For Sharon Goldfarb, a nurse educator in California, crisis care is second nature: She worked at a Harlem H.I.V. clinic during the AIDS epidemic, at ground zero after Sept. 11 and in New Orleans after Hurricane Katrina. When the coronavirus outbreak began to spread, she was ready to prepare her 85 nursing students for front-line care, if necessary.
Then the calls came from local hospitals: They no longer wanted nursing students to come for clinical rotations, primarily because of public health advisories on limiting the spread of the virus. Not only would her students be unable to help — most would not be able to graduate on time.
The United States is facing a nursing shortfall, and California will be especially hard hit; the state’s vacancy rate for registered nurses is now above 4 percent. The coronavirus will place a tremendous strain on already understaffed hospitals. Yet a growing number of hospitals are discontinuing clinical rotations for the state’s nursing students. The California Board of Registered Nursing requires that 75 percent of a nursing student’s clinical education be completed with patient contact during hospital rotations. Dr. Goldfarb, dean of health sciences at College of Marin, said that if the state did not change that requirement or encourage hospitals to find clinical roles for nursing students, there would be few nursing students graduating in the coming months.
“They’re trying to marshal the resources they have as wisely as they can,” Dr. Goldfarb said of the nursing schools’ clinical partners. “They’re working with limited resources, in people and supplies.” Still, she added, “We’re looking at 14,000 nursing students not graduating in the time of most dire need I’ve seen in my years as a professional nurse. It’s incredibly shortsighted.”
For their part, the facilities that typically take in nursing students are scrambling to protect the health of their patients and work force. “In accordance with directives from county and state officials, we have restricted all nonessential personnel from our inpatient facilities, which includes students in clinical nursing rotations,” said Anna Kiger, chief nurse officer at the North California health system Sutter Health. She added that some student involvement in ambulatory settings could be arranged, with proper precautions.
A spokesman for Kaiser Permanente, another clinical partner for the nursing schools, said that all of the decisions they had made were meant “to limit the spread of the virus to our members, staff and the public.”
California’s nursing students, for their part, are frustrated that their hands are tied as the number of coronavirus cases rises. “We see all the posts about staffing shortages, and I’m sitting at home thinking I could be helping,” said Sarah Joseph, 27, a nursing student in the health sciences department at the College of Marin who was supposed to graduate in May. “The nurses in clinical settings are on the front lines and we desperately want to be with them, because that’s what we went into nursing to do. But we’re being pushed out.”
In a letter last week to Gov. Gavin Newsom, the deans of several nursing schools called on California to temporarily lift the rule requiring 75 percent in-person care and instead allow nursing students to complete their graduation requirements through 50 percent simulations, which use mannequins, videos and online platforms for training.
“With swift and temporary action, we can keep California’s nursing students on track and prevent a decline in the overall number of registered nurses in our state,” wrote Robyn Nelson, dean of the College of Nursing at West Coast University. Dr. Nelson has had more than 3,600 nursing students displaced by the clinical policy change; she said the temporary rule change can be enacted through use of the governor’s emergency powers.
On Sunday, California nursing students released a petition on Change.org asking the Board of Registered Nursing to “find an alternate solution” to clinical hour requirements; it has gathered more than 43,000 signatories so far.
A spokesman for the California Department of Consumer Affairs said on Wednesday that the department and the nursing board “are monitoring the situation and are looking into various options,” adding, “To date, we are still bound by our regulation.”
Donna Meyer, chief executive officer of the Organization for Associate Degree Nursing, said that allowing nursing students to temporarily meet requirements through simulations was a simple solution, and desperately needed. A 2014 study from the National Council of State Boards of Nursing found that substituting 50 percent of clinical experience with simulations had no significant effect on “knowledge acquisition and clinical performance.”
But many nursing students and educators are not just calling for a change in licensing requirements; they also want to return to rotations, to provide clinical assistance where possible as hospital intake surges. In a survey of nursing students at the College of Marin this week, 85 percent of respondents reported that they would be willing to provide front-line care throughout the coronavirus outbreak.
Ms. Joseph, the nursing student, was scheduled this spring to complete her preceptorship in labor and delivery, which is now canceled. Her disappointment at the delayed graduation quickly turned to frustration. She said that she could play a useful role at a clinic without directly treating coronavirus patients — helping the triage nurses take patient vitals, distributing masks, assisting with screening questions, communicating with patients’ families and visitors. Instead, she is in her apartment, wondering when she will be able to return to work.
Paige Hilt, 24, another nursing student in California, was set to graduate in May. “Of course it’s scary, but as nurses we encounter people with different illnesses all the time,” she said. “We don’t know how bad this is going to get, and we need as many people as possible. Not to mention a lot of nurses are older, and what happens when they get sick?”
Joanne Spetz, a professor at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco, said her research indicated that patient numbers would far outstrip hospital staff capacity in the coming months, as coronavirus cases continue to rise. There are nearly four million registered nurses in the United States, but only 20 percent work in critical care. More nurses will need to be freed to move into intensive care units, meaning others will need to be ready to take their places.
Dr. Spetz said that states and nurse licensing boards should be preparing by easing licensing requirements for registered nurses who need to cross state lines, and ensuring medical workers have emergency child care. In the meantime, the need is simple: to prepare as many nurses and nursing students as possible to help.
“Students of all health professions have knowledge and training already,” Dr. Spetz said. “There are going to be many roles they’ll be useful in as we rapidly deploy in an emergency.”
Each day on her way to the office, Dr. Goldfarb passes a poster with the face of a smiling World War I nurse. “Wanted: 20,000 nurses,” it reads. A sense of duty is ingrained in the nursing profession, she said. Even during the 1918 Spanish flu pandemic, student nurses were called to hospitals to care for the ill.
“We walk toward what most people walk away from,” Dr. Goldfarb said. Now she wonders: Will her students be able to do the same?