(Illustration by Ard Su)
For decades, policymakers, philanthropists, and economists have lamented that the United States spends almost 20 percent of its GDP on medical care yet has worse health outcomes than other wealthy countries and many middle-income ones. One explanation for this paradox is that the US health-care system has a reactive approach to health, prioritizing the treatment of disease and illness while doing little to address the social determinants of health, such as educational attainment and economic status.
We believe that to close the gap between health-care costs and health outcomes, nursing education must be reimagined. Historically, nurses have addressed social determinants of health through home and community-based care. At the turn of the 20th century, nurse and humanitarian Lillian Wald advocated for nurses to form an “organic relationship with the neighborhood.” Credited with pioneering public-health nursing, Wald founded the New York City Henry Street Settlement in 1893, which, under her stewardship, offered in-home medical care for New York City residents, as well as social services such as temporary housing, food security, and employment.
Nurses comprise the largest share of the health-care workforce, and they have ranked as the most trusted profession in a US Gallup poll for more than 20 years. Nearly 60 percent of the four million US nurses work in hospitals, which means that a majority of the workforce is trained to provide hospital-oriented nursing care that involves specialized and technical medical procedures aimed at the immediate treatment and stabilization of patients in a hospital environment. The workforce at large has not been trained to provide community-oriented nursing, which encompasses preventive, chronic, and restorative care of individuals in their homes and communities and addresses the social determinants of health and health inequities.
Both types of care are crucial; however, community-oriented care focuses on the “upstream” social and environmental factors influencing a patient’s health. This approach is vital because upstream prevention measures—such as promoting a balanced diet, mental health, and moderate exercise—can reduce the prevalence of chronic disease, improve quality of life, reduce medical costs, and decrease mortality rates.
Community-oriented care also recognizes the importance of diversifying nursing, beginning with student recruitment and education. Studies show that better communication, increased trust, and improved health outcomes can result when patients receive care from caregivers who have similar backgrounds. However, according to the American Association of Colleges of Nursing (AACN), about 80 percent of registered nurses are white (non-Hispanic) and nearly 90 percent of registered nurses are women.
Just as important as broadening the demographic profile of nursing students is the need to broaden their clinical training opportunities. Where care is delivered affects how it is delivered. More than 12 million Americans, most of whom are over the age of 65, receive home-based health care in the United States annually. Cherished photos on the wall, the family pet on their lap, their favorite chair—all can boost morale and make treatments easier. Community centers, where surroundings are familiar and less imposing than those of large hospitals, may serve a similar purpose for people who require care outside the home. Nurses, therefore, should be trained to practice not just in hospitals but in diverse settings: homes, schools, clinics, community centers, and acute and long-term care facilities.
Together, we have more than 30 years of nursing education experience and 50 years of direct patient engagement as nurses in a variety of settings, from secondary schools to migrant-worker fields to homeless shelters. We lead the Johns Hopkins University School of Nursing, one of the preeminent nursing schools in the United States. Our wide experience in caregiving and education has taught us that because nurses play a foundational role in health-care delivery, they must also play a principal role in correcting its shortfalls.
To fully optimize nurses’ contribution to healthier, more equitable, more resilient communities, we must do three things: 1) expand the areas in which nurses consistently work; 2) diversify the demographic makeup of the nursing workforce to mirror the nation’s diversity; and 3) ensure that nursing graduates are well prepared to practice in a variety of settings. By adopting a competency-based education (CBE) model, nursing programs can become more inclusive and adaptive, ultimately enhancing the diversity and practice readiness of the nursing workforce. This approach trains nurses to care for underserved populations and address critical health inequities. The future of nursing hinges on embracing educational reforms that prioritize community engagement and support a diverse, competent workforce capable of meeting the evolving demands of the health-care landscape.
The AACN has taken the lead in advocating for such a transformation. The association offers guidelines for curricular development in nursing education and has urged nursing programs to move toward CBE in baccalaureate, master’s, and doctoral nursing practice programs to better address community health needs. We endorse this recommendation and equally emphasize CBE as a way to augment the reigning, hospital-based approach to educate new nurses. In what follows, we present suggestions for how to achieve this goal, offering our own school as a model.
How Nursing Left the Community
Leaders in nursing have highlighted the centrality of community health as a prerequisite for individual health. In the 19th century, Florence Nightingale, widely viewed as the founder of modern nursing, recognized the importance of housing quality, clean air and water, and nutritious food to both individual and community health. And Wald, who coined the term “public health nurse,” was a compelling advocate for addressing social and economic problems as a means of improving individual health.
