merriam and Tisdell (2015) stressed the importance of member checking. After data were
collected, sections of raw data were discussed with a few sample members to check for
credibility. Sample member feedback was a significant step of the data analysis to determine the
credibility of emerging themes, variations in data, and potential new avenues of inquiry
(Bazeley, 2009; Birt et al., 2016). Member checking is one method to ensure that the data
collected are valid and reliable.

42
Peer review was another avenue to ensure credibility and trustworthiness in research data
analysis (Merriam & Tisdell, 2015). As themes emerged through data analysis, it was crucial to
evaluate any variations in the data and the credibility of the findings (Merriam & Tisdell, 2015).
I consulted with an experienced colleague who has worked for 37 years in nursing and nursing
administration. After reviewing the data analysis, they confirmed the findings and gave
recommendations. Member and peer review enhanced the credibility and trustworthiness of the
research findings.
Adding secondary data sources, such as statistics from the NCSBN, CDC, and other
public organizations also enhanced the credibility of the data analysis (Merriam & Tisdell,
2015). Including the national data on the declining NCLEX pass rates lends credibility to the
nursing administrator’s perception that there is a nursing shortage affecting hospital operations
nationwide (NCSBN, 2024). This study used member checking, peer review, and secondary data
to support the credibility and trustworthiness of the data collection and analysis.
Ethics
Data credibility is directly linked to the researcher’s credibility (Patton, 2015). This study
took every precaution to maintain the confidentiality of all participants. All hospital nursing
administrators and hospitals will remain anonymous with a designated number (Kaiser, 2009;
Merriam & Tisdell, 2015). All identifying markers, such as hospital location, hospital purpose,
participant’s identifiable traits, or personal information, were removed to ensure anonymity
(Kaiser, 2009; Merriam & Tisdell, 2015). Sample participants understood that participating in
this study was voluntary and without financial compensation. The sample participants verbally
agreed to have their voices and images recorded during the interview process. The Zoom
recordings were deleted after 30 days, and the transcripts were also deleted once the required

43
data was extracted. Using the University of Southern California's Institutional Review Board
(IRB) protocols protects all research information collected as well as the interview subjects'
rights and welfare.

44
Chapter Four: Findings
Nursing students who attended school during the height of the COVID-19 pandemic
experienced disruptions to the board of nursing required clinical hours of in-hospital patient
training due to shelter-in-place mandates. This study explored the perspectives held by various
hospital nursing administrators in their evaluations of the impact of virtual clinical education on
post-pandemic nursing graduates' critical thinking skills, teamwork with other medical
professionals, skill set competencies, and demonstration of patient empathy in a hospital setting.
Fourteen nursing administrators participated in a qualitative interview protocol. To increase
interview opportunities, the initial research recruitment focused on nursing administrators
familiar with the researcher’s professional network. However, Merriam and Tisdell (2015)
cautioned about the potential bias from convenience sampling when only using participants
familiar to the researcher, a method that can limit the data-rich information required by a wellrounded study. Cognizant of eliminating bias, recruitment outreach included hospitals unfamiliar
to the researcher and referrals from sample participants, thereby eliminating potential bias
(Merriam & Tisdell, 2015).
This study employed a modified version of Albert Bandura’s Social Cognitive Theory (SCT)
as its theoretical framework. SCT is a comprehensive three-pronged learning construct that
includes environmental factors, an individual's social learning experience, and behaviors that
influence a dynamic and reciprocal cognitive human experience (Bandura, 1998). Utilizing a
modified SCT framework, this study delineated the first construct, environmental factors, as the
virtual clinical education experience during the height of the COVID-19 pandemic and the
hospital setting in which the post-pandemic nursing graduates were employed. The second
construct of SCT, an individual's social learning experience, assessed the post-pandemic nursing

45
graduates’ virtual educational experience during the height of the COVID-19 pandemic;
however, these insights were gathered by proxy from the perspective of nurse administrators.
Although the research protocol did not include interviews with the nursing graduates to directly
assess their self-efficacy, cognitions, or beliefs stemming from their virtual learning experience,
the study indirectly evaluated their learning outcomes through feedback gathered from nursing
administrators. The final construct of SCT for this study examined the observable behaviors,
efforts, and motivation of the post-pandemic nursing graduates in their roles, as perceived by
hospital nursing administrators, offering a comprehensive and reliable analysis of their learning
experiences.
The first research question explored how nursing administrators perceived the critical
thinking skills, teamwork with other medical professionals, skill-set competencies, and patient
empathy demonstrated by virtually trained post-pandemic licensed nurses in the hospital setting.
This question was framed by a modified SCT framework, focusing on the observable behaviors
of the virtually trained post-pandemic nursing graduates’ cognition, beliefs, and self-efficacy
they brought to the hospital setting as perceived by the nursing administrator.
The second research question examined whether the nursing administrators’ organization had
adjusted onboarding and training protocols to accommodate the needs of the virtually trained
post-pandemic nursing graduates. The findings indicate that each interview participant’s
organization adjusted pre-pandemic hospital operations in some way to support the training and
onboarding of post-pandemic nursing graduates. Nursing administrators noted that the crucial
piece of social learning through hands-on classroom and bedside experience, as seen in prepandemic nursing education, had significantly reduced post-pandemic nurses' confidence and

46
self-efficacy in job performance, requiring hospitals to enhance onboarding and training
protocols.
The third research question examined how nursing administrators perceived virtual clinical
education modalities in nursing education. The COVID-19 pandemic’s shelter-in-place mandates
required nursing education to adjust and incorporate virtual clinical modalities, replacing handson clinical rotations that were standard in pre-pandemic nursing education. With the effects of
virtual education now evident in the hospital setting, the nursing administrators’ insights should
be considered in future nursing education recommendations.
Research Questions
1. What are the nursing administrator’s perceptions of the impact of virtual clinical
education on post-pandemic nursing graduates’ critical thinking skills, teamwork with other
medical professionals, skill set competencies, and demonstration of patient empathy in the
hospital setting?
2. Have nursing administrators adjusted new nurse onboarding and training protocols to
accommodate the needs of virtually trained post-pandemic nursing graduates entering the
hospital setting?
3. What are the nursing administrator’s recommendations for continued use of virtual
clinical education?
Participants
This study included a variety of nursing administrators, including chief nursing operators
(CNO) and chief nursing executives (CNE), whose titles are interchangeable in some
organizations. One interview participant had recently been promoted from CNO to a hospital
chief executive operator (CEO). Other sample participants included department directors (DD)

47
and department supervisors (DS) and nurse educators (NE), who are commonly associated with
university-affiliated hospitals. The participants' average number of years working as a nurse was
approximately 22.4 years and the average for working in administration was approximately 16.4
years. This study collected data from 14 interview participants who worked at organizations that
employed at least 200 nurses. The average number of nurses at the sample participant’s
organization was approximately 1,825.
Participants #13 and #14, who were from a region in the United States that had not
experienced the COVID-19 pandemic as intensely as the West and East Coasts, acknowledged
that their healthcare system had discontinued clinical rotations for nursing students at the start of
the pandemic and had a modified return to nursing education by the fall of 2020. Although there
were some disruptions to traditional pre-pandemic hospital rotations and an increased reliance on
virtual and simulation modalities, the impact on new nursing graduates in their area was less
severe than Participants #1 through #12 reported. The importance of including Participants #13
and #14 in this study is to demonstrate that even moderate changes to the traditional hands-on
clinical education model in nursing education has had an impact on both the confidence levels of
the post-pandemic nursing graduates and hospital operations.

48
Table 1
Description of Sample Participants
Participant Title Years in
administration
Number of
nurses
State
#1 DD 18 years 3,000 CA
#2 CNE 34 years 2,800 CA
#3 CNE 7 years 800 CA
#4 NE 7 years 400 CA
#5 CNO 15 years 540 CA
#6 CEO 12 years 520 CA
#7 CNO 18 years 220 CO
#8 CNO 24 years 670 CA
#9 DS 12 years 1,500 CA
#10 DS 9 years 6,400 UT
#11 CNE 30 years 500 NV
#12 CNO 20 years 1,200 PA
#13 DD 5 years 3,500 OK
#14 DD 19 years 3500 OK
Roadmap of Chapter 4 Research Findings
The research findings are organized by the three research questions, followed by
subsections highlighting themes identified through data analysis, including additional themes not
directly represented by the research questions, as shown in Table 2.

49
Table 2
Roadmap of Chapter 4 Research Findings
Research question Theme
Research question 1 Critical thinking skills
Collaboration with hospital professional
Skill set competencies
Patient empathy
Research question 2 Onboarding and training
Professionalism
Increase in nursing turnover
Nursing shortage
Research question 3 Virtual education limitations
Additional findings not represented
by a research question
Lack of confidence
Generational differences
Technology and social media
Mental health
Hospital actions to address post-pandemic
nurse needs

50
Research Question 1: What are the Nursing Administrators’ Perceptions of the Impact of
Virtual Clinical Education on Post-Pandemic Nursing Graduates’ Critical Thinking Skills,
Teamwork with other Medical Professionals, Skill Set Competencies, and Demonstration of
Patient Empathy in the Hospital Setting?
The COVID-19 pandemic forced many hospitals to discontinue clinical student
education, freeing hospital personnel to concentrate on COVID-19 patients (Chan et al., 2021).
The transition to a virtual learning model posed significant challenges in replicating the clinical
education experience for nursing students (Kells & Jennings Mathis, 2023). Following shelter-inplace mandates, many nursing programs implemented virtual clinical teaching models despite
limited evidence of effective learning outcomes (Kells & Jennings Mathis, 2023). Various
concerns are now emerging as post-pandemic nursing graduates are entering the medical
community. Virtually trained nurses lacked hands-on interactions with patients, which limited
opportunities to develop critical thinking skills through real-world medical procedures and
emergency events in collaboration with patients and medical colleagues (Choi et al., 2022).
Additionally, these nurses had fewer opportunities to participate with and observe clinical
instructors and medical personnel demonstrate patient empathy than in pre-pandemic traditional
nursing learning modalities (Choi et al., 2022).
Albert Bandura’s Social Cognitive Theory emphasizes the dynamic and reciprocal
relationship among environmental factors, an individual’s beliefs, cognition, self-efficacy
stemming from the learning experience, and behaviors such as effort and motivation (Bandura,
1988). This study used a modified SCT framework, with nursing administrators as proxies to
share their perceptions of the post-pandemic nurses’ cognition, self-efficacy, and beliefs based
on observed behaviors. All 14 nursing administrators in this research study agreed that virtual

51
clinical education did not adequately prepare newly licensed nurses entering the hospital setting
post-pandemic. The lack of social interaction with other nursing students, instructors, and patient
experience hindered the competency of this newly emerging generation of nursing graduates.
The research gathered from various organizations - small, midsize and large community
hospitals; university-based hospitals; hospitals that service specific conditions and or specific age
groups; and multi-location systems -- reveals consistent data findings. The following section
addresses each of the behaviors embedded in Research Question 1.
Critical Thinking Skills
Research participants agreed that clinical virtual education implemented during the height
of the COVID-19 pandemic did not adequately equip the current nursing graduates for the
demands of the nursing profession. Eleven of the 14 interview participants emphasized that this
new generation of nurses is entering the medical field with a solid theory base; however, it has
not had the hands-on experience to translate that knowledge into practice. Participant #12
reiterated the importance of SCT, stating that “without trial and error during nursing education
and seeing patient care in action they are unsure what to do.” Participant #10 remarked that the
repetition of “hundreds of clinical hours that happen with human beings, real patients, during
nursing training cannot be replaced by a screen or a sim (simulation).”
A recurring concern noted by the participants was that the lack of confidence exhibited
by virtually trained nurses is introducing complications in all areas of nursing competency.
Participant #10 stated, “New nurses always have a learning curve, but these new nurses are
specifically slow to engage and lack confidence.” All interview participants agreed that the postpandemic cohort lacks the hands-on experience typically seen in traditional pre-pandemic
nursing education clinical rotations, which hinders their job performance. Participants used

