We need more nurses. Here's how to train them. | Blake Halladay | TEDxNightingale College

In my very first lecture, in my very first class,

on my very first day of nursing school,

I was taught one of nursing's most foundational principles, evidence.

Evidence-based practice is at the root of everything we do in nursing.

Every intervention, every medication,

every treatment must be based on solid evidence

that shows that it works

and that it's safe.

Years later, I transition in my career to start working with the laws

and the regulations that govern nursing practice,

specifically nursing education. the very education that taught me just how necessary evidence is.

So, imagine my surprise

when I found that many of those laws aren't based on any sort of

reliable,

consistent evidence at all.

In fact, many of them aren't based on anything more than opinion. well-meaning opinion,

I'm sure, but opinion nonetheless.

So, why does this matter?

Well, it matters because of who it hurts.

In the United States, to become a nurse,

you have to graduate from nursing school

and then pass an exam

or pass your boards,

as you've probably heard it said.

Many licensed professions follow the same process in the US.

So, this makes sense.

But here's what doesn't make sense.

Nursing is apparently the only major licensed profession in this country

that judges the quality of its schools based on how many of their graduates

pass that exam on the very first try.

Not whether they pass at all, but whether they pass the first time.

In fact, if any of you wanted to become a nurse,

the school that you graduated from

that taught you everything you need to know to be a new competent nurse

can be totally and completely shut down

if too many of you simply need a second try.

I have read and studied every single law

and every single regulation governing nursing education in this country,

50 states plus territories.

And in my research, there's always two questions that come to mind.

First, where is the evidence for this whole first time passing thing?

especially in relation to your ability to pass a highstakes multiplechoice style exam

and the quality of the school

that you graduated from.

And two, well, if we're going to do this whole first time thing,

how many is enough?

How many of you have to pass

that exam the very first time in order for your school to be determined

as good enough?

Well, the answer to the first question, I think you already know.

I couldn't find any reliable evidence tying your ability to pass

that exam on the very first try

and the quality of the school

that you graduated from.

But it was really the answer to question two that shocked me.

How many is enough?

Well, apparently nobody knows.

Out of 50 states plus DC,

I found 26 different answers to

that question. 26 different mathematical calculations used by boards of nursing across the country

to determine if a school is good enough.

But here's the kicker.

I found that if you have a school

and you put it in a state,

we'll call this state A,

and not enough graduates of

that school are passing

that exam on the first try,

they're passing it, they're just not passing it the first time for whatever reason.

Maybe it's an underserved community, test anxiety, whatever it may be.

So now this school here in state A is at risk of being shut

down.

If you took that school, the exact same school, same administration, same faculty,

picked it up and put it over here in state B,

perhaps even right next door to state A,

the school could be just fine simply

because state B uses a different mathematical calculation.

What's more, the graduates of this school in state B, they graduate,

they pass their boards, they get licensed as nurses, and they say, "Hey,

I would love to go work in state A."

In most cases, state A says, "Come on over.

We would love to have you.

We have a nursing shortage here, too.

We trust state B."

Even though the school in state B would have been completely shut down in

state A for not being good enough.

If you're feeling like this is crazy, you are not alone.

Okay, so some of you are probably asking,

there's got to be a reason for this, Blake.

These are nurses, right?

Maybe it's a safety thing.

And that's a very great question.

I've asked myself the question many times.

So what does the actual evidence say?

A few years ago,

the journal of nursing regulation po posted a groundbreaking study

and the authors of this study wanted to know is there any difference between

nurses who pass the exam on the very first attempt

and those who pass on any subsequent attempt.

Is there any difference in safety?

So they looked at a group of nurses,

every single nurse who passed the exam for a period of time,

almost a quarter of a million nurses,

and then they followed them to see were there any disciplinary level errors?

In other words, were patients being hurt?

Well, the answer was clear.

The evidence said no.

There was no relevant difference in safety between anyone who passed the exam on

that first attempt and any who passed on any subsequent attempt.

Put another way, if you pass the exam,

the studies show that you were a competent and safe nurse.

To emphasize this, the National Council of State Boards of Nursing,

the organization that represents all state boards and who writes the exam,

did their own study a few years ago.

They specifically wanted to know what are the actual quality indicators of a nursing

school.

Well, their study came up with a whole list of evidence-based indicators.

But what was not on that list was this first time pass rate metric.

So again, who does this hurt?

In my role, I've had the opportunity to work with nurses, nursing students,

nursing applicants all across the country.

And years ago, I got to work with the best CNA

that I have ever met.

She was proactive.

She's incredibly smart.

Her critical thinking skills were exemplary.

And she desperately wanted to be a nurse.

The problem was the system was stacked against her.

If you hold a school to a single metric or risk being shut down,

that school is going to be forced to admit people,

only people who are likely to help them meet that metric.

And in this case, that means passing a multiplechoice,

highly stressful exam the very first attempt.

Well, nothing about my friend and her application said that she was that person.

She grew up in a very small town.

She was lucky to have nursing or have educators,

teachers at all because of the national teacher shortage,

let alone support for higher education.

Definitely not rigorous programs like nursing school.

English was not her first language.

So nothing about her application said

that she was likely to pass

that exam the first time.

It took years for her to find a nursing school

that was finally willing to take a risk on her.

Now I am happy to say my friend graduated nursing school.

She passed her boards, got licensed as a nurse,

and the last time I checked in on her,

she actually has completed graduate school

and is now working

as a licensed nurse practitioner,

no doubt, helping hundreds of people improve their lives.

Very awesome.

Very excited for Yes.

But what about the tens of thousands of people like her

that didn't get admitted to nursing school?

We are in the midst of a crisis level nursing shortage

and every year tens of thousands of qualified applications are turned away from nursing

schools in part because of baseless metrics like this.

So, who does this hurt?

It hurts all of us.

Every single person in this room at some point in time is going to

need health care,

is going to be a patient of some form or another.

And we need a system

that will provide enough competent health care professionals to make sure

that there is care available

when it is needed.

So, what do we do about this?

If you are a nurse, reach out to your state board of nursing.

Encourage them to implement rules

that are based on evidence like the model rules from the National Council of

State Boards of Nursing.

If you're an academic or a policy maker,

advocate for policy that heeds the call of the National Academy of Medicine

that calls on nursing to look beyond pass rates entirely.

If you are someone who just cares about healthcare in this country,

spread this message.

Public opinion matters and it is how change is made.

The nursing shortage is real.

We need a radical system transformation

that will tear down these invisible baseless barriers

that are designed to keep people out

and instead build bridges.

Bridges to bring people in. bridges to greater education access

so that we can finally unleash the healthc care workforce

that we so desperately need.

Thank you.