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Associate Professor and Interim Associate Dean, Clinical and Global Partnerships, and Clinical Director, University of Alabama at Birmingham (UAB) PATH Clinic, Adult/Acute Health, Chronic Care and Foundations Department, UAB School of Nursing.
Management of the COVID-19 pandemic required healthcare leaders and frontline workers to rapidly innovate and adjust to a new reality that has forever transformed nursing education and practice. Throughout the pandemic, key stakeholders in Alabama lobbied for transformations in clinical training practice that ultimately improved students’ exposure to clinical environments and alleviated the pressure on practicing nurses and other healthcare workers during pandemic hospitalization surges. The present article highlights the key partners and regulatory innovations that led to these successes in Alabama.
Maintaining the highest level of nursing care requires appropriate staffing levels and competent nurses. However, in the current landscape, challenges in achieving either or both of these requirements exist. Although much of the nation is facing a nursing shortage, which was exacerbated during the COVID-19 pandemic, the southern United States has been particularly challenged by extreme nursing shortages and increased hospitalization rates (
During the height of the pandemic from 2020 to 2022, nursing academic/clinical partnerships emerged as a distinct approach to prepare and mobilize a new nursing workforce equipped to support and expand nursing’s frontline capacity in clinical environments. Nursing faculty and students nationwide stepped up to supplement nursing care and support COVID-19 testing and vaccine administration. With the pandemic easing and life returning back to “normal,” it is essential to evaluate and identify the benefits and potential growth from academic/clinical partnerships for future crises in the healthcare workforce. Likewise, it is important to understand the long-term implications and changes, particularly those to any regulatory processes that impact educational and practice policies.
The primary aim of the current article is to describe a successful academic/clinical partnership between the School of Nursing at the University of Alabama at Birmingham (UAB), its academic health center nursing service, and the Alabama Board of Nursing (ABN) that transformed an academic/clinical nursing education paradigm concomitantly and into the future. This integrated academic/clinical partnership offered workforce and regulatory solutions to the healthcare system at a time of great stress with increased patient volumes and demanding clinical care needs. Simultaneously, the partnership offered an opportunity to strengthen clinical knowledge and skills for students and faculty.
A secondary aim of this article is to describe how recently approved ABN regulations benefitted partnership outcomes. Working within new regulatory ABN guidelines designed to address the urgent nursing workforce needs exacerbated by the pandemic, we built on extant faculty and student nursing competencies, allowed students to practice (with supervision) to the top of their nursing skills and competencies, enhanced care delivery for patients and families, and supported nurses and other health professionals (
). This responsive change in regulation prompted opportunities for our academic/clinical partnership innovations over time.
Background of the Partnership
The academic/clinical partnership between the UAB School of Nursing (UABSON) and Nursing Services at UAB Medicine in Birmingham, Alabama, is a long-standing relationship that leverages the strengths of nursing education and service to achieve value-based outcomes for both partners. The partnership aligns the academic resources of the School of Nursing (faculty and students) with the clinical resources of Nursing Services at UAB Medicine (
The more than 15-year partnership was put to the test during the COVID-19 pandemic surges at the height of some of healthcare’s most challenging conditions, including increased patient volume and acuity and excessive clinical demands and work hours placed on employed nurses, who also had to grapple with workforce shortages and exposure to and infection with COVID-19. Academic and clinical nursing administrative leaders, with the support of the health system and UAB leadership, set out to mobilize faculty and students to assist with patient care during the COVID-19 surges and beyond these critical periods. Faculty and students were employed for the first COVID-19 surge and then in subsequent surges, the students received clinical hours for their time worked.
Like much of the United States, Alabama saw four main surges in COVID-19 hospitalizations since the pandemic emerged in March 2022. In Alabama, these surges peaked in August 2020, January 2021, August 2021, and January 2022, with the last three peaks each seeing more than 2,900 people hospitalized with COVID-19 (
In light of these challenges, the partnership response to the COVID-19 pandemic provided an opportunity to test a new model of care for consideration of regulatory change by the ABN. The evolution of this partnership regulatory innovation, including the main partners, the emergency rule from the ABN, and resulting opportunities, are explored further in this article.
The partnership regulatory innovation involved the UABSON (faculty and students), Nursing Services at UAB Medicine, and the ABN. The primary role of UABSON was to partner with Nursing Services at UAB Medicine as an accredited nursing program to provide the necessary skills validation and competency levels needed for employment opportunities at Nursing Services at UAB Medicine. The primary role of Nursing Services at UAB Medicine was to stay in close contact with the ABN and to communicate these updates to UABSON faculty. With the first surge of COVID-19, several conference calls and email exchanges between Nursing Services at UAB Medicine and the ABN provided current state of nursing updates. During these exchanges, all avenues for students to enter nursing services were explored. Additionally, the ABN worked closely with the Alabama governor and other regulatory boards to eliminate barriers to patient care. These frequent communications continued throughout each surge.
