There’s a widening gap between what a nursing degree certifies and what a hospital unit actually demands in practice, nursing leaders say.

New nurses are arriving on the job less prepared for the nuances and complexity of clinical care, leaving hospitals and health systems to increasingly shoulder the additional training and education required for real-world practice.

Many nursing schools are built to produce graduates who pass their licensing exams on the first try, nursing executives told Becker’s, not graduates who are ready for the floor. New data from the National Council of State Boards of Nursing shows registered nurse candidates passed the National Council Licensure Examination-RN exam at a 74.4% rate in the first half of 2026, up from 69.1% in 2025.

Holly Muller, DNP, RN, senior vice president and system chief nursing officer of Presbyterian Healthcare Services in Albuquerque, N.M., has been circling this challenge inside her own system, though she’s not alone.

“I hear this from my peers across the country,” she told Becker’s. “They all have mitigation strategies in place, but what’s happened is, as employers, we’ve had to absorb work that may have — in previous ways in schools — been done to a greater degree than it seems to be done [now].”

Dr. Muller highlighted three specific deficits she sees among new nurses on day one: a lack of critical thinking; compassionate, authentic communication; and basic hands-on experience with clinical procedures.

Several forces are compounding this gap. More low-acuity care has shifted to ambulatory settings over the past 15 years, meaning the patients who remain in acute care are sicker and more medically complex than they were a decade ago. Nursing students who trained during the pandemic, when clinical rotations moved partly or fully virtual, also missed hands-on hours their predecessors had. And the pipeline of experienced nurses available to backfill and mentor is itself shrinking, according to Dr. Muller, since seasoned nurses are largely either settled into roles they do not want to leave or approaching retirement.

The critical thinking skills gap shows up in how new nurses process what is in front of them, according to Donna Berizzi, DNP, RN, associate chief nursing officer of the oncology service line at Johns Hopkins Medicine in Baltimore. The technical pieces, she said, are the easy part to teach. What is harder to teach is synthesizing a patient’s physical, psychosocial and technical needs into a single picture in real time.

“What we can’t teach is how to look at a patient situation and determine all of the things that are going to need to be tied up in a bow all at the same time for them to care for those patients,” Dr. Berizzi said.

The stakes of that gap are high in oncology, where patients can look fine until they suddenly are not, she said. Blood counts can plummet without visible warning signs, and a new nurse may not recognize the pattern quickly enough to escalate in time.

“For a new nurse to be able to understand what that process looks like and being able to escalate in the most complex environment can be incredibly challenging,” she said.

The second gap surfaces in everyday communication between nurses and patients or other members of the healthcare team. When a new nurse calls a physician or an on-call provider to report a concern, Dr. Berizzi said, they often lead with an isolated data point instead of the full clinical picture.

Dr. Muller sees the same erosion from a different angle. Nurses are not just losing comfort with escalation, she said, but the basic skill of connecting with patients and families, in part because of how tethered everyone has become to devices.

“It’s like a lost language,” she said, noting that during her own education, nursing schools had specific modules on team communication.

The third gap is the most literal: hands-on repetition. Dr. Muller said she came through nursing school with more clinical hours than today’s graduates typically get, and could handle most of the clinical assessments her first job required. Today, she said, some new hires have performed a given bedside procedure only once or twice before their first day.

“Nurses are coming out of school with less skills,” she said.

What’s more, the shrinking pool of experienced nurses is straining the system meant to close these gaps. Dr. Berizzi said preceptor pairings do not always work on the first try, and finding a good match takes trial and error. The preceptors who do work well with new hires are asked to carry that load again and again, on top of their own patient assignments.

“A preceptor’s work is doubled when you have them working with a new nurse, and their level of responsibility is doubled,” she said. Demand has outpaced the supply of nurses willing and able to teach. “It’s not fair, it’s not possible,” Dr. Berizzi said.

Health systems are not waiting for nursing schools to close the gap on their own. Presbyterian Healthcare Services opened its Healthcare Advanced Learning Lab, an advanced simulation center, about two years ago and has since made it mandatory for every new nurse. Nurses spend their first week there, working through validated competencies with clinical educators, before ever taking a patient assignment. The system has also built its own framework, called Compassionate Connected Care, to teach caregivers how to interact with patients and their families.

At Johns Hopkins, Dr. Berizzi has moved oncology onboarding away from a fixed timeline entirely. New nurses meet weekly with their preceptor, manager, clinical nurse specialists and educators throughout orientation, and progress through clinical milestones rather than a preset number of weeks before taking on higher-acuity assignments such as chemotherapy administration. Even after formal orientation ends, the transition continues gradually.

“They don’t get a full assignment for weeks,” Dr. Berizzi said.

That oversight extends into daily habits. Dr. Berizzi said her team reviews new nurses’ documentation and checks in with them at the end of every shift.

“We’re reading their notes, we’re meeting with them at the end of the day. How was your day? Tell me a little bit about how you tackle this situation,” Dr. Berizzi said, describing how she makes sure new nurses are seeking out education on their own between shifts.

“A lot of this is like being back in school. They’ve got to go home, they need to read, they need to have access to education,” she said.

For now, Presbyterian and Johns Hopkins — like many other systems — are absorbing this work themselves, one preceptor, one shift and one new nurse at a time.

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