The College of Nursing receives up to 3,500 applicants every year for 150 first-year openings in its Bachelor of Science in Nursing (BSN) program at University Park. Undergraduate and graduate nursing degree programs exist at 12 other campuses as well, so at any given time, Penn State is educating about 2,000 nursing students across the commonwealth. The BSN program is rigorous, with 855 clinical hours of training—increasing to 900 clinical hours in 2024—built into its curriculum, and a different grading scale than the university at large: Whereas the numerical grade range for a C is typically 70–79, nursing students must get at least a 75 to earn a C. And they must get a C or better in every required nursing course to progress in the program.

“The level of responsibility that our graduates have to take on is significant, so we really do have to set the bar high,” Garrison ’87 H&HD says. “We’re one of the few programs [in which] our graduates have to pass a licensure exam after they graduate in order to work.”

Given all those requirements, nursing faculty were in an immediate bind when classes went online and clinical sites closed to students. They quickly adapted class work typically done at clinical facilities and in the college’s many simulation labs—where students perform real-life procedures on high-tech manikins—to a virtual format by collaborating with a handful of simulation software companies to offer students virtual clinical experiences that would, for the time being, substitute for the real thing.

“Nothing, in my opinion, will ever replace face-to-face clinical with a real patient, because that’s where you really learn empathy, you get to hold someone’s hand, talk to them about their fears, counsel them,” says Michael Evans, assistant dean for undergraduate nursing education at the commonwealth campuses. “But what was beautiful about the virtual clinical was, you could make the avatar have whatever disease, whatever you’re teaching about, make them get better, make them get worse, and it provided a realistic learning opportunity.”

Those learning opportunities were especially important for the hundreds of students who needed to finish program requirements in order to graduate in May 2020. “We didn’t want to delay graduation,” Evans ’03, ’16 PhD Nur says. “Nurses were needed more than ever.”

Mindful of the fear and uncertainty gripping the world and their students, nursing faculty began holding weekly “open Zoom” sessions for students and graduates who needed questions answered or anxiety assuaged. Were they ready for real-world patient care? How could they convince their worried family members they were making the right career choice? Amid all the questions about safety and job prospects, faculty and recent alumni say there was hardly any second-guessing about their chosen field. Logan DeSanto ’22 Nur, then a sophomore at Penn State Scranton, called the pandemic “motivating.” Her overriding thought during that chaotic year: “Once I graduate, I’ll be able to help.”

Virginia Sharff’s personal demarcation line is lost to her now. The sudden ramp-up of the crisis is too much of a blur, the memories too difficult to focus on for long. She does know it came months before Penn State’s March closure, since at the time she was a PCU (progressive care unit) nurse in a hospital in Orange County, N.Y.—one of the first to open to COVID patients from New York City, an early hotbed of the virus. “It was baptism by fire,” she says. “I don’t recall this amount of death in my life. It was a constant state of panic.”

What Sharff ’14 Nur remembers is the continuous confusion and shifting protocols for personal protective equipment and for COVID patient care. She remembers doctors sending nurses into patient rooms to assess them, rather than risking exposure themselves. She remembers taking care of co-workers in the ICU, and the hospital losing a nurse to the virus. She remembers getting into her car at the end of every long shift, bursting into tears, and seeing a half-dozen other health care workers sitting in their cars crying, too.

Sharff says it was a never-ending feeling “like you failed even though you’re doing everything you can do. We were pulled in every direction; every nurse worked everywhere they were needed.”

Bequie Perry had a very different experience in the early days of the pandemic. Now an assistant teaching professor at Penn State Fayette, in 2020 she was an ER bedside nurse at Excela Health Westmoreland Hospital in western Pennsylvania, where the virus was slower to reach, but the fear was not—the ER’s typical load of 130–150 patients a day slowed by more than half. “People were so afraid to come in to the hospital,” she says. “A lot of people delayed the care that they needed.”

By that summer, though, COVID-19 had swept across Pennsylvania, and Perry was following the same after-shift routine Sharff had been doing for months: Get home, wipe down the car’s interior with Lysol, take off scrubs while still on the porch or in the garage, put clothes directly into the washing machine, and head straight to the shower. “I didn’t kiss my husband for close to a year,” Sharff says.

Perry’s extended family—which includes a critical care nurse and a long-term-care licensed practical nurse—remained apart for a year, an isolation safety protocol she says was even more difficult to witness at work. “The hardest thing for us during COVID was, we completely eliminated visitors,” she says. “So many of us didn’t take our lunch [breaks]; we’d sit with our patients so they didn’t have to be alone.”

With students home instead of visiting clinical sites, College of Nursing staff donated unused gloves, medical gowns, masks, and other PPE to help front-line workers. They sent their newest graduates off to those front lines via a virtual commencement in May, then spent all summer prepping for a safe, albeit limited, return to campus that fall.