The roles of the partners developed over time through collaboration in response to the COVID-19 pandemic. These partners created a pilot clinical training program (described previously by
) that engaged nursing students, faculty, and professional nursing staff that began with the second surge (December 2020–January 2021) of patients hospitalized with COVID-19. Three iterations of this pilot program were deployed to meet the needs of the hospital and strengthen the learning experiences for students and faculty during the pandemic. All iterations included an immersive experience for students and included one faculty for supervision of four students in various units in the hospital. Each faculty-student team was assigned a particular unit and aided in the needs of the patients. For example, a faculty-student team was assigned to one of the dedicated COVID-19 intensive care units. Within this unit, the faculty-student team was responsible for proning patients. Each COVID-19 surge provided opportunities to educate students with faculty in nontraditional ways, such as smaller faculty to student ratios. These nontraditional approaches to education informed a new way to educate nursing students while they work collaboratively with faculty to provide workforce relief in times of need. Faculty volunteered to supervise students in this program, and they were paid for their additional time by the practice partner. Supervision and mentoring of students were also provided by staff nurses as part of the program initiative. Additionally, this competency-based approach allowed nursing students to demonstrate competence in various settings and contexts as detailed in the article by
. In doing so, students and faculty provided workforce relief, students were allowed to practice at the top of their skills and competencies, and care was enhanced for patients and families.
Emergency Rule: Expanded Student Scope of Practice
Under the leadership of the ABN’s Executive Officer, Peggy Sellers Benson, MSN, RN, MSHA, NE-BC, a Nursing Student Aide Program proposal was introduced in April 2020 just before the state governor enforced the stay-at-home order for the COVID-19 pandemic (
). The emergency rule allowed nursing students in accredited programs to perform specific nursing skills beyond the scope of a certified nursing assistant if the nursing student or graduate was employed by a healthcare entity within the state of Alabama. The ABN board members also voted to mandate that every accredited nursing education program in the state maintain and file an emergency plan for the continuation of didactic and clinical instruction if a natural disaster or disease outbreak prompted the closure of the program or the clinical sites used by the program. The emergency rule from the ABN (
) allowed hospitals and health systems throughout the state to capitalize on the increased availability of healthcare aides (nursing student aides) in the workplace.
Outcomes of the Partnership: New Regulations
These academic/clinical initiatives (e.g., pilot program and emergency rule) offered needed workforce relief that provided a foundation for regulatory change to be considered and sustained. These initiatives were also opportunities to re-envision the teaching models for nursing students with respect to the school of nursing as well as the healthcare entity. Thus, experts in nursing student competencies and nursing regulation worked collaboratively with key team members from the UABSON and academic/clinical partners to identify creative teaching models and move them forward. Operational details were discussed and included budgetary needs, the appropriate number of students to recruit based on their competency levels, credentialing and hiring of the students, scheduling of the students who were hired, identification and engagement of faculty needed to launch the project, and orientation and training of both students and faculty role placement. A data collection, management, and evaluation plan was discussed and applied to this initiative to eventually measure outcomes.
With each COVID-19 hospitalization surge, the UABSON responded by deploying teams of faculty and students (1:4 ratio) to work alongside nursing and medical colleagues to help support the workforce, care for acutely ill patients, and administer the COVID-19 vaccine in local communities. The students were employed by Nursing Services at UAB Medicine and identified as nursing student aides. As part of the regulatory guidance, these students were supervised by UABSON faculty and UAB Medicine’s professional nurses who lead the patient care teams.
As a result of the pandemic, the nursing student/graduate aide role was quickly established through the emergency rule. Based on early success, this expanded student role now included graduated students who had not yet passed the NCLEX to allow them to remain in the role pending licensure. These rules were made permanent through
. Although introducing a new role to nursing services in the middle of a pandemic may not be ideal, it was understood by all stakeholders to be necessary for workforce development.
