May 2023
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TD Magazine

Mend the Gap

Monday, May 1, 2023

Healthcare's experience-complexity gap, resulting from fewer experienced healthcare professionals, requires TD's assistance.

Though COVID-19 led to numerous changes in the US and global healthcare workforce, particularly in nursing, shifts were occurring before 2020 and are continuing. Challenges such as increasing burnout, anxiety over workplace physical and psychological safety, and lack of appropriate staffing to meet complex patient needs have been compounded by the growing number of experienced employees leaving the workforce. Those newer to healthcare, perhaps a year or two postgraduation from their initial academic preparation program, are now becoming the most experienced individuals on their patient care units. In addition, the patients they are caring for are becoming increasingly complex, have numerous comorbidities (diseases), and require multiple medications and other therapies.


The situation is particularly true with nurses, who represent the largest segment of the overall healthcare workforce. The experience-complexity gap found in hospitals today poses both challenges and opportunities for talent development professionals to make a more significant impact on their organizations' health and well-being.

What is the current state?

A variety of factors are contributing to the experience-complexity gap.

Nursing shortage. The shortage of nurses continues to grow, fueled by both planned retirements and retirements spurred on by burnout from the pandemic. That has led to situations where there are fewer experienced clinicians able to precept, guide, and mentor newer employees as they onboard and develop their professional role identities.

In addition, hospitals have been employing a larger number of travel (or contract) nurses to help fill the shortages. Though their use is necessary to maintain patient care needs, travel nurses must still perform the same work as those who are employees in a facility, yet they typically earn more money and thus affect the overall cost of care.

Due to the nature of travel nurses' short-term contracts, the onboarding and training can pose significant challenges for facilities that use travel nurses. Nonetheless, TD should onboard and train travel nurses in a similar manner to other nurses who are employees and ensure travel nurses maintain the same documented competencies for the specific patient care unit as the other nurses.

Effects of the pandemic on academic preparation. As a result of decreased clinical time with patients due to COVID-19 restrictions from 2020 through 2022, preprofessional students from all disciplines faced numerous challenges in their academic preparatory years. Although many academic programs were able to integrate simulation methods using a variety of highly technological interactive computerized manikins, standardized patients (also known as trained medical or healthcare actors), and other computerized learning tools, the importance of gaining experience with actual patients is essential.

Further, many of the newer clinicians are now finding themselves in challenging situations because they do not have the safety net of working with colleagues who have significantly more years of experience than they do. Though staffing numbers on a patient care unit may reflect that enough individuals are working per shift to adequately care for the patients, the experience mix of those individuals may not be ideal.

Inadequate staffing. According to the American Association of Critical-Care Nurses, appropriate staffing is essential to a healthy work environment because it influences performance, retention, quality of care, patient outcomes, and cost. Appropriate staffing is not just about nurse-to-patient ratios but takes into account the mix of nurses and unlicensed individuals (such as nursing assistants) and their experience and skill sets.

For example, older models of staffing may only look at the number of nurses and unlicensed individuals needed to take care of a full patient census on a cardiac acute care unit. However, newer models factor in experience level both in nursing as well as in the specific specialty, in this case cardiology care.

Exodus of experienced clinicians. It is important to note that the nursing shortage affects the entire healthcare system broadly because staffing issues can change the way interprofessional team members engage with each other to accomplish patient care tasks, procedures, and overall management. With their breadth of clinical and institutional knowledge, experienced nurses have traditionally served as role models, leaders, mentors, and teachers for not only new nurses but other new professionals. When those nurses leave employment, that tacit knowledge is lost.

There is no doubt that numerous challenges exist for healthcare facilities, and TD professionals are in a prime position to help navigate and effect change.

Focus on interprofessional teams

One opportunity for TD practitioners lies in breaking down silos and integrating themselves more into the interprofessional team environment. Although healthcare professionals traditionally received their prelicensure education in silos, such as nursing, medicine, pharmacy, or physical therapy, the past decade has seen increasing emphasis on interprofessional team training and communication.

National associations of schools of health professions, including the American Association of Colleges of Nursing and the Association of American Medical Colleges, originally developed the Interprofessional Education Collaborative (IPEC) core competencies in 2011 and reaffirmed them in 2016. Under the domain of interprofessional collaboration, the IPEC developed topic areas of values and ethics, roles and responsibilities, interprofessional communication, and teams and teamwork with competencies in each area. Since IPEC introduced the competencies, many academic programs have integrated them into their curriculums so that preprofessional students have opportunities and educational sessions to learn with and from each other.

Students from many different healthcare professions are now graduating with greater knowledge of how to work and communicate more effectively in the interprofessional team. They also have greater knowledge of their specific role on the team as well as what the other professions bring to the team and their different scopes of practice.

Given such broad movement toward interprofessional collaboration, TD professionals can increase involvement with their facility's simulation educators and collaborate on continuing education and professional development offerings that encompass the interprofessional team and its dynamics. For example, academic preparation programs and hospital simulation programs use those interactive techniques to practice emergency response team training involving the interprofessional team. They also use simulation methods to test systems processes, including patient movement through the facility and external patient transfer to other facilities. Systems testing helps identify educational gaps that TD professionals can further address in collaboration with facility leadership.

In addition, the TD team can work more broadly with individuals from the different clinical fields so that all participants can gain a greater appreciation for one another's roles and responsibilities. TD professionals in healthcare tend to interact on committees with other nonclinical employees, and seeking ways to participate in more clinically focused committees—such as the critical care committee or the emergency response committee—can help the TD team identify more learning gaps and systems needs.