Penn State’s partial return to in-person learning was difficult for all disciplines, but the College of Nursing faced unique challenges. For one, University Park students enrolled in the BSN program spend either their entire junior or senior year at Hershey, living on the campus of Milton S. Hershey Medical Center and completing a hefty load of clinical rounds. To reduce the chances of spreading the virus, in fall 2020 students at Hershey were not allowed to visit others’ apartments or travel more than 30 minutes away for the first eight weeks; they remained essentially in a bubble of isolation as a cohort for most of that semester.

 Izzo ’22 Nur, who spent the 2020-21 academic year in Hershey, says students were given the option to remain at Hershey or go remote, taking classes online and doing virtual clinicals. She chose to attend in-person because she was eager to get real patient experience. At times that semester, Izzo—who’d set her sights on nursing after the rush of rescuing a man while lifeguarding at 16—second-guessed her decisions to be in-person, or to be in nursing at all. But she says she never reached a point of really wanting to switch. “I got the best experience working with [pediatric] patients there,” says Izzo, now an RN on the hematology-lymphoma floor at Memorial Sloan Kettering Cancer Center in New York. “I learned so much.”

Nursing classes at all of Penn State’s campuses—like everything at the university—looked and felt different that fall. Social distancing protocols meant that only half the typical number of students could be in a health assessment lab at a time. Simulation rooms were limited to two or three students, and sim sessions were streamed so other students could view them from a different room in the sim lab. When students were doing lab work that required them to be within 6 feet of each other, they donned gloves, gowns, masks, and face shields, much of which had to be procured anew, since the college had donated much of its inventory.

Professors recorded lectures, gave exams over Zoom, and talked a lot about the ethics of nursing—and of taking tests over Zoom. They also juggled a constantly changing makeup of class participants depending on who was in isolation or quarantine, online or in the classroom. By way of necessity that year came the first monumental, lasting change to nursing education at Penn State: flexibility.

By design, the BSN’s curriculum is very “lockstep,” Brown explains, with foundational science courses building into basic nursing courses, then mid-level and senior-level clinical rounds and classes. That means a particular course is generally offered just once a year, and that in-person, hands-on participation was always required. “If you can’t take a [pediatrics] and OB course because you broke your arm, you don’t get that course for another year. So students had to step out and come back next year, which is a horrible thing, to put a person’s life on hold,” she says. “Now we know that with the technology, the simulation, we can support that student. I don’t think I will ever have to ask another student to drop the course and come back next year because of an unfortunate accident.”

Such flexibility came in handy when Izzo contracted COVID from a roommate early that fall. Hershey nursing students who tested positive were sent to a local hotel that had been reserved for students in isolation, which for Izzo lasted more than two weeks. On days when she was feeling better, she could Zoom into class from her hotel room and work on virtual sims. This helped her keep up with her peers and keep her mind off everything else. “Being in Hershey was very hard,” she says. “Isolation, quarantines, weekly testing, not being able to see my friends. I felt like it took a toll on my mental health, plus the workload we have. It showed how resilient nursing students are, because damn, that sucked.”

One of the things that made the first year of the pandemic so difficult for nurses like Sharff was that there was no escaping it. Restaurants were closed. It felt unsafe to go anywhere on vacation—not that she could have taken time off. TV news and social media feeds were consumed by the virus. And worried family and friends were constantly calling with frantic questions. “Coming home was not recovery,” she says. “You were the resource for everyone; that was draining. You never got that mental downtime.”

Nurses did what they could to care for themselves. Sharff got rid of cable and stopped watching the news. Perry learned how to play the violin. “If I could focus on notes, I wasn’t focusing on other things, like the fact that in my last shift I helped intubate multiple people and sent them up to the ICU, and I have no idea how they’re doing.”

Hearing about more and more nurses burning out as the crisis dragged on gave faculty a heightened awareness that teaching their students self-care skills was imperative. Brown, who spent the early part of her nursing career on the front lines of the AIDS epidemic, remembered what it was like to care for scores of dying patients whom others were afraid of, day after day after day. “Nurses have to be healthy first. That came across loud and clear at all levels,” she says. “We have to be more conscious of the health of our students—their mental health, their physical health, all kinds of health.”

Dean Laurie Badzek, whose nursing background is in ethics and health policy, was increasingly concerned about the students’ well-being. “Every study I saw showed increased use of alcohol or other things,” she says. “We really needed to pull them all back and give them a refresh, start them off in a new way.”

The college added the MINDSTRONG for Students course into the sophomore year BSN curriculum, and it was made available to any junior, senior, graduate student, faculty, and staff member who wanted to take it. Created by researchers at Ohio State University, MINDSTRONG teaches students how to cope with stress, regulate their emotions, and build mental resiliency.