Despite this heritage, the original and still dominant model of nursing education trains nurses for service in hospital settings. In fact, nursing and nursing education have evolved in tandem with the modernization of the hospital system. In the late 19th century, the first nursing schools were established in hospitals, and by 1900 as many as 800 hospital-based schools of nursing existed in the United States. By the late 1940s, the number of hospital-based schools had grown to 1,100.
These programs primarily followed an apprenticeship model managed by the hospitals. Nursing students were required to work under the supervision of experienced nurses, providing free labor during their training. This system greatly benefited hospitals by ensuring a steady supply of human capital while offering students practical, hands-on experience. Signs that the model needed replacing emerged following World War II, amid the explosion of technology growth, shifting family dynamics, and changing social norms—all of which required higher-level skills more readily available in broad-based college and university settings. In response to the health-care needs of returning veterans, as well as the baby boom that began in the postwar years, the federal government supported the construction of more hospitals through the Hill-Burton Act of 1946. Since high-quality medical care could alleviate serious health problems and prevent early deaths, these facilities soon filled with patients with complex medical conditions in need of technology-driven care, such as newly invented resuscitation tools. The fact that hospitals were quickly becoming scientific institutions of caring fueled the demand for trained nurses who could closely observe patients, tend to their needs expertly, and document their findings. The days of reliance on student nurses as primary caregivers were coming to an end.
In an influential 1948 report for the National Nursing Council, anthropologist Esther Lucile Brown argued that the increasing complexity of health care, as well as the need for what are referred to as “soft skills”—such as effective patient communication and cultural awareness—compelled a shift from hospital-based to university-based education. Others would follow in a similar vein, and research findings up to the present have corroborated Brown’s insights.
CBE represents a major conceptual shift in the delivery of nursing education because it places emphasis on full command of essential skills and applying knowledge in practice. It establishes deliberate links between knowledge, attitudes, and skills through active learning strategies.
In the 1950s, nursing schools started migrating to universities. The Nurse Training Act of 1964 accelerated the shift to institutions of higher education by providing $283 million for college-based nursing programs and students. The following year, the American Nurses Association issued a position paper advocating a four-year degree as the standard requirement for all professional nurses.
Momentum toward college- and university-based nursing education continued to gather momentum, and in 1983 the Institute of Medicine joined the campaign for four-year college-trained nurses. By the end of the 1980s, the shift from hospital-based to university-based training was effectively complete.
Today, only roughly a few dozen hospital-based nursing programs remain in the United States—a 98 percent decline from the peak of 1,100 only two generations prior. Despite the consensus that university-based nursing education better equips nurses to function effectively in highly technologized medical settings, industry and expert opinions are divided on how best to deliver high-quality training between a time-based and competency-based education.
The CBE Framework
Today’s education model, dominant for the past century, is time-based and requires students to satisfy a standard number of credit hours and clinical rotations in different departments, such as pediatrics and ob-gyn, making no allowance for actual skill levels. Instead, the framework measures academic progress in terms of semesters and program duration. It emphasizes meeting credit requirements, rather than proficiency requirements. For example, a student could take the stipulated 120-130 credits that most four-year baccalaureate programs for graduation require but still fall short of learning all the competencies needed for delivering high-quality care in multiple settings. All educational degrees except for the PhD are time-based.
CBE represents a major conceptual shift in the delivery of nursing education because it places emphasis on full command of essential skills and applying knowledge in practice. It establishes deliberate links between knowledge, attitudes, and skills through active learning strategies. This approach is not novel: Educators in medicine and aviation have already integrated elements of CBE into their curricula to bridge the divide between theoretical knowledge and practical application. This approach can be implemented via learner-centered methodologies, enabling learners to assess their own performance and develop the competencies required for their professional roles. Educational support is tailored to the strengths and areas for improvement of each student.
In addition to contributing to practice readiness, competency-based models of education are better for the learner and use the limited resources available in nursing-education settings more efficiently. Compared with traditional time-based models, CBE offers greater productivity in resource utilization by personalizing learning to meet the needs of nurses in training. Each learner receives the necessary resources to achieve the required competencies. The pace of learning is determined not by a fixed time frame but through student-paced formative and summative assessments, which allow students to demonstrate their competencies at progressively advanced levels.