52
descriptive words, characterizing post-pandemic nurses as “timid,” “unsure,” “awkward,” and
“slow to engage” with patients. Participant #7 noted, “They are not comfortable walking into a
room and talking to patients” and are uneasy with basic patient interactions. Participants noted
that this is particularly concerning in complex or emergency patient care situations when a nurse
must demonstrate critical thinking skills. Many interview participants recounted instances of
novice nurses walking away and abandoning patient care, noting insufficient critical thinking
experience meant they were unsure of what to do.
As noted previously, Participants #13 and #14 are from a region in the United States that
had not experienced the same degree of COVID-19 restriction seen in other areas of the country.
Nursing students in their region continued to participate in some clinical education rotations;
however, they indicated that virtual clinical education had occurred at various times during the
pandemic. Even with some hands-on student practice, Participants #13 and #14 agreed that postpandemic nursing confidence levels are lower than pre-pandemic, highlighting a lack of critical
thinking skill sets. Participant #13 reported that their facility has conducted surveys of new nurse
confidence levels since 2018. According to Participant #13, “In 2018, the confidence levels of
new nurses hired at our facility were very high.” However, they noted a decline in these
confidence levels at the onset of the pandemic in 2020, levels that continued to decline through
2021 and 2022. While the facility saw a slight improvement in 2023, confidence levels had not
yet returned to pre-pandemic levels. Participant #13 attributed this decline in confidence to
pandemic-related fears and other personal factors. However, Participants #13 and #14 agreed that
limited hands-on clinical experience contributes to lower confidence levels among new nurses,
impacting their ability to think critically in medical scenarios.

53
The research findings suggest that the absence of hands-on patient care has contributed to
a lack of confidence and resilience among post-pandemic licensed nurses, hindering critical
thinking skills. Participant #2 emphasized, “They do struggle with a lack of confidence and
inability to perform under pressure; I see them give up easily.” This theme aligns with Bandura’s
belief that learning comes from a dynamic and reciprocal interaction between the environment,
social learning experiences, and an individual’s behavior. The COVID-19 mandates that forced
direct patient clinical education to shift to a virtual modality altered the second construct of SCT:
the individual’s learning experience. Individualized learning in virtual education did not have the
dynamic and social engagement that is central to SCT. The collaborative learning experience
between classmates and nursing instructors, in which they engage in patient case scenarios by
applying deductive reasoning, trial and error, and repeated observation of patient interactions,
was missing in virtual education. The absence of this critical construct of SCT is now impacting
nurses’ confidence, resilience, and ultimately their critical thinking abilities in practice.
Participant #5 summed it up well, “They are lacking in critical thinking, they may know it, but
they don’t know why or how to do it.”
Collaboration with Hospital Professionals
One limitation of virtual clinical education in fostering nursing competency is that it
deprives students of the opportunity to collaborate with various medical professionals so they
can observe and participate in daily hospital operations. On this subject, Participant #3 remarked:
“The hospital environment is tough for a new nurse to master. They lack teamwork experiences
they should have had on rotations and from instructors, and they struggle.” Likewise, Participant
#2 noted that the “hectic nature of the hospital is a shock that they are not prepared for.” The

54
participants emphasized that the hospital environment is dynamic and complex; quick,
coordinated responses are crucial for patient safety and positive outcomes.
According to participants in this study, performing efficiently and accurately in a medical
crisis is vital to determining positive or negative patient outcomes. Virtually trained nurses did
not have hospital experiences to help them understand their role in executing collaborative
patient care. Participant #8 noted the lack of “collaboration with classmates to work through
patient scenarios in a group is an important factor in learning how to work together as a team.”
Virtual clinical education limited nursing students’ exposure to hospital interdisciplinary
teamwork and collaboration with classmates, gaps that are now beginning to impact hospital
operations. Participant #9 shared, “If they do not know what to do, they do not do anything, or
they will look it up on their phone instead of asking for help.” Ten of the 14 participants
highlighted a recurring theme: new nurses often struggle to know where to go for answers,
frequently relying on technology for guidance, much like during their virtual clinical education
experiences.
Skill Set Competencies
Developing nursing skills begins with understanding the underlying theory; why you
should perform the skill, and when (Perry et al., 2018). Skill development is supported by
practice in a lab setting and observing a nursing instructor in the field before engaging in handson patient care (Ewertsson et al., 2017; Perry et al., 2018). SCT emphasizes the social construct
of learning through observation and reciprocal activities, which is critical in learning hands-on
skills. Participant #1 noted that although many of the new nurses are strong in theory, “Many
nurses who just came to us for their first nursing job have never even touched a patient or
completed any skills, other than in simulation.” Participant #6 shared:

55
“Because of the altered clinical education during COVID, they did not get to practice and
were confused, and not sure what to do, and we have had to discontinue onboarding and
training due to nurses’ inability to perform basic skills.”
As the steps of nursing competency are interlayered: didactic learning, lab practice, and hands-on
observation, the nursing graduates who received virtual clinical training during the height of the
COVID-19 pandemic missed these crucial steps in developing skill set competency.
The findings show that the lack of nursing observation and patient interaction in a
learning environment has limited the competency and safety of post-pandemic licensed nurses
entering the hospital. Although not directly asked in the interview questions, ten of the 14
participants specifically noted concerns around patient safety. Participant #4 stated, “I worry
about the safety of patients. I see more and more reports of errors. They just don’t have the
experience to do the skills correctly. It's the basics, using a blood pressure cuff and taking vitals.”
Participant #13 noted that “the basics such as head to toe assessment seems confusing, and
unsure what to do.” Participant # 8 shared, “The quality of patient care has decreased. I am very
concerned about the skills novice nurses are bringing to the table. They pass NCLEX but cannot
perform.” All 14 participants observed that a lack of confidence from insufficient direct patient
care education impairs post-pandemic licensed nurses’ ability to perform accurate skill sets.
Patient Empathy
Participants in this study were divided on whether post-pandemic nurses lacked patient
empathy. All participants noted that post-pandemic nurses' hesitancy to engage with patients due
to lack of clinical patient experience may appear as a lack of empathy. Participants
acknowledged that factors such as a lack of confidence in patient care and poor communication
skills may contribute to the perception that post-pandemic nurses have less empathy than pre-

56
pandemic nurses. Participant #8 reported:
“At the beginning of COVID-19, we saw a lot of empathy from nurses caring for COVID
patients. Then, it switched to fear and distance. Not interacting with patients' families,
there were fewer interactions to show compassion, and some of those habits have
continued with staff who are now working with new nurses. I believe in the “Golden
Rule,” and I expect our nurses to feel that way, and I do not always see that.”
Eight of the 14 participants noted poor communication and social skills in post-pandemic nurses,
supporting the assertion that they lack empathy; however, no clear consensus emerged around
the idea that the new nurses' “timid,” “anxious,” or “socially awkward” behavior is indeed a lack
of empathy.
Ten of the 14 participants expressed a belief that many newly licensed nurses who missed
clinical rotations have a misguided understanding of the role of a nurse. The participants noted
that the media’s portrayal of nurses as frontline heroes saving lives during the COVID-19
pandemic may have influenced some nursing students who enrolled into nursing programs at that
time. Unfortunately, not having experienced the direct patient care seen in pre-pandemic clinical
rotations, post-pandemic nurses did not fully understand what it meant to be a nurse. By the time
they became nurses, the pandemic had ended. Participant #10 emphasized that when “the veil of
the superhero dropped after COVID, the reality is nursing is just not that glamorous.” Participant
#12 reported, “They do not want to deal with the smells, wound dressing changes, the raw part of
the job.” Participant #12 continued, “They do not want to touch the patient or make eye contact.”
Participant #3 echoed this sentiment: “I hear that there is a lack of empathy and desire to do
bedside care overall.” Participant #1: “They seem uncomfortable dealing with the more
unpleasant tasks such as diaper changes, but I do not know if that means a lack of empathy.”

57
As previously mentioned, Participant #8 referred to the “Golden Rule” as a standard
expected to be demonstrated and reciprocated with their nurses, a principle that aligns with the
learning constructs of SCT. Participant #11 took the concept of empathy and applied a SCT
approach by “showing empathy to these new nurses.” Participant #11’s organization recognized
that post-pandemic licensed nurses were arriving at the hospital with significant deficits,
primarily due to a lack of hands-on patient experience. Participant #11’s organization
implemented plans to address their needs as the “Covid Generation” by showing them empathy
for their unique situation. Participant #11 reported that “we needed to value them as they are.
They do have deficiencies, but we did not focus on the deficits. We used a strong approach to
overcome the deficiencies and limit intimidation factors, creating an inclusive working
environment, by showing them empathy.” Participant #11 believed that exemplifying empathy
and compassion for the new nurses fostered a reciprocal learning environment that not only
enhanced their ability to demonstrate patient empathy but also improved overall nursing
competency.
Because empathy is a subjective quality, the participants were divided on whether the
post-pandemic nurses possess the qualities of patient empathy or if their lack of confidence and
experience with patient engagement appears as a lack of patient empathy. Direct interviews
would be necessary to obtain reliable data on patient empathy among post-pandemic nursing
graduates. Research indicates that demonstrating empathy can improve a patient’s psychological
well-being and medical outcomes (Durkin et al., 2022; Edstrom, 2023; Nourallah et al., 2020).
All participants agreed that patient empathy is a fundamental foundation of nursing competency,
and from their observations, there is a lack of observable patient empathy among post-pandemic
licensed nurses.