“We built it right into a core course because we thought that’s how critical it was,” says Evans of MINDSTRONG, which the college is slowly refining based on student and faculty feedback. “We know nurses are getting burned out, we know nurses are leaving the field, and we want to make sure our students are equipped with the perseverance to do well and to be able to take care of themselves.”

Students and faculty saw firsthand the strain on nurses when they resumed limited clinical rounds that fall. Garrison recalls that the 60-bed unit at UPMC Altoona where he led students on rounds that semester had COVID patients at the far end of the hallway. There were just a few at first, but as the semester wore on the makeshift barrier between COVID patients and “regular” ones kept getting closer. By the last week, there were just eight non-COVID patients the students could tend to on rounds.

The rest were off-limits, because Penn State students were not allowed to care for patients with COVID. To make sure they still got some experience with the virus, Garrison, the college’s simulation lab director, programmed one of the sim manikins to create a COVID patient: a 63-year-old overweight male with Type 2 diabetes and worsening symptoms. “I can make his lungs sound congested, his O2 levels drop, all kinds of things,” Garrison says. “Simulation has really enhanced our ability to educate our students.” During the COVID sim session, students don the required PPE, do an assessment, listen to their patient’s lungs, analyze chest X-rays and diagnostic test results, and communicate with the physician.

Clinical sites that typically allowed 10 or 12 students per clinical section were allowing only four or five. Students rotated between in-person care with their professors and working on virtual sims. With less time spent at the bedside, faculty spent more time helping their students practice how to approach patients, get them to answer questions, and walk them through procedures. They also engaged students from other disciplines—those studying medicine, nutrition, social work—to role-play the coordination of patient care during sim exercises. “We have much more content on what we call interprofessional education,” Brown says.

One of the clinical rounds DeSanto was most looking forward to, labor and delivery and pediatrics, was still closed to students, so she settled for sim sessions, caring for a lifelike patient simulator designed as a pregnant woman in labor. The professor can control the manikin’s changing symptoms and what it says, whether the labor goes smoothly or has sudden complications. “In the moment you’re like, ‘Oh my god, this is kinda stressful,’” DeSanto recalls. That stress is by design, to give students the chance to learn how to handle themselves in an emergency, and how to handle high-acuity but low-incident issues, such as cardiac arrest or placenta previa, before a real life is on the line.

DeSanto did get real-world nursing experience, and a big boost of professional pride, when the vaccines began rolling out. Nursing students at all campuses helped administer vaccines to community members at free clinics across the state during the spring of 2021. “That was super rewarding, to feel like you were giving back,” she says.

With the vaccines came a wave of cautious relief to health care workers everywhere, and more clinical sites began opening to students, though in smaller numbers than was typical pre-pandemic. In January 2021, Perry took a job as a clinical nurse educator at her hospital while continuing to work part-time in the ER. In her new role, she got to work with Penn State students returning to clinical rounds. They followed strict requirements regarding PPE, including wearing P100 respirator masks during their entire shifts. Perry was impressed with the students’ attitudes: “They were always happy to be there, ready to learn, asking questions.” The aspiring nurses told Perry the areas they’d missed, like behavioral health and labor and delivery, because of limited clinical round opportunities, and she tried to find them relevant experience with patients who came through the ER.

In the summer of 2021, Sharff and her husband took a much-needed vacation. They road-tripped to Tennessee and Mississippi, taking in New Orleans and wading into the Gulf of Mexico. Besides the weeks she spent sick with COVID in late 2020, it was the first break she’d had since the pandemic began. “We still avoided people, but it was like, ‘We have to start living,’” says Sharff, who suffers from long COVID. She returned to the hospital not so much refreshed as resigned—and, if she’s being honest, a little resentful. Nurses like her who’d shouldered the traumatic brunt of bedside care during the pandemic were facing dwindling numbers and morale as the pandemic eased. A nursing workforce analysis published in Health Affairs in April 2022 found that the number of RNs in the U.S. had plummeted by more than 100,000 from 2020 to 2021, the largest decrease in four decades. Pandemic burnout, early retirement, and a job change due to family needs were cited as the most likely contributors to the decline.

That growing issue quickly trickled down to the College of Nursing, as Brown and her staff tried to find experienced nurses to be paired with senior nursing students for one of their final requirements: 80 hours of direct patient care with a BSN-prepared nurse. “With the nursing shortages, it’s been harder to find nurses in the field who aren’t already spending their time orienting new graduates to their nursing staffs,” Brown says. “They don’t have time to also take on a nursing student.”