Competency-based nursing education includes both psychomotor and higher-order conceptual skills, such as critical thinking, interpersonal communications, cultural sensitivities, and related people-oriented capabilities. These skills are crucial in caregiving, where nurses routinely encounter patients and families in distress and at their most vulnerable. Nurses must possess the emotional capacity to not only address but anticipate complicated situations. Competency-based education gives them the skills to do so.
This is not to say that nurses graduating from time-based training programs are incapable of exercising higher-order thinking—far from it. But students in standard-education programs typically learn these capacities by absorption: watching and intentionally (and unintentionally) emulating senior nurses who model appropriate behavior in various scenarios. This form of learning doesn’t go far enough. CBE makes explicit what is typically implicit.
In nursing, higher-order skills run the gamut: critical thinking (objectively analyzing and interpreting clinical information), problem-solving (because care scenarios don’t always follow textbook models), clinical judgment (making the right call based on a patient’s history and symptoms), and interpersonal communications (with physicians, colleagues, patients, and families). They also include patient-centered skills, such as establishing mutual respect and active listening (eye contact, nodding, and repeating language to confirm understanding).
(Illustration by Ard Su)
To support higher-order skill mastery, CBE connects theoretical knowledge and practical skills through active learning strategies, such as project-based learning, where small groups of students work together on solving complex clinical problems, and flipped classrooms, where students might watch a prerecorded lecture and then discuss the contents with the instructor during standard class time.
CBE also encourages self-reflection. Because students must demonstrate mastery of a concept before moving on, they are encouraged to assess their own comprehension and recognize shortfalls before an instructor does so for them, and to ask for guidance when they need it. The ongoing, real-time feedback from instructors can inculcate a more self-reflective mindset that carries over into professional practice. Other tools that promote self-reflection include self-assessment checklists, learning journals, and frequent debriefing sessions. The aim is to ensure that nursing students are truly practice ready by addressing gaps that multiple-choice tests often overlook.
Assessing Competency
Proponents of standard assessment methods such as multiple-choice tests argue for the efficiency of quick administration and grading. These assessment methods, however, often fail to measure the true competencies and critical-thinking skills required in contemporary nursing practice, such as communication in teams or critical thinking in a high-stakes crisis.
While more four-year nursing programs are adopting competency-based components, they still use the conventional, A-F grading system based on a 100-point scale. However, this approach is not well suited for assessing comprehensive competency.
For example, in a rough calculus, a B-minus grade signifies that a student has mastered 80 percent of the content, but they can still move on to the next course or semester. To be practice ready, though, nursing graduates should have no critical gaps in essential knowledge and skills. A competency-based grading system, on the other hand, provides clear and personalized feedback for continuous improvement. If a student demonstrates a critical gap, they work with the instructor until they have resolved it before moving on to the next learning module.
Tests still occur, but students advance by demonstrating their competencies in theoretical and clinical courses. The latter include direct patient care on medical/surgical floors, in the intensive care unit and emergency and delivery rooms, at neighborhood-based clinics, and in the home. Education scholar Chris Sturgis has proposed that a competency-based grading system should include clear learning steps and proficiency levels, in addition to detailed feedback. In this system, grading consists of four levels: beginner, where a learner shows basic understanding; developing, where a learner is improving but needs more practice; proficient, where a learner meets the expected level of competence; and advanced, where a learner exceeds the expected level of competence. Educators provide ongoing assessment of skill deployment and immediate feedback in real time, ensuring that students retain the imparted information better. Each level comes with specific feedback to help students understand their progress and what they need to do to improve. We have begun discussions within our own school to rethink how we assess student competency, and Sturgis’ ideas have become conversation starters.
Technological Tools
CBE also includes simulations, where students engage with practical scenarios that mimic real-life encounters nurses face every day. Over the years, nursing education has made significant strides through the increased use of simulations because it allows students not only to learn through engaging in lifelike scenarios but also to develop critical-thinking and decision-making skills. A systematic review of 33 studies shows significant improvements in nursing students’ knowledge and skills through simulation-based learning. Students become competent and confident nurses through personalized and progressively complex simulation experiences.
Simulation is another tool for gaining experience in complex clinical situations. The immersive and interactive nature of VR technology allows them to improve their decision-making skills and gain confidence in performing procedures and talking with a virtual patient's family members.