In spring 2021, to aid in expanded student scope of practice, the ABN began releasing just-in-time trainings in the form of short and informative videos to educate nurses, nursing students, and the public on the scope of practice of nursing student/graduate aides. These rules were further developed and defined and then enacted into nursing regulation as the Student Nurse Apprentice rules, which became effective March 17, 2022 (
The pilot program that allowed our partnership to pursue this collaborative work was essential to our progress and successful outcomes and is a tribute to the ABN’s regulatory leadership in response to the pandemic challenges in our state. As described by
, this partnership resulted in the hospital nursing workforce, which included 111 students and 15 faculty, providing 10,000 hours of hospital nurse staffing in 770 worked shifts during the period of highest need, from December 2020 through January 2021. The faculty and students provided approximately 30% of the care at a 500% lower cost than if travel nurses had been hired. Additionally, faculty and students were involved in 46,000 vaccine encounters in regional community sites (
UABSON and Nursing Services at UAB Medicine both agreed that the project was mutually beneficial. Nursing students received experiential learning opportunities with supervision by faculty and staff who were able to assess student competency. They also gained experience in working as members of real-life healthcare teams, which we expect will accelerate their transition to practice once they are licensed as registered nurses. Similarly, the hospital had more nursing care, and the collaborative teamwork between faculty, students, and nursing staff opened doors for new opportunities. This provided opportunities for students to continue employment after the surges ended and provide earlier assimilation into the role of a nurse. Simultaneously, the partners (i.e., UABSON, Nursing Services at UAB Medicine, and the ABN) recognized the long-lasting impact that the pandemic was having on the nursing workforce and the need for greater support through policy and regulatory change to allow for these innovations.
The workforce relief efforts provided an opportunity to test an innovative pilot project that positioned the partners for formal and more elaborate innovative nursing workforce programs needed for the future. The COVID-19 pandemic and the regulatory innovation prompted not only the Nursing Student/Graduate Aide pilot program but also provided an opportunity to test three iterations of the pilot program and ultimately led to the development and enactment of the Student Nurse Apprentice Program (Ala. Adm. Code 610-X-15, 2022).
Despite what initially seemed like insurmountable challenges, the ultimate goals of the partnership were achieved as measured through an extensive evaluation process that is beyond the scope of this paper. Patients received quality care, students had valuable learning experiences, the nursing workforce had relief, and the academic/clinical collaboration functioned within the changes to the Alabama emergency rule and administrative codes, which allowed nursing students to work in clinical settings during the pandemic. These challenges ultimately led to amendments in the hospital’s policies and procedures and later to the amendment to the Alabama Nurse Practice Act (
). If not for the abrupt nature of a pandemic, these collaborative opportunities among all partners may have taken much longer to get buy-in and move to implementation, validating our just-in-time approach to this crisis.
Even with our existing academic/clinical partnership, the challenges to provide relief to the nursing workforce while ensuring meaningful clinical learning experiences for students warranted considerable time for planning and collaborative work. Ensuring compliance with regulatory and accreditation policies was crucial. The partners learned that in-person meetings to address these considerations and meet our goals required sessions that were longer than 1 hour. Thus, dedicated time to facilitate communication and collaborative work together with detailed plans and outcome measures was essential.
Status of Changes in a Post-COVID Environment
Innovations occur in the most unlikely of moments, but with a strong academic/clinical partnership, it is possible to achieve better results when working in alignment than working in silos. This pandemic demanded strong and persistent partnership activities to ready a nursing workforce response. Many aspects of our innovations have proven to be worthy of continuation. The evaluation of our partnership work has been essential to further sustaining and expanding the student apprenticeship positions piloted during the COVID-19 surges and has the potential to further meet nursing workforce demands.
To date, the academic/clinical partnership has used the lessons learned from the innovative pilot program to guide our nursing workforce and nursing care delivery models. We are in the process of evaluating the experiences of the nursing staff, the nursing students, and the faculty and combining this evaluation with patient experiences to determine next steps. The partnership innovations between the UABSON, Academic Health Center, and ABN are contributing to the evolution of statutes, rules, and regulations and continues to be a crucial aspect for developing work in adopting competency-based education for professional nursing (
The structural challenges in today’s healthcare system and the emerging issues exacerbated by the COVID-19 pandemic (eg, nursing shortages) have created new partnership opportunities. Nursing programs are called upon to provide students with clinical hours and prepare them to be practice ready, which requires innovative approaches to facilitate entry into practice. These new approaches need to recognize and take advantage of nursing workforce state regulatory changes that expand practice to meet care needs. Stakeholders have begun to recognize how academic/clinical partnerships can promote patient outcomes, reduce turnover expenses, and support the development of nursing competencies. The progressive regulatory changes by the ABN that evolved to the official nursing student/graduate aide role and then the Nurse Apprenticeship Act through the amendment to the Nurse Practice Act allow students to practice in healthcare settings with supervision, enable academic/clinical partnership innovation to achieve ongoing positive educational and patient care outcomes, and increase workforce capacity.
Building on our findings of the pilot Nursing Student/Graduate Aide Program, we anticipate that students who participate in the Nurse Apprenticeship Program will continue to benefit through enhanced critical thinking and clinical judgment abilities, communication and skill development, health assessment proficiencies, collaborative role development, and implementation and evaluation of nursing plans of care. The evolution of innovative partnership programs, as described in this article, can ease transition to practice for the increasing number of new nurses entering the profession, support the workforce, and lessen the burden brought on by the nursing shortage by supplying a pool of new nurses with practice-ready competencies.