By the time Izzo was nearing graduation in the spring of 2022, she knew that getting a job—provided she passed her licensure exam—wouldn’t be difficult. But she wondered about the workload she’d be asked to take on because of the nursing shortage. She’d spent time working in an ER and knew that nurses are sometimes treated terribly by sick patients or their scared loved ones. She also knew that the pandemic and vaccines had become political hot-button issues, which to her minimized the humanity of real people she’d seen die of the virus.

Finally, she and her fellow students watched closely that spring as a nurse in Tennessee was put on trial and convicted for killing a patient after accidentally administering the wrong medication. “They need nurses so badly,” Izzo says, “but new grads especially are scared, because of everything that’s happened.”

Health care facilities recognize that the newest graduates entering the field have more sim experience and slightly less live clinical in-person experience. Many hospitals now have nurse residency programs or extensive orientation initiatives to support new nurses and help them transition to the rigors of the job. After passing her licensure exam that summer, Izzo was hired into such a program at Memorial Sloan Kettering (MSK), where for the first 18 months she meets regularly with a cohort of new nurses like herself. She also went through a three-month orientation during which a nurse on staff oversaw everything she did and taught her everything about working on the clinical unit. “I’m never afraid to ask questions,” she says. “I don’t want to mess up. There’s a lot on the line.”

Sharff and Perry both took new jobs last year, too. Sharff is now a nursing supervisor at Bon Secours Community Hospital in Port Jervis, N.Y., and Perry took a full-time position at Penn State Fayette. “I love teaching,” Perry says. “I love being a nurse, but it’s really awesome to be able to show people how much you love being a nurse.”

By the end of 2022, COVID-19 had killed more than 1 million people in the U.S. And its impact went beyond even that catastrophic loss: The decisions many made in 2020 to delay testing and treatments for non-life-threatening issues, along with hospitals pausing elective surgeries, eventually caused myriad problems in hospital systems and among already burned-out nursing staffs. “There’s a lot of compassion fatigue,” Perry says. “I think what COVID started to bring into light is, there needs to be a focus on the wellness of the nurse. You can’t pour from an empty cup.”

To cope with the shortages, medical facilities have been hiring more travel nurses—RNs who sign short-term contracts at high-need hospitals for compensation that can be twice as high as the salaries of staff nurses at the same facility. “It’s a double-edged sword,” Sharff says of how staff nurses often feel about the disparity in pay between themselves and their short-term co-workers. “You’re angry because you don’t feel appreciated by your employer, but then again you do, because they found you help.”

To some degree, Brown says, nurses have always been overworked and underappreciated. She recalls the days when there would be a single RN assigned to three floors of the hospital, an era of mandatory overtime and everyone at a nurse’s station expected to stand up when a doctor walked in. Nurses have long been the ones quietly running the hospital, the ones getting to know patients and their families, advocating for the sick, and doing whatever’s needed to keep them clean, comfortable, and reassured. “I think coming out of the pandemic, nurses realize there is a ceiling to what they can do without harming themselves, without harming their families,” she says. “We have to right-size that. Sometimes an upheaval like the pandemic makes those problems bubble up to the surface.”

At MSK, Izzo works 12-hour overnight shifts—13 per month, including at least three weekend shifts, with an additional differential tacked onto her compensation for the nighttime hours. She’s careful to keep her health a priority, including getting enough sleep, regularly going to the gym, and exploring the city on her days off. DeSanto uses running as a means of stress relief, a necessity given that she’s juggling a full-time job—also on the night shift—on the cardiac floor of Geisinger Community Medical Center in Scranton, plus part-time schoolwork through Penn State World Campus, where she’s working toward a doctor of nursing practice (DNP) degree.

DeSanto, Izzo, and their fellow May 2022 graduates proved their own resilience and the strength of the university’s nursing program with an aggregated pass rate of 87% on the National Council Licensure Examination for Registered Nurses (NCLEX-RN) that year, which was above both the national (82%) and statewide (79%) averages for first-time NCLEX takers. “The State Board of Nursing and our accreditors hold us to the first-time taker results, which is a major program outcome,” Badzek says. “Penn State has a really strong program.”

The number of applications for the College of Nursing hasn’t dropped in the last few years, a strong sign that the pandemic didn’t dampen enthusiasm for the profession. Sharff’s daughter, Morgan, is a senior nursing student at Penn State Scranton, soon to be among the ranks of Penn State nurses in the field.

Despite the grief of the last few years, in addition to the lasting memories of patients she grew close to and lost to COVID, Sharff also remembers the many acts of kindness from her community: Encouraging messages posted on church signs in town. Food delivered to the hospital by local businesses. Little hearts left on their windshields in the parking lot, or hand-written notes telling them You can do this! and Thank you! “I think that carried us through some of the darker times,” she says.

Asked if she ever thought of quitting, though, she grows resolute. No, she says firmly. “Even though it was scary,” she says, “somebody had to do it.”