For instance, clinicians often do not have background knowledge about change management principles and may not take into account the effects of human behavior and resistance to change. One example of where the TD team could help with change management is based on revisions the American Heart Association has advocated. It recommends a newer approach to basic life support training that requires individuals to demonstrate chest compression and bag valve mask skills on a manikin every three months rather than the traditional two-year skills renewal period. Using change management principles is essential for a facility to switch to the newer model. TD practitioners can bring their skills in working through resistance to help their facility move to the updated model, a process that could otherwise easily stall.

Collaborate with nursing professional development departments

Formerly known as nurse educators, nursing professional development (NPD) practitioners constitute a nursing specialty that works primarily with employees and trainees in the workplace environment, similar to TD professionals. Because the American Nurses Association requires the word nursing to be in the NPD practitioner's title, employees and others in the workplace often assume that they only work with nurses, but NPD practitioners work with everyone on the interprofessional team.

They are often visible leading new-nurse orientation and teaching American Heart Association courses such as basic life support. In addition to those essential duties, they have a much broader role in the healthcare environment and can be synergistic, collaborative partners of the TD team.

The NPD Practice Model indicates the seven roles that NPD practitioners have—including learning facilitator, change agent, and mentor—as well as the larger areas in which they work such as education, role development, onboarding/orientation, and competency management. NPD practitioners often perform similar functions to the TD team, the difference being that NPD practitioners tend to be more clinician focused.

Because of their close connection to the clinical environment, NPD practitioners possess a wealth of knowledge about challenges, opportunities, knowledge gaps, and practice gaps. In fact, in many facilities, they may offer similar educational programs for clinical employees that the TD function offers, such as communication and leadership skills. However, NPD practitioners and TD professionals often operate in silos, most likely due to their organizational reporting structure. More frequent collaboration between TD professionals and NPD practitioners can bring increased efficiency and effectiveness to development programs and potentially deepen learners' educational experiences.


For example, a TD professional with a nonclinical background can cofacilitate a conflict-resolution course with an NPD practitioner, who by definition has a clinical background and thus a different lens. The cofacilitators can integrate general conflict-resolution information and add targeted practice to situations that occur in the clinical setting, including perceived power differentials, bullying, and incivility. Such a partnership can bring richness to the situation and optimize learning.

Note that nursing is the only healthcare profession that has so fully developed a specialty role that is focused on TD, with responsibilities ranging from orientation and onboarding new hires to the continuing education of specialized nursing. NPD practitioners often perform their roles as full-time positions and typically do not serve as patient care or staff nurses.

Regardless, both NPD practitioners and TD professionals have expertise in critical areas—clinical and nonclinical—and can seek to partner more in educational programs rather than duplicating them and operating in silos.

Develop preceptors to influence the practice environment

The nursing profession has developed the important role of preceptors, individuals who work on patient care units and serve as guides for new employees as they orient and onboard into their new jobs. In recent years, research has shown that it is essential for nurses to have a quality precepted experience as they enter their new work environments.

NPD practitioners are leaders in that effort as they identify appropriate preceptors who have both solid clinical and teaching skills. Preceptors must ensure new nurses' psychological safety and integrate them into the patient care unit's culture.

In the past, hospitals did little to ensure that new preceptors attained the necessary skills to be successful. However, as hospitals and clinicians have gained respect for preceptors and their role linked to employee satisfaction with the onboarding process, employers have designed increased incentives for preceptors, including clinical ladder advancement leading to increased pay. The Association for Nursing Professional Development has developed extensive resources to help NPD practitioners mentor preceptors as they grow into their roles. This is especially critical because preceptors are currently not as experienced as they have been traditionally due to the nursing shortage and the ongoing experience-complexity gap.

Given how preceptors can influence the practice environment for nursing, other healthcare professions are starting to see how they can develop their own preceptors for new clinical employees.

Precepted experiences must be tailored to different employee experience levels, given that, for example, travel nurses, new graduate nurses, and those transferring from one area to another all require different precepting techniques. For instance, travel nurses, who must quickly assimilate into their assigned unit, need focused precepting on hospital policies and procedures pertinent to their area, such as specialized equipment, documentation, and navigating hospital systems. Meanwhile, new-graduate nurses need significant precepting on how to integrate their newly acquired patient-care skills into the broader interprofessional work environment postgraduation.

TD professionals can be integral in developing preceptors, particularly because many of the skills that new preceptors need to work on are often nonclinical, such as communication, time management, and giving feedback.

Remain relevant

Healthcare as a sector is constantly changing and is not immune from societal forces, including the effects of the pandemic and the Great Resignation. TD professionals have many opportunities to have a positive impact on those who work in this sector and, ultimately, those who need healthcare.

About the Author

Mary E. Holtschneider, MEd, MPA, BSN, RN, NPD-BC, NREMT-P, CPTD, is simulation education coordinator and co-director of the Interprofessional Advanced Fellowship in Clinical Simulation at the Durham, North Carolina Veterans Affairs (VA) Health Care System. She serves as nursing program manager for Duke Area Health Education Center (AHEC) and holds a position of adjunct faculty for the UNC School of Nursing.

Holtschneider is a past president of the ATD Research Triangle Chapter in Research Triangle Park, North Carolina, and serves national ATD as an awards reviewer, item writer for the CPTD exam, and volunteer for ATD International Conference and EXPO.

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