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In summary, the nursing administration’s perceptions of the impact of virtual clinical
education on post-pandemic nursing graduates’ critical thinking skills, teamwork with other
medical professionals, skill set competencies, and demonstration of patient empathy in the
hospital setting are consistent. All participants agreed that there are serious concerns about the
post-pandemic nurse’s ability to perform at the level of pre-pandemic first-year nurses. The
absence of reciprocal and dynamic social interactions vital to Badura’s SCT learning constructs
has left the post-pandemic virtually trained generation of nurses lacking key elements in nursing
competency. With this knowledge, all participants reported changes to hospital protocols,
onboarding, and training processes. These changes are a crucial step in compensating for the
reality of virtually trained nurses and to ensuring their successful integration into the healthcare
system. Research Question 2 addresses the hospital’s response to post-pandemic licensed nurses
entering their medical facility post-pandemic.
Research Question 2: How have Nursing Administrators Adjusted New Nurse Onboarding
and Training Protocols to Accommodate the Needs of Virtually Trained Post-Pandemic
Nursing Graduates Entering the Hospital Setting?
As noted in the data from Research Question #1, virtual clinical education has allowed
new nurses to enter the medical field with inadequate hands-on patient experiences, contributing
to observed deficits in critical thinking skills, teamwork, skill-set competencies, and patient
empathy. All participants reported their organization’s adjustments to nursing onboarding and
training protocols to address these competency gaps. Along with these deficits, other factors
noted by the participants have also impacted hospital operations. The participants in this study
noted an overall lack of professionalism and reliability, and an increased nursing turnover rate
with new nursing graduates. All participants noted financial challenges incurred by enhanced

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training protocols, increased nursing turnover and difficulties maintaining adequate staffing, all
of which affects day-to-day hospital operations. As medical facilities transition beyond the
challenges of the COVID-19 pandemic, nursing administrators are now confronting new
obstacles in the post-pandemic landscape. This section reviews the participants’ observations and
experiences integrating post-pandemic licensed nurses into the hospital setting.
Onboarding and Training
All participants indicated that the onboarding and training protocols for newly licensed
nurses at their facilities had changed from their pre-pandemic protocols. Participants shared
specifics around increased training timelines and continued mentoring on the floor. Participant
#1 shared that they were so desperate for nurses during the pandemic that they used a 3-month
virtual training module to get new nurses on the floor as soon as possible without taking current
nursing staff off the floor to train them. However, they realized that the virtual training was not
working and as the pandemic subsided, they “extended the pre-pandemic training protocol from
one year to 18 months.” Participant #3 reported that their facility increased training from “3
months to 6 months” and Participant # 12 indicated, “we have doubled the onboarding and
training process.” Even Participant #13 and #14 who had less nursing education disruption
during the pandemic noted increased training and mentoring timelines post-pandemic as needed.
Eleven of the 14 participants indicated that even with the increased training timelines
were still not enough to compensate for virtual clinical educations’ lack of direct patient care and
hospital experience. All participants reported that their organizations had initiated new
approaches to the pre-pandemic new nurse onboarding and training protocols and were still
considering other options. Nine of the 14 participants had implemented an extended

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preceptorship/mentor program, or “transition to practices,” or “nurse residency” programs.
Participant #2 initiated a program from the past,
“Extern to hire, where new nurses who were about to graduate were assigned one trainer
in their last semester and would essentially shadow the trainer focusing on the details of
actually working in the hospital. It is a more in-depth look at operations of the hospital,
while they are still a student, but like a pre-employee.”
Participant #2 continued, “The trainer would continue as a touchpoint for the new nurse through
the next year.”
The increased efforts and expenses incurred by hospitals are significant concerns.
Participant #4 noted, “We have so many budget cuts post-pandemic. We are challenged to
decrease the onboarding program which is scary when what we are doing is not enough.” Along
with financial strains, were reported concerns with trainer and preceptor burnout. Participant #8
struggled to cover the training needs of the new nurse hires, “We have hired traveling preceptors
to give our preceptors a break. Our preceptors are getting burned out.” Participant #3 agreed that
it is a financial issue and a “drain on employee morale to continually train and support
unprepared nurses.” Participant #6 summed it up, “It is a financial strain on the budget. We are
burning out our preceptors. It is difficult all the way around in nursing right now.”
Although training and onboarding of the virtually trained nursing graduates had been a
challenge, as indicated by all participants; one participant reported a different onboarding
approach with successful results. Participant #11 shared:
“During COVID-19 we were not in the position to train and onboard new nurses. We live
in a smaller community, and we hired recent graduates to work in the capacity of a
nurse’s aide to support the trained nurses. This approach worked. They got to partner

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with the seasoned nurses and observe hands on skills, teamwork, soft skills they needed
to be a nurse. Then when the COVID crisis began to subside we took the new nurses who
worked as aides and started the official training and onboarding. This group of nurses
then had the skills they needed to be successful as independent nurses. The next group of
nurses that graduated did not have any patient care experience and we partnered them
with the newly trained nurses who had worked as nursing aides through COVID, and it
has worked out. We extended the length of the training, and it seems to be working.”
Although Participant #11 found a successful training protocol, the size of the community and
lack of local employment options for nursing graduates may have factored into the positive
training outcomes. As in Participant #11’s creative approach in addressing the need to enhance
new nurse training protocols by developing a robust mentorship, six of the 14 participants had
also incorporated extended mentor/preceptor programs along with enhanced onboarding and
training protocols to address the lack of clinical experience for post-pandemic licensed nurses.
Professionalism
Along with attributing nursing competency deficiencies to virtual clinical education, the
participants in this study noted an overall lack of professionalism in the post-pandemic nursing
generation. Eleven of the 14 participants cited concerns during the interview process with new
nursing graduates, who were demonstrating a lack of professionalism and sharing goals that do
not align with patient care. Participant #3 reported that nurses were “showing up late for
interviews, wearing jeans, or not showing up at all.” Participants noted this unprofessional
behavior continued to the hospital floor. Participant #8 agreed “They just do not show up for the
interview, and the issues continue. Late for shifts, leave early.” Participant #12 noted “We have
noticed a big attitude change. They are here for their own needs. If they do not come to a shift,

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that is the hospital’s problem.” Participant #2 reported that post-pandemic nurses are “unreliable,
call off at the last minute, or not show up, then comes the email that they will not be back.”
Participant #5 summed it up: “They are not professional. Period. They are unreliable.”
The nursing administrators agreed that the post-pandemic nurse presented with a lack of
confidence, identifying that this cohort appeared “timid,” “socially awkward,” “emotional,” and
“anxious.” Participant #5 noted that they are “fragile” and unprepared to deal with “serious
social issues like mental health, unhoused individuals, and drugs.” Participant #1 shared that new
nurses have “Walked out of the ED (Emergency Department), especially with mental health
patients.” Participant #6 reported that they are “not prepared to work in a hospital, and they do
not understand the job. They think three 12-hour shifts are easy with good money.” Ten of the 14
participants noted that the rigors of the job scare many away. Participant #12 echoed the
sentiments of many, “They will quit if they are unhappy with a shift or just not enjoying their
job.” The participants agreed that the reality of nursing is that it is a challenging, and intense
profession with added responsibility as patient health is on the line.
The post-pandemic nurses entered the profession with a lack of patient experience and
having had limited opportunities to observe the professional standards of a nurse in practice.
Many participants described limited hiring options and struggling to work with the nurses they
had. Participant #4 noted the challenges of a small hospital in a small community with fewer
options to replace a position explaining “There are problems with performance, but we cannot
write them up. We are too small of an organization. We do a lot of coaching and remediation.”
Concerns about professionalism and reliability on the job also added to the participant’s concerns
about increased nursing turnover rates, which have significant financial implications and present
challenges to maintaining day-to-day hospital operations.

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Increase in Nursing Turnover
All participants in this study reported an increase in nursing turnover rates during the
height of the COVID-19 pandemic, which was continuing post-pandemic. Increased turnover
rates have contributed to financial and operational strains as hospitals have scrambled to deliver
patient care. Participant #1 indicated that their organization has a “28% nursing turnover rate.
Which is a significant increase compared to pre-COVID.” Participant #12 reported a “35%
increase in new nurse turnover in their first year.” All participants noted the significant financial
opportunities during the pandemic for travel nurses, signing bonuses, and enhanced employee
benefits. These lucrative incentives drove many nurses to job hop. Participant #1 reported,
“There is much more turnover, performance issues, not showing up for shifts. It was the worst at
the end of COVID when they were going from hospital to hospital for higher salaries.”
All participants noted an increase in first-year nurse turnover. The data collected in this
study pointed to multiple factors impacting nursing turnover rates: COVID-19 fear, early
retirement, financial incentives to move to a new organization or become a travel nurse, burnout,
and the desire to focus on personal mental health. Participants noted the impact of the pandemic
on many healthcare professionals' decisions to leave the medical field all together. Participant #3
specifically cited personal feelings of lingering trauma from the impact of COVID-19 on her
organization and the personal loss she experienced. Participant #3 recounted receiving calls in
the middle of the night about needing more nurses and new locations “to store the bodies.”
Participant #2 echoed the sentiments of many who were severely impacted by sending nurses to
the front lines of the pandemic. Participants #2 and #12 noted that surviving the pandemic was
like going through “war.” Although statistical data from COVID-19 illnesses and deaths were
consistently updated in the news, much of the suffering and devastation that occurred in hospitals

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was not portrayed in the news according to many of the participants. Many participants
expressed lingering emotional trauma and how the pandemic had transformed them personally,
altering their approach to their profession. The term “PTSD” (post-traumatic stress disorder) was
frequently attributed to their current psychological state. Considering the impact of the COVID19 pandemic on the nursing community, it is not surprising that the findings demonstrate an
increase in nursing turnover rates during and after the pandemic.
Nursing Shortage
The findings in this study indicate an increase in nursing turnover rates during and postpandemic. As noted in the literature review, there is an anticipated nursing shortage due to baby
boomers retiring; however, pandemic-related factors have also exacerbated the nursing shortage.
Another theme with which all participants concurred was the absence of a traditional nursing
mindset in post-pandemic nurses. Many participants shared their early nursing experiences, when
they willingly took the night and double shifts and worked every holiday, knowing that with
seniority, they would eventually get the more desirable schedules and assignments. Participant
#9 recalled knowing it would “be a grind the first few years.” All participants agreed that the
post-pandemic nurses as a whole do not share that mindset. Participant #10 shared, “In my day,
there was so much pressure to show up to a shift and not let the patients or your fellow nurses
down. Even if you were really sick there was always pressure to be on your shift.” Participant #9
noted, “This generation wants to just walk into the best shifts and not do the time.” Eleven of the
14 participants noted that the post-pandemic generation of nurses has unrealistic expectations
about nurses’ role due to the limited clinical experiences during their education.
This study found that all participants agreed that virtual clinical education created deficits
in nurses’ competencies, which had implications for hospital operations. As post-pandemic

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nurses struggle to meet the nursing standards of competency and professionalism, as noted in the
findings, participants indicated that the patients also report concerns. Nine out of the 14
participants reported increased dissatisfaction with direct nursing interactions in post-pandemic
patient surveys. The findings of this study indicate that the post-pandemic generation of nurses is
struggling to demonstrate standards of professionalism and nursing competency, with increasing
patient dissatisfaction, high turnover rates, increased organizational financial strain due to
enhanced onboarding and training programs, nurses struggling to process the effects of the
COVID-19 pandemic, and urgent concerns about a nursing shortage. As participant #6
summarized, “It is difficult all the way around in nursing right now.”
Research Question 3: What are the Nursing Administrator’s Recommendations for
Continued use of Virtual Clinical Education?
The findings in this study consistently reveal that the limitations of virtual clinical
education during the height of the COVID-19 pandemic have negatively impacted the learning
outcomes of post-pandemic licensed nurses integrating into the hospital setting. As seen in prepandemic clinical rotations, a lack of reciprocal and social engagement between nursing students,
their classmates, and instructors hindered the critical construct of SCT, leaving nursing graduates
ill-equipped to enter the hospital setting. All participants in this study noted deficits in nursing
competencies, requiring extended onboarding and training protocols that financially taxed
hospital operations. All participants agreed that increased nursing turnover adds to the nursing
shortage, challenging hospitals to maintain day-to-day operations. Although the issues plaguing
the nursing profession cannot all be ascribed to the virtual clinical education post-pandemic
licensed nurses underwent, the lack of hands-on patient education has significantly stressed the
medical community as it attempts to bounce back from the peak COVID-19 pandemic period.