The combination of high- and low-fidelity simulations prepares students for real clinical situations. They can learn from high-fidelity simulations, where they interact with advanced mannequins capable of replicating real-life physiological responses, such as cardiac arrest. A mannequin’s realistic responses allow students to practice many of the competencies they need—including performing chest compressions, administering medications, and using a defibrillator—within a safe and controlled environment. This hands-on experience helps students to build confidence and competence without the risk of causing harm to actual patients. Students can also engage in low-fidelity simulations, such as using oranges for injection training or basic mannequins for CPR practice. These simpler simulations offer valuable opportunities for them to refine specific skills at their own pace.
Virtual reality (VR) simulation is another tool for gaining experience in complex clinical situations. In one scenario, students may find themselves in a busy emergency room, making quick decisions about a patient’s care. The immersive and interactive nature of VR technology allows them to improve their decision-making skills and gain confidence in performing procedures and talking with a virtual patient’s family members during a crisis. Students can practice situations over and over, as with a video game, to develop invaluable skills without causing harm to real patients.
In standardized patient simulations, students interact with trained actors portraying patients with various illnesses and conditions. For example, they might meet a patient who is experiencing severe anxiety. Through active listening, assessment, and treatment planning, they learn to provide empathetic and effective care. The immediate feedback from the patient helps them refine their skills and become more effective providers. The performance arena is a safe space in which to make and learn from mistakes. Crucially, this exercise always involves a debrief with clinical instructors to help the participating student and the students who only watched to integrate these experiences into their existing knowledge.
Similarly, team-based simulations bring together interdisciplinary teams to work on simulated clinical scenarios, which improve students’ competencies in collaboration, communication, and teamwork. Each member’s role in a situation is vital, and they learn the importance of effective communication under time constraints and teamwork in stressful situations.
Community as Clinic
Even more important than advanced teaching tools, however, is the opportunity to learn in the right setting. Community-based learning settings are a necessary component of CBE. The aim is to serve community members better and expose students to actual care scenarios they might practice in their career.
By expanding their experience beyond hospital environments, students can engage with diverse patient populations and understand health-care delivery in a variety of contexts. This approach enhances clinical skills and fosters a deeper understanding of social determinants of health.
A hallmark of nursing education has been the non-class time that nursing students spend in clinical situations. Even though nursing students no longer provide free labor for hospitals, clinical rotations are an opportunity for nursing students to apply theoretical knowledge, develop practical skills, and understand nurses’ day-to-day responsibilities. Most clinical rotations occur several days per week and vary in length from 4 to 12 hours. Nursing clinicals are widely regarded as a crucial part of nursing education where students gain hands-on experience in health-care settings.
The CBE approach requires students to receive ongoing feedback to guide their progress, followed by a summative assessment to determine whether they have met the necessary competency. For instance, delegating tasks to a team member is a competency that prelicensure students must achieve to be practice ready. Nursing students spend fewer hours in clinical rotations while deriving greater benefits from those experiences. They are also placed in clinical settings with the objective of achieving specific competencies and are supervised by a nurse prepared to provide both formative and summative assessments. The preceptor is responsible for guiding the students’ development through formative assessments and evaluating the achievement of required competencies. Upon demonstrating competency, the student progresses to the next stage. Additionally, the preceptor may identify areas in need of improvement and recommend remediation strategies, such as reviewing relevant materials or practicing skills in a simulation laboratory.
By expanding their experience beyond hospital environments, students can engage with diverse patient populations and understand health-care delivery in a variety of contexts. This approach not only enhances clinical skills but also fosters a deeper understanding of social determinants of health while supporting community-based health-care organizations and the patients they serve.
The Johns Hopkins Approach
We have taken to heart the above insights in developing our own pilot program. Our school was 1 of 10 nursing schools awarded funding by the AACN to implement pilot projects that accelerate the move to CBE, using its The Essentials: Core Competencies for Professional Nursing Education as the guiding framework. Our intention for the pilot was to develop and implement targeted CBE before either scaling up or making formal student progress dependent on their performing the skills in the model. We developed the pilot to simulate hospital-, community-, and home-based settings.
By engaging directly with patients in community settings, students like India develop critical-thinking and problem-solving skills essential for effective nursing practice. They learn to see beyond immediate symptoms and consider the broader context of a patient’s health.
For the 2023-2025 academic school years, three cohorts of students (approximately 390 students in total) participated in five CBE activities across six courses. The program asked students to demonstrate a range of competencies at their own pace; these ranged from physical assessments to analyses of structural and social determinants of health and their impact on care outcomes. Students first participated in a refresher course on relevant content and target competencies and their operational definitions, after which senior students served as peer facilitators, leading small groups of students through formative assessments. Students could stay in the group or work in pairs; either way, they continued to benefit from peer-facilitator feedback. When students were ready, they chose when to advance to the summative assessment, conducted by a clinical faculty member who assessed their ability to demonstrate the targeted competencies.