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Virtual Education Limitations
Virtual education is a learning modality that is part of the overall education platform. As
technology has advanced, opportunities for education delivery have expanded. Many participants
noted that they have participated in some form of virtual education; however, all participants
agreed that effective nursing education combines theory and hands-on practice to ensure the full
scope of nursing competencies. Participant #2 noted that virtual education “has been very
effective in certain fields and can be for nursing if combined with rigorous clinical rotations.”
Participant #7 explained, “It is part of education. But it is not effective for clinical hands-on
training. You have to learn the information, but they have to be able to see it and practice handson.” Participant #9 agreed, “It is part of our world. It is good for didactics. We do see that these
new nurses have an increase in theory, just not application. Clinical education needs a hands-on
component.”
Virtual Education Affordances
Many participants pointed to the convenience of remote education. Participant #8
remarked, “It is very convenient for students who are working and have families.” Participant
#10 continued, “Virtual education is accessible to more people who could not do traditional
school.” Participant #8 further noted that “adult learners like flexibility.” Participant #12 stated,
“Virtual education works in many areas, such as bridge programs that go from ADN (Associate
Degree Nursing) to BSN (Bachelor of Science Nursing).” Although the findings address lifestyle
convenience, opportunities for larger audiences, and positive outcomes for theory-based
learning, the participants believe virtual education is not a comprehensive platform for hands-on,
skill-based learning.

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All participants agreed that virtual clinical education nursing students' opportunity to
develop confidence in skill competence, a quality that requires the interactive learning
experiences emphasized in SCT’s learning construct as seen in pre-pandemic clinical rotations.
Participant #1 noted, “A computer screen is not enough in nursing education.” Participant #3
shared, “Nursing education still needs a patient and hospital component. Simulation manikins is
not enough.” Participant #8 explained that in nursing education, “you have to be able to do
clinical rotations. Work in a team dynamic. If you only have virtual education, you miss the body
language cues.” Participant #11 echoed these sentiments,” In nursing education, we need to look
at the patient care piece that cannot be replicated by a screen. They still need hands-on patient
training and the opportunity to observe nurses in action.” Likewise, Participant #10 offered:
“There is no way a computer screen and a sim (simulation manikin) can replace a human.
The patient’s pain and emotions, they have to experience it to truly understand how to do
effective patient care. It is one thing to know how to do a skill, but it is completely
different doing it on a sick patient.”
Participant #1 agreed and recounted an exchange with a recent nursing graduate who
“Showed me a game on her phone that her school had used during the pandemic to teach
breath sounds. The student had to answer questions to get points. It was interesting, but
not realistic with what happens in patient care.”
In summary, all participants agreed that the virtual education platform has many positive
advantages. As new technology continues to advance the possibilities of education, the
participants note there is a place in nursing education for virtual learning modalities; however,
clinical nursing education must have an observable, dynamic, and reciprocal engagement and
practice in hands-on patient care.

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Additional Findings Not Represented by the Research Questions
While the findings in this research study support the three research questions, additional
recurring themes warrant further acknowledgment. These topics include a lack of confidence,
generational differences, social media and other technology, emotional and mental health
concerns, and additional activities hospitals have implemented to address the limitations of the
post-pandemic licensed nursing pool. The following section addresses the additional findings.
Lack of Confidence
A recurring theme in the interviews was that post-pandemic nurses lacked confidence,
which hindered their ability to perform their jobs effectively. Participants attribute this lack of
confidence to the limited opportunities to observe and participate in patient care under direct
supervision, as seen in pre-pandemic clinical rotations. Participant #10 remarked that the
repetition of “hundreds of clinical hours that happen with human beings, real patients, during
nursing training cannot be replaced by a screen or a sim (simulation manikin).” Observing nurses
in action and practicing patient care under the guidance of a nursing instructor allowed students
to become familiar with and gain confidence in their abilities. Participant #4 stated, “They just
do not have the experience to do the skills correctly. It is the basics, using a blood pressure cuff
and taking vitals.” Taking a patient’s vital signs is one of the most basic skills in nursing;
however, if a student did not have the opportunity to practice this skill numerous times with
classmates in the lab and then during the ‘hundreds of clinical hours’ as seen in pre-pandemic
clinical rotations, it would be difficult for a post-pandemic licensed nurse to feel confident in
their abilities. Most nursing programs establish the foundation of skill competency by
introducing the theory behind the skill, practicing the skill in a lab setting, and performing
clinical observation with faculty instruction before the nursing student participates in hands-on

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patient care (Perry et al., 2018). Many studies have highlighted the need for didactic, hands-on
practice in a lab setting, and observable interactions in patient care before a nursing student
attempts to complete clinical skills on a patient (Ewertsson et al., 2017). SCT also emphasizes
the social construct of learning through observation and teamwork to develop confidence and
self-efficacy (Bandura, 2002).
Generational Differences
All study participants expressed concern that virtual clinical education has impacted the
competency levels of post-pandemic licensed nurses as they transition into the hospital setting.
Research Question 1 specifically examined nursing qualities that, according to the findings, show
a deficiency compared to pre-pandemic licensed nurses. However, many participants noted that
the “Generational Cohort” differences may also affect these nursing competency deficits. As
Generation Z enters the workforce, they bring unique experiences with them. Generation Z has
experienced disruptions to their education during the COVID-19 pandemic, and they missed
many life milestones by isolating at home. Generation Z missed social events, such as
graduations, proms, sporting events, and traditional dating activities (Mahmoud et al., 2021). The
effects of social isolation during a critical period in their life cycle have materialized as the
“Anxiety Generation” with a heightened focus on mental health and prioritizing work-life
balance (APA, 2018; Mahmoud et al., 2021).
Along with post-pandemic nursing graduates’ limited patient education experiences,
Eight out of the 14 participants referred to the observed differences in the new generation of
nurses compared to pre-pandemic nurses; however, the differences may not just be due to virtual
education. The research findings suggest that the differences between pre-and post-pandemic
nursing graduates may also be connected to the Generation Z mindset (Mahmoud et al, 2021).

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Participant #9 noted that they “do not interact well socially; they are more comfortable with
technology than humans.” Participant #8 reported “This generation, Gen Z, has been more
involved in technology and less inclined to engage socially, which makes collaboration and
working on the hospital floor difficult.” Participant #2 noted, “These new nurses are a different
breed. They want to get into aesthetics, pharmaceutical sales, telehealth, not interest in bedside
(patient care).” Participant #12 observed, “They are much more focused on their needs, work-life
harmony, and money; they are not loyal to the profession. This is Gen Z.”
Technology and Social Media
Among the acknowledgments of generational differences, another recurring theme was
the emphasis on post-pandemic licensed nurses relying on technology and social media. Many
participants observed that Generation Z's connection to technology, reinforced by their virtual
education in nursing school and, for some in high school, makes technology a significant factor
when working with post-pandemic licensed nurses (Mahmoud et al., 2021). Although all
participants noted that post-pandemic nurses rely more on technology than on colleagues for
support, not all viewed this shift negatively - just a factor to be aware of as they enter the hospital
setting. Four of the participants indicated that this generation of nurses often prefer to ask for
policies or Google questions rather than to seek answers from a colleague. The virtual education
the post-pandemic nurses received reinforced what Participants #3 and #8 called “isolated
learning.” In virtual education, the post-pandemic nursing student often would rely on their
research and inquiry. As noted in the findings, the post-pandemic nurses are strong in theory;
however, remote learning hinders their ability to socialize and connect with humans, which is
crucial in hospital operations. Participant #12 noted, “They do not make eye contact. They have
poor communication.”

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While all nursing administrators noted an increased reliance on technology, seven of the
14 also pointed out that social media is influencing the post-pandemic generation of nurses.
Participant #4 stated, “They are always on their phones, not paying attention.” Five of the 14
participants reported new nurses using platforms such as TikTok and YouTube, which host
nurse-related content, as guidance in their careers. Social media, like virtual education
simulations, serves as a way for this generation to engage remotely, which may contribute to the
observed lack of interest or confidence in direct patient care among post-pandemic nurses.
Mental Health
As highlighted in the additional findings, nursing administrators are increasingly focusing
on mental health when integrating post-pandemic licensed nurses, particularly those from
Generation Z, into the hospital setting (APA, 2018; Mahmoud et al., 2021). The participants
noted that the post-pandemic nurses’ priorities often focus on their personal goals. Participant #5
noted, “There is more of a focus on themselves and their self-care.” Participant #2 added: “We
keep hearing about nurses requesting more downtime to reduce anxiety and take care of their
mental health.” Participant #10 had observed new nurses requesting “mental health breaks
often.” Participant #9 agreed that “there are so many issues covering shifts because of increased
mental health days off.” Eight of the 14 participants reported nurses abandoning patient care in
challenging circumstances. Of this trend, Participant #4 stated, “I have seen nurses walk out of
stressful situations because they are scared.” Participant #5 noted, “They are much more fragile
than what we saw in new nurses in the past. There are lots of discussions on mental health and
self-care.”
One construct of SCT emphasizes that the level of an individual’s self-efficacy is directly
linked to the effort and persistence demonstrated in dealing with a challenging task (Bandura,

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2002). As the findings indicate, nursing administrators noted a lack of confidence and resilience
in post-pandemic nurses. Participant #10 noted, “They lack the emotional capacity to handle
difficult situations. They want to do as little work as possible.” Participant #5 observed an
“inability to keep up physically and emotionally,” explaining "They cannot handle pressure.”
Participant #12 shared, “I always believed that you do not cry on the job, but that is not the case
now. You have to be comfortable with nurses crying on the job.” Participant #3 noted, “There is
a lack of resilience. They give up easily.” Participant #1 remarked: “They lack confidence, do
not have the reliance we saw in pre-COVID nurses.” Participant #5 said, “New nurses do not
want to work long hours.” As Participant #2 states, “pre-COVID nurses would pick up extra
shifts if the hospital needed it, but these new nurses will only do what is required. They do not
push through extra work.” The contrast between the resilience of pre-pandemic nurses and the
lack of resilience in post-pandemic nurses underscores the need for nursing administrators to
address this critical piece of nursing competency in the hospital setting.
While considering the increase in mental health concerns among post-pandemic nurses,
along with the generational differences, technology, and social media, all participants highlighted
the impact of the COVID-19 pandemic on the medical community. Participant #2 said, “We have
all changed since COVID; it makes you feel different about things.” Participant #3 noted,
“COVID-19 changed everything. It was so traumatizing.” Participant #7 explained: “Things with
these new nurses are complicated. Many are still struggling with the trauma they went through
with the pandemic and are reacting to that.” Considering the impact of COVID-19 on nursing
graduates, an unexpected topic emerged: post-pandemic nurses as victims.
Approximately half of the participants noted that post-pandemic nurses consider
themselves victims. Of this theme, Participant #7 reported, “These new nurses come to us with a

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victim mentality from the trauma of going to nursing school through the COVID-19 pandemic."
Participant #7 noted that the new nurses have started “wearing badge holders that are burning
dumpster fires,” indicating that they have been through a traumatic situation or are still
struggling as new nurses post-COVID. Participant #8 noted that the post-pandemic nurses seem
to be “grieving the beginning of their nursing journey, and very much have a victim mentality.”
Participant #9 also observed a victim mentality with an increase in complaints by new nurses,
“They are so sensitive. This doctor was mean to me, or this nurse hurt my feelings.” Participant
#9 continued, “We actually had a hospital-wide “kindness campaign” to make sure everyone was
smiling and being nice to each other.” Participants #13 and #14 cited programs at their hospital
that take a holistic approach to nursing, including Resilience for Caregivers and employee
assistance programs, offering self-care guidance such as meditation, stress management, personal
finances, and other emotional and mental health topics to improve the overall quality of postpandemic nursing needs.
Hospital Actions to Address Post-Pandemic Nurses Needs
Through the interview process, many participants shared initiatives they had
implemented to address the needs of the post-pandemic nurse. While all participants noted
increased onboarding and training protocols, many participants have taken the approach that they
need to meet the nurses where they are, find out what they need, and adjust hospital operations to
address those needs. Participant #8 shared, “Some people are waiting for things to return to
normal, and we have to adjust to our new reality and work with the nurses we have.” Participant
#5 agreed, “Covid taught us a lot, and we need to look at everything differently and adjust our
approach.” Participant #2 noted:

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“With newer nurses quitting due to their inability to adapt to the hospital rigor, we need
to look at patient-to-nurse ratios and reconfigure what covering a floor looks like.
Incorporate AI and other technology and overhaul the scope of nursing.”
As stated in the findings, all participants agreed that ensuring sufficient nursing coverage
post-pandemic has been a challenge. Twelve of the 14 participants noted changes or were
considering changes to the traditional 12-hour shift. Participant #8 explained: “We cannot
continue to fight against the needs of our new generation of nurses; we need to meet their needs.
We now offer 4, 6, 8, 10, and 12-hour nursing shifts to fit in with their schedules.” Participant
#12 had offered a “9-2 shift so they can put the kids on the bus and pick them up after school.”
Participant #3 elaborated: “We all need to be looking at creative solutions, such as 6 to 8-hour
shifts, increasing CNA (certified nursing assistant) pay to support the nurses on the floor to allow
LVNs and RNs to work at the top of their license.” Participant #7 agreed, “We need to look at
adjusting job assignments, sharing positions, and team nursing. We need to be more flexible with
our schedules.”
As noted in the findings and the literature review, there has been an expected increase in
aging nurses retiring and an unexpected increase in early retirement due to the COVID-19
pandemic. Some participants noted outreach to recently retired nurses to ask for support through
the post-pandemic nursing staffing challenges. One example noted came from Participant #12:
“We developed an Emeritus Program to use the experience of our retired nurses to come
back to new nurse orientation, mentoring, leadership development, and clinical tracks.
This program has supported our nursing gap. We are meeting our GENZ’s needs. We call
it the GENZ Movement.”

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While the findings in this research study support the three research questions, these additional
findings are worth noting: generational differences, social media, and other technology;
emotional and mental health concerns; and additional activities hospitals have implemented to
address the limitations of the post-pandemic licensed nursing pool. Although virtual education
contributed to the limitations, as reported by nursing administrators in the post-pandemic nursing
generation, the additional findings are worth considering in addressing this problem of practice.
Summary
Chapter 4 presents this study’s research findings on the impact of virtual clinical
education on nursing students during the COVID-19 pandemic shelter-in-place mandates. The
research employed a qualitative methodology, interviewing 14 nursing administrators across the
United States who provided their perceptions of critical thinking skills, teamwork, skill set
competencies, and patient empathy among post-pandemic licensed nurses. The study applied a
modified version of Albert Bandura’s Social Cognitive Theory (SCT) as the framework to
examine the triadic reciprocal relationship among environmental factors, the virtual clinical
education and hospital setting, and the individual’s social learning experience observed outcomes
and observed behaviors of the post-pandemic newly licensed nurses by the nursing
administrators.
The findings in this study supported the research questions:
1. What are the nursing administrator’s perceptions of the impact of virtual clinical
education on post-pandemic nursing graduates’ critical thinking skills, teamwork with other
medical professionals, skill set competencies, and demonstration of patient empathy in the
hospital setting?

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2. Have nursing administrators adjusted new nurse onboarding and training protocols to
accommodate the needs of virtually trained post-pandemic nursing graduates entering the
hospital setting?
3. What are the nursing administrator’s recommendations for continued use of virtual
clinical education?
All participants agreed that virtual clinical education during the height of the COVID-19
pandemic impacted the overall nursing competencies of the post-pandemic nursing generation.
The lack of reciprocal and dynamic learning at the core of SCT failed to deliver the postpandemic performance outcomes observed in pre-pandemic traditional clinical nursing education
conducted at the bedside during hospital clinical rotations. As noted in this research, postpandemic nursing graduates had limited educational patient experience; the result is a generation
of nurses who lack confidence, which hinders their ability to perform their jobs effectively. The
limited interaction between classmates and instructors engaging in patient care reduced the
opportunity for nursing students to develop critical thinking skills, teamwork, skill set
competencies, and patient empathy, which are typically cultivated through repetition and the
application of deductive reasoning in a hospital setting. All participants agreed that the
generation of nurses who received virtual education understands the theory behind nursing
competencies; however, they do not know when and how to use the knowledge. A human patient
has emotions, experiences pain, emits odors, produces bodily fluids, and may have mental and
emotional health issues, along with the presence of family and loved ones - all of which factor
into patient care, which is not evident in virtual education.
While the data supports this study’s research questions, additional recurring themes
appeared: lack of confidence, generational differences, social media and other technology,

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emotional and mental health concerns, and additional activities hospitals have implemented to
address the limitations of the post-pandemic licensed nursing pool. The nursing administrators
agreed that virtual clinical education does not support effective and competent nursing
performance; however, there is a consensus that other factors contribute to the deficiencies in
post-pandemic nurses affecting hospital operations.
This research study underscores the limitations of virtual clinical education practices in
nursing education. During the height of the COVID-19 pandemic, shelter-in-place mandates
severely restricted the traditional hands-on nursing student experience. Short of discontinuing
nursing education altogether, many nursing programs implemented virtual education to ensure
that the medical community continued to support the need for future nurses. As reported by the
participants, once the pandemic subsided, nursing programs transitioned to the board of nursingapproved clinical requirements for each state. Although technology plays a role in education and
hospital operations, the element of human-to-human contact in patient care remains unreplicated
in virtual education.
Chapter 5 concludes this research study by discussing the findings, recommendations,
evaluation, and the study’s limitations and delimitations. It will close with a recommendation for
future research and the study’s conclusion.

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Chapter Five: Recommendations
This study examined the impact of virtual clinical education during the height of the
COVID-19 shelter-in-place mandates from the nursing administrator’s perspective as postpandemic licensed nurses transitioned into the hospital setting. Compared to pre-pandemic
clinical education, the limited hands-on patient care during training has resulted in a generation
of newly licensed nurses demonstrating competency deficiencies, leading to significant
challenges for the medical community. A qualitative methodology was incorporated to collect
and analyze data from 14 nursing administrators across the United States. Chapter 5 includes a
discussion of the findings, synthesized with the literature review working through the lens of a
modified framework of Albert Bandura’s social cognitive theory. Chapter 5 continues with
recommendations for practice, an evaluation of recommendations in practices, limitations and
delimitations, future research recommendations, and a conclusion.
Discussion of Findings
The findings in this study support the research questions, with all participants agreeing
that virtual clinical education during the height of the COVID-19 pandemic impacted the overall
nursing competencies of the post-pandemic generation of licensed nurses. The absence of
reciprocal and dynamic learning at the core of SCT did not deliver the post-pandemic
performance outcomes noted in pre-pandemic traditional clinical nursing education conducted at
bedside during hospital clinical rotations. Post-pandemic nursing graduates had limited hands-on
patient experience; the outcome is a cohort of nurses who lack confidence, which hinders their
ability to perform their jobs effectively. The restricted interaction between classmates and
instructors engaging in patient care limited the opportunity for nursing students to develop
critical thinking skills, teamwork, skill set competencies, and patient empathy, typically

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cultivated through repetition, collaboration, and the application of deductive reasoning in a
hospital setting. All participants in this study agreed that this generation of nurses who received
virtual education understands the theory behind nursing competencies; however, they do not
know when and how to use the knowledge.
Discussion of Research Question 1: Nursing Administrator’s Perceptions of the Impact of
Virtual Clinical Education on Post-Pandemic Nursing Graduates’ Competencies in the
Hospital Setting
The literature review supports the importance of this study’s findings. Nursing
administrators’ perceptions of post-pandemic nursing graduates’ competency deficits due to
virtual clinical education have impacted hospital operations. The data highlights the postpandemic nurse’s lack of critical thinking skills. The medical field is a fast-paced, ever-changing,
and complex environment. Nursing students need exposure to various clinical experiences to
develop critical thinking skills in a structured learning environment, as seen in pre-pandemic
traditional hospital rotations (Mlinar Reljić et al., 2019). The findings support the principle that
nursing students develop critical thinking skills by partnering didactic comprehension with
hands-on clinical experience (Sharif & Masoumi, 2005). The research points to problem-based
learning (PBL), often used in nursing education to evaluate patient case-study reviews (Schmidt
et al., 2011). PBL is typically used in a group setting to encourage activation of prior knowledge
regarding a patient case study, collaborative research beyond prior knowledge, and the
opportunity to consider new concepts in patient care scenarios to promote critical thinking skill
sets (Schmidt et al., 2011).
The findings in this study align with previous research indicating that efficient
collaboration between nursing staff and physicians promotes positive patient outcomes (Aiken et

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al., 2002; Needleman et al., 2002; Tourangeau et al., 2007). The virtually trained nurses missed
the opportunity to collaborate in a hospital setting with nurses, physicians, and other medical
personnel to observe and participate in collaborative patient care. In 2023, the World Health
Organization (WHO) reported that the foremost cause of adverse medical events in hospitalized
patients is poor teamwork and ineffective communication among medical personnel. Interpreting
multiple perspectives requires a dynamic synthesis of knowledge, critical thinking skills, and
effective collaborative interactions, which are necessary when making clinically sound decisions
(Bandura, 1998; Facione & Facione, 1996; Gazarian et al., 2010; Horlait et al., 2021; WHO,
2023). Understanding and performing effectively in the medical team environment is crucial for
competent nursing and patient safety (Gazarian et al., 2010). Although this research interview
protocol did not directly ask if there were concerns with patient safety in their organizations, ten
of the 14 participants shared concerns, noting an increase in “errors” and “mistakes.”
The study’s findings also indicate that virtual clinical education did not prepare nurses to
deliver accurate clinical skills. Research studies further suggest that hands-on clinical skill
development requires didactic knowledge and observable, and repetitive practice (Bandura,
2002; Ewertsson et al., 2017). Kuzgun and Denat’s 2020 study concluded that a student’s
attitude toward and motivation in their education played a large part in overcoming any issues
with manual dexterity and physical ability to complete successful nursing skills. SCT also
supports Kuzgun and Denat’s study and other research indicating that executing successful
nursing skills hinges on a student’s ability to mimic observed behaviors, receive feedback from
instructors and peers, and motivation to learn (Bandura, 2001; Ewertsson et al., 2017; O’Mara et
al., 2014). Even with the most advanced, interactive, and high-fidelity simulated learning
environments, virtual education cannot replace the reality of patient care: the sounds, smells,

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emotions, and complexities of the human experience (Cunico et al., 2012; Edstrom, 2023; Mlinar
Reljić et al., 2019).
As the nursing profession has expanded its scope of practice throughout history, the
mission of a nurse remains consistent in delivering competent patient care while demonstrating
the humanistic quality of empathy (Gillespie, 2002). Research shows that demonstrating
empathy can improve a patient’s psychological well-being and medical outcomes (Durkin et al.,
2022; Edstrom, 2023; Nourallah et al., 2020). The study did not establish a clear correlation
between virtual clinical education and a lack of patient empathy in post-pandemic licensed
nurses. While most participants did report a perceived lack of patient empathy, many attributed it
to a lack of confidence in patient interactions, rather than the virtual clinical education itself. The
post-pandemic generation of nurses, who had limited or no patient interaction during the
COVID-19 shelter-in-place mandates, entered the workforce ill-equipped to engage in patient
care socially, emotionally, or clinically.
Discussion of Research Question 2: Nursing Administrators Approach to Post-Pandemic
New Nurse Onboarding and Training
All participants in this study reported that their organizations had adjusted pre-pandemic
new nurse onboarding and training protocols to address the observed deficits in post-pandemic
licensed nurses’ competencies. In comparison, all participants reported expanded training
programs, with nine of the 14 implementing mentorships, transition to practice, or residency
programs to support post-pandemic licensed nurses, which has doubled or more the prepandemic onboarding and training timelines. The nursing administrators also noted a general
decline in post-pandemic nurses’ professionalism, reliability, and other job performance
concerns that affect hospital operations. A common topic was the virtually trained nurse’s

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limited understanding of the role of a nurse in a hospital setting, which led to increased
complaints from nurses, complaints from patients regarding nursing care, and overall job
dissatisfaction (Bagwell et al., 2024). The findings also noted an increased turnover rate among
new graduates, specifically in the first year of employment (Bagwell et al., 2024). The changes
to pre-pandemic training programs, job performance concerns, and increased turnover rates have
impacted hospital operations, leading to financial and staffing challenges.
Some of the post-pandemic challenges hospitals have experienced in maintaining a
satisfactory nursing pool were predicted pre-pandemic. The literature review noted a 7.6 million
nursing shortage by 2030 due to retiring baby boomers (Bagwell et al., 2024; Buerhaus, 2021;
Sommers, 2024; WHO, 2023). Along with the anticipated retiring baby boomers, the National
Council of State Boards of Nursing (NCSBN) in 2024 reported a national decline in first-time
pass rates on the National Council Licensure Examination (NCLEX). The NCSBN reported that,
in 2019, approximately 171,387 nursing graduates attempted NCLEX, with an 88.18% pass rate.
In 2022, 188,005 nursing graduates attempted NCLEX with a 79.90% pass rate (NCSBN, 2024).
This decline represents a significant decrease in the expected licensed nurses entering the
medical community post-pandemic, compounding concerns about a long-term nursing shortage
(Buerhaus, 2021). Predictions of a nursing shortage are being exacerbated by pandemic-induced
factors, including COVID-19 burnout, as noted by participants in this study and previous
research, causing more nurses to retire or quit than expected (Anthony, 2024; Bagwell et al.,
2024; Donnelly, 2022). The literature also aligns with participant’s perceptions that postpandemic nursing graduates entering the workforce with limited patient experience also factored
into an increase in nursing turnover rates, specifically in younger nurses within their first year of
employment (Anthony, 2024; Auerbach et al., 2022; Bagwell et al., 2024; NSI, 2023). The

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findings in this study noted that post-pandemic nurses were not prepared to work in the hospital
setting as compared to pre-pandemic licensed nurses, which has contributed to an increase in
turnover among new nurses.
In addition to the concerns highlighted in the literature and by the study participants, the
ongoing nursing shortage impacts our healthcare system. The literature review and the study
participants have aligned concerns around understaffed healthcare systems with inadequate
staffing ratios compromising patient care and increasing error rates (Bagwell et al., 2024). The
combination of baby boomer retirements, pandemic-related challenges, lower post-pandemic
NCLEX pass rates, higher nursing turnover rates, and the need to extend training and onboarding
of virtually trained post-pandemic nursing graduates places significant financial and operational
strain on hospitals.
Discussion of Research Question 3: Nursing Administrator's Recommendations for
Continued Use of Virtual Clinical Education
The training and education of nurses require two types of knowledge -- theoretical
knowledge and clinical skills. Didactic theoretical learning is essential to create a foundation of
nursing competency, as supported by the literature review and this research study. (Sharif &
Masoumi, 2005). Virtual education, PBL, lab competency, and skill-based training can augment
a student nurse’s knowledge; however, the ability to think critically, perform skills competently,
work in a team environment, and demonstrate patient empathy requires observable and practiced
bedside care in the clinical environment (Durkin et al., 2022; Edstrom, 2023). The nursing
administrators unanimously agreed that virtual education can effectively support and enhance
nursing education; however, a virtual nursing education format must be combined with hands-on

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clinical experiences in hospital settings, as required in pre-pandemic clinical rotations (Durkin et
al., 2022; Edstrom, 2023; Sharif & Masoumi, 2005).
Discussion of Additional Findings
While the data supports this study’s research questions, additional themes emerged,
including lack of confidence, generational differences, the impact of social media and
technology, mental health concerns, and hospital initiatives addressing the limitations of the
post-pandemic nursing workforce. Nursing administrators agree that virtual clinical education
does not support effective and competent nursing performance; however, there is a consensus
that these other factors listed contribute to the deficiencies in post-pandemic nurses, impacting
hospital operations.
Lack of Confidence
A recurring theme in the interviews was that post-pandemic nurses lacked confidence,
which hindered their ability to perform their jobs effectively. This lack of confidence appears
linked to the limited opportunities to observe and participate in patient care under direct
supervision, as in pre-pandemic clinical rotations. All participants in the study agreed that the
post-pandemic nurse came to the workforce with limited patient experience, and the hesitancy in
patient engagement is evident. Many studies have highlighted the need for didactic, hands-on
practice in a lab setting and repeated observable interactions in patient care before a nursing
student attempts to complete clinical skills on a patient (Ewertsson et al., 2017). SCT also
emphasizes the social construct of learning through observation and teamwork to develop
confidence and self-efficacy (Bandura, 2002). Participants in this study acknowledged that
enhanced training protocols can address the gap in hands-on patient education, which should
boost confidence in patient engagement among this generation of post-pandemic nurses.

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Generational Differences
Many participants in this study noted that the “Generational Cohort” differences may also
affect these nursing competency deficits seen in the post-pandemic licensed nurse. Generation Z
brings unique life experiences to the hospital setting as they enter the workforce. Through the
shelter-in-place mandates of the COVID-19 pandemic, Generation Z experienced disruption to
many life events by isolating at home during a critical period in their young life cycle (Mahmoud
et al., 2021). Generation Z’s education modality dramatically changed to a remote learning
environment, which limited social events, such as graduations, proms, sporting events, and
traditional dating activities (Mahmoud et al., 2021). Participants in this study reported that
Generation Z’s social isolation during the pandemic may have contributed to a lack of
confidence and social awkwardness observed in post-pandemic nurses.
Technology and Social Media
The participants observed that post-pandemic nurses, particularly from Generation Z,
heavily rely on technology and social media in the hospital setting. Many participants attributed
Generation Z’s dependency on technology, reinforced by the virtual education they received in
nursing school and, for some in high school, as a significant factor when working with postpandemic licensed nurses (Mahmoud et al., 2021). Participants provided examples of postpandemic nurses requesting digital policies and googling questions instead of seeking guidance
from colleagues or supervisors. This generation’s recent virtual education experience and social
isolation taught them to rely on technology for learning and socializing. Additionally, platforms
such as TikTok and YouTube, which feature nurse-related content, have become resources for
post-pandemic nurses. Similar to virtual education simulations, social media allows remote
engagement, potentially contributing to a lack of interest or confidence in direct patient care.

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Mental Health
The additional findings highlight that nursing administrators are placing a greater
emphasis on mental health when integrating post-pandemic licensed nurses, especially those
from Generation Z, into the hospital environment (APA, 2018; Mahmoud et al., 2021). The
effects of social isolation during a critical period in their life cycle have materialized as the
“Anxiety Generation,” with a heightened focus on mental health and prioritizing work-life
balance (APA, 2018; Mahmoud et al., 2021). Some participants shared instances where postpandemic nurses referred to themselves as victims of pandemic-induced education restrictions,
which attitude carried to the hospital floor. Many participants used the term “victim mentality”
when discussing post-pandemic nurses’ attitudes, noting that their priorities often focus on their
personal goals and self-care. The participants also noted that post-pandemic nurses request more
breaks to alleviate stress on the job and request mental health days much more compared to prepandemic licensed nurses. The nursing administrators noted that the increased requested time off
adds to the already strained operational challenges in staffing.
Participants also observed a lack of resilience in post-pandemic nurses, which they
attributed to a combination of factors: limited patient experience, generational differences,
reliance on technology over human interaction, and increased focus on emotional and mental
health (APA, 2018; Cole, 2020; Mahmoud et al., 2021). Nursing administrators described the
post-pandemic nurses as “fragile” and “timid,” citing incidents where they abandoned patient
care in stressful situations. According to SCT, self-efficacy directly influences an individual’s
effort and persistence in challenging tasks (Bandura, 2002). Virtually trained nurses lacked the
dynamic, reciprocal learning environment central to SCT, and the nursing administrators noted
that these deficiencies have added to the operational challenges hospitals face post-pandemic.

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Hospital Initiatives to Address Post-Pandemic Nurses Needs
Participant #8 stated, “Some people are waiting for things to return to normal, and we
have to adjust to our new reality and work with the nurses we have.” This sentiment reflects the
broader consensus from this study, as organizations have adopted or are considering adjustments
to meet the needs of Generation Z and post-pandemic nurses entering the hospital setting. Many
organizations have already implemented or are exploring more flexible schedules, job sharing,
and shorter four-, six-, eight-, or ten-hour shifts, rather than the traditional 12-hour shifts (Cole,
2020; Mahmoud et al., 2021). 12 of the 14 participants in this study emphasized that it is time to
re-think the traditional 12-hour nursing shift to support the needs of today’s nurses (Cole, 2020;
Mahmoud et al., 2021).
The literature and data from this study also note the value that Generation Z places on
feeling supported and appreciated (Cole, 2020). This generation values work-life balance and
prioritizes self-care, which many participant organizations have acknowledged by proactively
incorporating wellness workshops, meditation, and other holistic activities to support the needs
of the post-pandemic nurse (Cole, 2020; Mahmoud et al., 2021). One participant shared the
details of a “GENZ Movement,” while another participant shared the details of a “Kindness
Campaign,” both of which are programs designed specifically to support the post-pandemic
generation of nurses who are looking for more emotional support and professional validation
(Cole, 2020).
While the findings in this research study support the three research questions, these
additional findings are worth noting: lack of confidence, generational differences, social media,
and other technology; emotional and mental health concerns; and additional activities hospitals
have implemented to address the limitations of the post-pandemic licensed nurse entering the

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workforce. Although the participants agreed that virtual education contributed to certain
limitations in the post-pandemic nurse’s competencies, the additional findings are worth
considering in addressing this problem of practice.
Discussion Summary
Reflecting on the findings of this research study and the literature review, it is clear that
virtual clinical education implemented during the pandemic did not prepare nurses for the rigors
of patient care in the hospital setting. The COVID-19 pandemic was an unprecedented global
event that impacted many aspects of day-to-day life, including nursing education. As the
pandemic has subsided and the shelter-in-place mandates have lifted, we have resumed many
pre-pandemic routines, including nursing education. The participants in this study acknowledged
that their organizations have resumed nursing student clinical rotations post-pandemic. If the
only concern with the post-pandemic nurses is the virtual clinical education they received during
the pandemic, then in a few years, this challenge would likely be resolved, and the future nurses
should be comparable to pre-pandemic nurses; however, this situation is much more
complicated.
The participants in this research shared stories and expressed concerns about the
challenges faced by the frontline nurses during the height of the COVID-19 pandemic. A
recurring sentiment among the nursing administrators was that ‘covid changed everything.’ The
findings in this study aligned with the literature review highlighting that many nurses
experienced “Covid-burnout,” driven by high levels of stress, prolonged exposure to human
suffering and death, fear, and the pressure to save lives amid unprecedented uncertainty (Aiken
et al., 2011; Anthony, 2024; Bagwell et al., 2024; Buerhaus, 2021; Ménard et al., 2023). This
pandemic-induced trauma continues to manifest as ongoing stress, anxiety, depression, and job

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dissatisfaction, as noted in this study. (Anthony, 2024; Bagwell et al., 2024; Ménard et al., 2023).
The frontline pandemic nurses are now training the generation of ill-prepared pandemic-induced
virtually trained nurses, who will be training the next generation of nurses, further compounding
the challenges in the field of nursing.
The competency deficits found in pandemic-induced virtually trained nurses are not an
isolated issue that will be resolved by simply returning to pre-pandemic boards of nursing
required clinical student rotations. This historical period has profoundly shaped these new nurses
beyond just a few semesters of virtual education. The data revealed recurring themes beyond the
participants’ perceptions of post-pandemic nurses’ deficits in critical thinking skills, teamwork,
skill competency, and patient empathy. The findings reveal that the pandemic-induced virtual
clinical education aftereffects, along with the noted lack of confidence, generational differences,
reliance on technology and social media, and increased emotional and mental health concerns
attributed to post-pandemic licensed nurses, will continue to be an ongoing and evolving
dilemma for the nursing profession and hospital operations, necessitating continuous adaptation
and innovation.
Considering the numerous factors affecting post-pandemic nurses, as noted in the
literature and this study, the nursing shortage, COVID-19 burnout, job dissatisfaction, retiring
baby boomers, and the concurrent increase in an aging population requiring healthcare, lowered
NCLEX pass rates, increased nursing training to compensate for the virtual clinical education
limitations puts the nursing workforce in a vulnerable state. We are facing what Donnelly (2022)
called the Perfect Storm.