These competencies addressed social and structural determinants of health and included delivering compassionate care, recognizing the effects of health disparities and social determinants of health, evaluating population health data, establishing mutual respect, distinguishing between normal and abnormal findings, and prioritizing problems. For example, to understand the impact of health-care disparities on health outcomes, students were presented with a scenario in which a patient lived in a community lacking reliable or safe transportation. They had to articulate the connection between transportation and health-care access, explaining how limited transportation can prevent individuals from attending regular health-care appointments, such as timely screenings and preventive services. This lack of access can lead to advanced stages of illness. Students who did not fully demonstrate these competencies reviewed them one-on-one with their teacher.
At the conclusion of the pilot, students reflected on the process through written self-assessments and summaries of lessons learned. We are currently using the pilot’s results to fine-tune program components and expand to more courses and more students. We are also evaluating the introduction of artificial intelligence (AI) into our model for developing individualized assessments and support for students. While AI is helping to solve some of health care’s most pressing challenges, it has not been fully integrated into health-care training. The applications we have seen indicate that AI can help nursing education become more learner centered, customizable, and competency focused, as well as enable appropriate attention to the community-facing side of nursing.
For example, AI can craft personalized, competency-based learning plans that meet the unique needs of each learner while exposing them to a range of care settings. Such an approach could take into account the diverse experiences and educational backgrounds of students and accommodate their individual learning preferences—kinesthetic (i.e., hands-on), visual, auditory, or a combination thereof.
Like many businesses, nursing schools could augment large language models’ internet-based training with their own data—such as board license pass rates—to drive AI-enabled personalization of student learning. This approach would enable course correction by adjusting learning plans in real time based on a student’s and/or peers’ performance.
In addition to the pilot, we are testing new approaches to clinical rotations by adding community-based applications. Since the summer of 2024, Johns Hopkins School of Nursing has been piloting a first-in-the-nation, community-oriented clinical group called Outside Track. Students in the Outside Track cohorts complete all their clinical hours in rotations outside the hospital. These students receive the same opportunities as their peers in hospital settings to develop their skills, albeit in non-hospital settings, including outpatient clinics, hospices, community health centers, aging facilities, and infusion centers.
India Grant, a student in Outside Track, conducted her clinicals at a mental health facility. “One patient recently started having falls, and others on the care team wanted to change her medicine,” she said. “I intervened, checked her feet, identified bruises and cuts, and found out she also had diabetes. We were able to intervene appropriately, with diabetic foot care, rather than working with providers to change this person’s psychiatric medication.”
By engaging directly with patients in community settings, students like India develop critical-thinking and problem-solving skills essential for effective nursing practice. They learn to see beyond immediate symptoms and consider the broader context of a patient’s health, thus bringing about more accurate diagnoses and better patient outcomes.
Improving the Health of the Nation
As our nation faces worsening health inequities and an aging population, we in nursing education must adopt approaches that diversify and strengthen the nursing workforce, turning it into one that is adaptable, community-oriented, and comprehensively knowledgeable. The strategies we have developed to individualize learners’ journeys in the classroom and through simulation, assessment, and clinical settings will pave the way toward this future.
The landscape of health care is rapidly evolving with AI. By utilizing machine learning and deep learning algorithms, AI can process vast amounts of data swiftly and accurately, quickly offering health-care professionals invaluable insights. The medical field is already employing AI to diagnose conditions and develop evidence-based treatment plans. As AI continues to transform medicine, the strengths of nursing in building and maintaining relationships with patients and communities will become increasingly important. Nurses will need to advocate for the ethical use of AI, ensuring that technology improves patient care without compromising human dignity.
The future success of nursing, and the health of all Americans, depends on equipping students with a range of skills for delivering compassionate, patient-centered care. This starts with transforming nursing education into a responsive, adaptive, competency-based system that allows diverse learners from any background to succeed. By providing individualized learning experiences and extensive engagement in community settings, nursing education can lead and adapt to the shift of health care from hospitals to community sites to better attend to the needs of an increasingly diverse US population. If we, as a nation, can achieve the goals we have outlined—of admitting diverse learners, individually calibrating their learning to their skills, on their own timeline, and training them in communities—we will have gone a long way toward improving the health of this country.
Read more stories by Robert Atkins & Sarah Szanton.