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Recommendations for Practice
The following section discusses three recommendations based on the study’s findings and
prior literature review. These recommendations focus on the post-pandemic nursing competency
deficits due to virtual clinical education and the hospital’s response. Along with the
recommendations, there is also a section on evaluation as a potential indicator of implementation
achievement.
Recommendation 1: Develop Emergency Protocols to Ensure Uninterrupted Clinical
Nursing Education in Times of Crisis
As noted in the findings, all participants reported resuming pre-pandemic nursing student
clinical rotations following their state board of nursing (BON) requirements. It is recommended
that organizations review the lessons learned from the COVID-19 pandemic, particularly
regarding nursing education protocols and patient interactions. Applying an SCT framework to
guide collaboration between nursing programs and BON will be essential in developing a
comprehensive emergency protocol for future pandemics or global events. Developing an
emergency protocol will ensure the continuation of hands-on patient experience in nursing
education. The protocol should incorporate SCT constructs to build confidence in nursing skill
sets through observable, repetitive interactions with clinical instructors and peers, fostering a
reciprocal and dynamic learning environment (Bandura, 2001). As evidenced in this study,
developing an emergency nursing education protocol would alleviate the challenges hospitals
face with inadequately prepared post-pandemic nurses entering the hospital setting.
Recommendation 2: Implement Flexible Nursing Scheduling Options and Additional
Nursing Support Staff

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The findings in this study highlight that post-pandemic nurses entering the workforce are
ill-prepared for the realities of patient care in the rigors of the hospital setting. Along with
expanded training programs to bridge the gap in post-pandemic nursing deficits, nursing
administrators have raised concerns about generational differences, specifically Generation Z,
affecting hospital operations. The findings also note increased nursing turnover rates, requests
for frequent mental health breaks, and a focus on work-life balance, making maintaining
consistent nurse staffing challenging. The second recommendation is for organizations to adopt
strategies some participants have already implemented, such as flexible nursing work schedules
with four-, six-, eight-, and ten-hour shifts, and position sharing. Additionally, given Gen Z’s
focus on technology, hospitals could explore telecommunication roles that do not involve direct
patient contact, a concern identified among many post-pandemic nurses.
Highlighted in the additional findings, 12 of the 14 participants noted a need to
reconsider the traditional 12-hour nursing shift and incorporate more flexible options that cater to
the needs of post-pandemic nurses. Many participants have already incorporated alternative shift
structures to reduce nursing turnover rates. A key recommendation is to explore the scheduling
framework used by flight attendants at various airlines. Condé Traveler Staff (2023) states that
flight attendant schedules are organized by seniority, experience, location, and training levels.
Adopting a similar model for nursing could transform the current scheduling system by aligning
shift lengths with specific departmental needs. By determining the hours required for each
department and offering shifts of varying lengths, hospitals could provide nurses with greater
autonomy over their schedules. Under this system, nurses with the necessary training and
experience can select shifts that align with their personal and professional needs, ensuring they
meet the required hours to maintain full-time or part-time status. While this approach may

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initially involve a complex implementation process, once established, it could improve job
satisfaction and retention. Nurses would gain more control over their work-life balance, choosing
schedules that align with their priorities while still meeting the demands of their units.
Ultimately, this system could foster a more sustainable and supportive work environment that
attracts and retains skilled nurses in the long term.
Along with consideration of the expectations of the Gen Z population, the findings also
noted lingering effects of COVID-19 with nurses on the frontline during the pandemic (Kells &
Jennings Mathis, 2023). These frontline nurses have struggled through the pandemic and staffing
challenges due to the nursing shortage, and adding flexible schedules, reevaluating patient-tonurse ratios, and hiring more CNAs and LVNs would allow RNs to work at the top of their
licenses. The flexibility in schedules and increased nursing support may benefit the prepandemic and post-pandemic licensed nurses. By building policies that align with the needs of
the nurse, which is a value of Gen Z (Cole, 2020), the expected outcome could be lowered
nursing turnover rates and increased job satisfaction.
Recommendation 3: Incorporate Technology Advancements in Nursing Training and
Hospital Operations
Although all participants in this study agreed that virtual clinical education did not
prepare the nursing student for patient care and the rigors of the hospital setting, they all agreed
that virtual education has its place in education and training. The shelter-in-place mandates gave
nursing programs little time to research and limited opportunities to test and incorporate effective
virtual experiences. Recommendation three notes that with Artificial Intelligence (AI) advances,
new virtual education options create a more realistic version of the human experience. For
example, new research in gaming simulation creates adrenaline-inducing and stressful events to

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mimic a more realistic human experience, which could be incorporated into medical scenarios
(Alrasheedi et al., 2024). There are also advances in virtual reality education (VRE) that allow
the student to be included in simulated activities, which has shown increased student engagement
and provides authentic patient experiences (Choi et al., 2022; Elmqaddem, 2019).
As the medical field progresses and evolves, integrating robotics, AI, VR, and other
technologies holds significant potential to enhance the nurse’s role in practice (Lastrucci et al.,
2024). Many participants in this study highlighted the potential these technologies could bring to
their organizations, particularly in patient documentation, AI predictive analytics, robotics,
telehealth, interdisciplinary collaboration and communication, and leadership models
(Alhendawi, 2024; Rafferty et al., 2024; Tarsuslu et al., 2024). While the literature and the
findings of this study support the concept that virtual clinical education did not influence
learning outcomes necessary for nursing competency (Clark, 2001), it is clear that media can
impact the efficiency and cost of delivering instruction. Future studies could examine the
hypothesis that these technological advancements could improve nursing education and the role
of a nurse in practice in the hospital setting.
Implementation and Evaluation
The evaluation of an organization's implementation of the recommendations in this study
is crucial. The integration of Kirkpatrick and Kirkpatrick’s (2016) Four-Level Training
Evaluation Model will allow an organization to evaluate the effectiveness of an implementation
plan and align the organization’s predicted outcomes (Kirkpatrick & Kirkpatrick, 2016). The
Kirkpatrick Four-Level Model (2016) is a widely recognized framework for evaluating the
effectiveness of training programs and educational initiatives, making it an invaluable tool in this
context:

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● Level 1 measures a participant’s reaction to the training; this could include an end-oftraining survey to gauge satisfaction, the relevance of the training topic, and how the
training itself was received.
● Level 2 focuses on what the participant learned from the training by way of knowledge,
skills, attitude, confidence, and commitment; this could include a test or hands-on
demonstration.
● Level 3 evaluates whether the participant’s behavior changed as a result of the training;
this could be noted by improved job performance outcomes.
● Level 4 assesses the measurable outcomes of the training goals, such as improved sales
numbers, quality improvement, or other organizational outcomes.
While the recommendations in this study would not be considered training models, a modified
version of the Four-Level Evaluation Model can effectively assess the success of the initiative's
implementation (Kirkpatrick & Kirkpatrick, 2016).
Considering the budgetary constraints associated with each recommendation in this
study, a sequenced approach seems most appropriate. Of the three recommendations,
Recommendation 2 should be prioritized due to its potential to significantly impact the current
nursing staffing challenges. Recommendation 3 involves researching and evaluating potential
technology solutions, requiring input and investigations from multiple stakeholders.
Recommendation 1 would also require feedback from various stakeholders to develop an
emergency plan ensuring the continuity of nursing education in the event of another pandemic or
global crisis. Recommendation 2 proposes that organizations implement flexible nursing
schedules and provide additional support to reduce nursing turnover rates and improve job
satisfaction. Although implementing flexible nursing schedules and adding extra nursing support

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are not traditional training models, the Kirkpatrick Four-Level Training Evaluation can still
effectively measure the success of this initiative (Kirkpatrick & Kirkpatrick, 2016).
Recommendation 2 aims to improve nursing turnover rates and enhance job satisfaction.
Level 4 in Kirkpatrick’s evaluation model focuses on evaluating the training results or, in this
example, the Recommendation 2 initiative (Kirkpatrick & Kirkpatrick, 2016). In this case, the
expected outcome would be a statistical improvement from the pre-initiative nursing turnover
rate compared to the post-initiative turnover rate. Along with the statistical improvement noted, a
survey could determine a qualitative level of pre-and post-initiative nurses' perceptions of job
satisfaction after implementing flexible work schedules and increased nursing support.
Establishing measurable outcomes in evaluating initiative success is key (Kirkpatrick &
Kirkpatrick, 2016).
Level 3 in the Kirkpatrick & Kirkpatrick (2016) evaluation model would assess the
behaviors of the nurses post-implementation of Recommendation 2. Once the nurses were given
the option to work a more flexible schedule and more nursing support in day-to-day patient care,
was there a noted change in nursing behavior? Is there an observable change in attitude, a
reduction in time off requests, and improved patient surveys, which were all concerns noted in
this study? These changes would indicate behavior modifications due to improved job
satisfaction.
Level 2 in the Kirkpatrick & Kirkpatrick (2016) evaluation model assesses the learning in
a training model. In the case of implementing Recommendation 2, at this phase, it would be
essential to evaluate whether the organization’s stakeholders and the nurses understand what a
flexible schedule and extra nursing support look like in practice and the purpose of implementing
this initiative. This evaluation could be done with a survey, department meetings, or focus group

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discussions after initiative communication to ensure understanding and assess areas that need
further clarification.
Level 1 of Kirkpatrick’s Four-Level Training Evaluation Model (2016) evaluates the
reaction to the training or, in this case, the implementation of Recommendation 2. When
considering implementing an initiative to offer flexible work schedules and additional support on
the job, it is crucial to assess the nurses’ needs. Surveying the nurses to understand their needs
and gather insight is vital in creating a flexible work schedule and providing additional nursing
support that addresses their concerns. By building policies that align with the needs of the nurse,
which is a value of Gen Z (Cole, 2020), the expected outcome would be lowered nursing
turnover rates and increased job satisfaction. Implementing an initiative without targeting the
core issues is counterproductive.
As illustrated in this example of Recommendation 2, utilizing an evaluation model such
as Kirkpatrick’s Four-Level Training Evaluation (2016), serves as a diagnostic instrument for
analyzing outcomes throughout each stage of the implementation process. Using a similarly
modified version of the Kirkpatrick and Kirkpatrick (2016) method, the Four-Level Evaluation
Model could assess the implementation of Recommendations 1 and 3.
Limitations and Delimitations
Trustworthiness is at the heart of research (Patton, 2015). As the researcher of this study,
I made every effort to ensure ethical handling of all data collection and analysis in compliance
with IRB protocols; however, I cannot guarantee that the sample participants provided truthful
responses (Kuzmanić, 2009). The research questions seek the hospital nursing administrator’s
perspective and recommendations on post-pandemic nurses entering the workforce. Although the
research questions in this study are objective, the responses from participants are their personal

97
experiences and social perceptions (Kuzmanić, 2009). However, the interview participants from
across the US and my peer review participant shared similar findings, indicating trustworthiness
in the data.
Employing a qualitative methodology through face-to-face interviews limits the amount
of data that can be collected compared to a quantitative survey that could include a larger sample
group and more geographic diversity (Merriam & Tisdell, 2015). The sampling saturated the
research questions within the first seven interviews; however, the interviews continued to
produce additional findings, adding robustness and depth to the research project as noted in
Chapter 4 (Merriam & Tisdell, 2015; Wray et al., 2007). While this study explored the nursing
administrator’s perspectives on post-pandemic nursing graduate’s interactions in the hospital
setting, future research could consider the nursing graduates’ experiences with virtual clinical
education and how that translates to direct patient care.
Thirty days after the Zoom interviews, it was discovered that the recordings had been
automatically deleted from the server per organizational policy. At that point, the data had been
transcribed and transitioned into the analysis phase, and the recordings were no longer needed;
however, the automatic deletion of the recordings was unexpected.
Recommendations for Future Research
While this study explored the nursing administrator’s perspectives on post-pandemic
nursing graduate’s interactions in the hospital setting, future research could consider the nursing
graduates’ experiences with virtual clinical education and how that translates to direct patient
care. This study incorporated a modified SCT framework, with nursing administrators as proxy
observers of post-pandemic nursing student behaviors in the hospital setting. Interviewing post-

98
pandemic licensed nurses through a traditional SCT framework may uncover previously unseen
aspects of this problem of practice.
Another potential area for future research could be exploring the differences between
nurses who continued working after the peak of the COVID-19 pandemic and those who left for
reasons other than age retirement. What contributing factors allowed one nurse to preserve and
demonstrate resilience compared to another nurse who chose to leave the profession?
Conclusion
The foundation of nursing education lies in integrating didactic instruction with hands-on
clinical experience to promote critical thinking skills, teamwork, proficiency in essential skills,
and the development of patient empathy necessary for nursing competence (Sharif & Masoumi,
2005). The COVID-19 pandemic was an unprecedented global crisis, resulting in an incredible
loss of life and formidable challenges to maintaining employment, education, and personal
stability worldwide. Most countries adopted mandates that limited human contact to control the
spread of the virus, dramatically changing our day-to-day interactions (Callaway et al., 2020).
Following directives to shelter-in-place, schools quickly transitioned to remote learning
modalities (Chan et al., 2021). Nursing programs nationwide scrambled to develop virtual
clinical training to replace the hands-on clinical training typically conducted at bedside in
hospitals (Park et al., 2023).
The findings in this study and the literature review support the hypothesis that virtual
clinical education during the height of the COVID-19 pandemic did not adequately prepare postpandemic nurses for the demands of patient care in the hospital setting. Participants consistently
noted that the absence of reciprocal and dynamic learning, central to the SCT framework,
hindered post-pandemic nurses’ performance compared to pre-pandemic nurses who participated

99
in traditional clinical rotations within a SCT framework. The limited interaction between
classmates and instructors and reduced patient engagement impacted nursing education. These
limited opportunities hindered the development of critical thinking skills, teamwork, skill set
competencies, and patient empathy, typically fostered through repetitive observation and practice
of patient care in a hospital setting. While post-pandemic nurses may have learned nursing
theory through virtual education, the participants in this study observed that post-pandemic
nurses often lack the ability to apply this knowledge in patient care. A human patient has
emotions, experiences pain, emits odors, produces bodily fluids, and may have mental health
issues, along with the presence of family and loved ones - all of which factor into competent
patient care, which is not evident in virtual education.
Furthermore, the study highlighted that the competency deficits among post-pandemic
nurses represent a broader issue that cannot be resolved by simply returning to pre-pandemic
BON-required clinical student rotations. This historical period has profoundly shaped the cohort
of post-pandemic nurses beyond a few semesters of virtual education, revealing concerns such as
a lack of confidence, heightened emotional and mental health challenges, reliance on technology,
and shifting generational expectations. These challenges, attributed to post-pandemic licensed
nurses, will continue to be an ongoing and evolving dilemma for the nursing profession and
hospital operations, necessitating continuous adaptation and innovation.
The COVID-19 pandemic intensified the pre-pandemic projected nursing shortage due to
baby boomer retirements. The research findings show an increased nursing turnover rates due to
unexpected early retirements, nurses leaving the profession within their first year of licensure,
the post-pandemic decline in NCLEX pass rates, job dissatisfaction, and mental health struggles,
adding to the nursing shortage. Participants described the emotional toll on the nurses during the

100
height of the pandemic as ‘going through war,’ highlighting the magnitude of the lingering
effects of the pandemic, which is especially a concern as these pandemic nurses are now
responsible for training the next generation of post-pandemic nurses.
The nursing profession stands at a critical crossroads, what Donnelly (2022) termed the
Perfect Storm. As such, the assumption that nursing education and practice will naturally revert
to pre-pandemic norms is simplistic and unrealistic. The impact of the COVID-19 pandemic will
be felt for years to come, reshaping how we approach nursing training, workforce management,
and healthcare delivery. The future of nursing education requires a forward-thinking approach
that acknowledges the limitations of virtual clinical education while implementing innovative
solutions to support current and future nurses. This study calls for action to develop effective
technology to support virtual education and training and nursing workforce efficiencies.
Evaluating mental health support for nurses is essential to improving job satisfaction. Rethinking
the traditional 12-hour shift with flexible schedules and fostering a more supportive work
environment with adequate nursing support staff are also key priorities. Additionally, developing
emergency preparedness protocols is crucial to safeguarding the nursing profession, securing
continuity in nursing education models, and maintaining high standards of patient care in the
face of future disruptions to nursing education. Ensuring adequate and competent nursing staff is
not merely a priority for the healthcare system; it is an essential safeguard for patient safety and
public well-being.

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Appendix A
Interview Protocol
Research Questions
1. What are the nursing administratior’s perceptions of the impact of virtual clinical
education on post-pandemic nursing graduates’ critical thinking skills, teamwork with
other medical professionals, skill set competencies, and demonstration of patient empathy
in the hospital setting?
2. Have nursing administrators adjusted new nurse onboarding and training protocols to
accommodate the needs of virtually trained post-pandemic nursing graduates entering the
hospital setting?
3. What are the nursing administrator's recommendations for continued use of virtual
clinical education?
Sample
Hospital Nursing Administrators
Introduction to the Interview
Good afternoon, (Name). It is nice to meet you in person. Thank you for taking the time to meet
with me today. Your expertise is valuable to this research project. As we discussed, this study is
looking into the impact of virtually trained post-pandemic licensed nurses interacting with
patients in the hospital setting. I am interested in your feedback on a comparison of pre- and
post-pandemic nursing graduates in the hospital setting: onboarding, training, and patient
interactions. Thank you for agreeing to participate in this interview and I request your consent to
be recorded. This should take approximately 60 minutes.
Before we get started do you have any questions for me?

121
Interview Questions
1. I am interested in your background. How did you get into the field of nursing? And now
nursing administration?
RQ1
2. Due to the shelter-in-place mandates during the COVID-19 pandemic, many nursing
programs transitioned to virtual clinical training to replace traditional hands-on clinical
training. I
a. What are your thoughts on the virtual clinical education recent nursing graduates
received during COVID-19 pandemic?
b. Is this a topic of discussion at your organization?
3. I am interested in any differences you have observed between pre-pandemic newly
licensed nurses and post-pandemic newly licensed nurses regarding patient interactions.
a. What are your observations regarding post-pandemic nurses' confidence level
completing tasks?
b. What are your observations regarding post-pandemic nurses' engagement and
interactions with patients?
c. What are your observations regarding post-pandemic nurses; commitment to
persist under difficult situations?
4. I have a few questions regarding specific nursing competencies.
a. What observations have you made regarding post-pandemic licensed nurse’s skill
set proficiencies?
5. What observations have you made regarding post-pandemic licensed nurse’s critical thinking
skill sets?

122
6. What observations have you made regarding post-pandemic licensed nurse’s ability to work in
a team environment with other medical professionals?
7. What observations have you made regarding post-pandemic licensed nurse’s ability to
demonstrate patient empathy?
8. What observations have you made regarding the quality of job performance of post-pandemic
licensed nurses? Specifically around such attributes as professionalism, punctuality, and
reliability.
9. Suppose you have observed any changes in the behaviors of newly licensed nurses postpandemic from pre-pandemic. Do you believe those differences are from virtual education or
other factors attributed to the COVID-19 pandemic? Can you elaborate on why you think that?
RQ2
10..How has your hospital approached onboarding and training protocols for newly licensed
post-pandemic nurses compared to pre-pandemic licensed nurses?
11. Has your hospital implemented any virtual training for nurses or other medical personnel
post-pandemic? If you have, can you describe what this training looks like?
12. Has your hospital experienced an increase in nursing turnover rates post-pandemic? If there
has been an increase in nursing turnover rates, what do you attribute the increase to?
13. There are indications of a nursing shortage or that there will be129 in the future. Do you see
virtual clinical education affecting the nursing shortage? If you do, how?
RQ3
14. What recommendations do you have for effective virtual clinical education for nursing
education in the future?
Conclusion to the Interview

123
Thank you for sharing your time and insight surrounding your hospital’s experience with
virtually trained post-pandemic nursing graduates. Is there anything else you would like to share
with me that we did not cover today?
Once again thank you for your time and feedback.

Abstract (if available)

Abstract This study utilized a modified version of Albert Bandura’s social cognitive theory (2002) to explore the impact of virtual clinical education during the COVID-19 pandemic on nursing graduates entering the hospital setting. Using a qualitative interview protocol, 14 nursing administrators across the United States shared their observations on integrating nurses who were trained in virtual environments for clinical skills during the peak of the COVID-19 pandemic and subsequently graduated (post-pandemic nurses) critical thinking skills, teamwork, skill set competencies, and patient empathy into the hospital setting. The findings reveal deficits in post-pandemic nursing graduates’ competencies compared to pre-pandemic nursing graduates’ competencies. Nursing administrators agreed that virtual clinical education lacked the dynamic and reciprocal learning environment in traditional pre-pandemic clinical rotations. Contributing factors to these deficits may include lack of confidence, generational differences, reliance on technology and social media, and mental health challenges. Based on the findings and a literature review, this study recommends a clinical nursing education model that includes patient observation and hands-on experiences, as required by pre-pandemic clinical education requirements. Additionally, the study highlights the need for extra training for post-pandemic nurses while recognizing their need for work-life balance, flexible schedules, and mental health support.

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Core Title The impact of virtual clinical education during the COVID-19 pandemic on nursing graduates in the hospital setting

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