NCLEX-RN outcomes remain one of the most visible indicators of nursing program effectiveness, academic quality, regulatory confidence, and graduate readiness for entry-level nursing practice. Persistent low first-time pass rates create significant institutional risks, including heightened regulatory scrutiny, accreditation concerns, reputational harm, enrollment instability, and diminished student confidence. Historically, many nursing programs have attempted to improve outcomes through isolated interventions such as standardized testing requirements, remediation mandates, curriculum revisions, or high-stakes progression gates. These approaches may produce temporary improvement but often fail to create sustainable outcomes because NCLEX success is not the result of a single course, assessment, or remediation experience. Rather, NCLEX performance reflects the functioning of an academic ecosystem that includes curriculum design, assessment validity, faculty capability, student support, policy alignment, predictive analytics, and operational processes that support timely testing.

This paper describes the 51cg Comprehensive NCLEX Readiness Model as an integrated, data-driven system designed to improve first-time NCLEX-RN pass rates, reduce time-to-test, strengthen readiness decisions, and support sustainable continuous improvement. The paper then translates the Joyce model into broader evidence-informed strategies that nursing programs can use to improve NCLEX-RN outcomes within accreditation and regulatory expectations. The model is aligned with the Next Generation NCLEX emphasis on clinical judgment, the AACN Essentials competency-based framework, CCNE expectations for licensure outcomes and continuous improvement, and ACEN expectations for outcomes assessment and program effectiveness.

Keywords: NCLEX-RN, Next Generation NCLEX, nursing education, predictive analytics, remediation, curriculum alignment, accreditation, clinical judgment, ATI Comprehensive Predictor, continuous quality improvement

Introduction

NCLEX-RN outcomes are a critical measure of nursing program effectiveness because they represent the point at which academic preparation is externally validated through a national licensure examination. For nursing programs, first-time NCLEX-RN pass rates serve multiple purposes. They are indicators of graduate readiness, markers of program quality, signals to prospective students, and evidence used by boards of nursing and accreditors to assess whether programs are meeting expected outcomes.

The launch of the Next Generation NCLEX on April 1, 2023, increased the importance of clinical judgment preparation across nursing curricula. The NGN was designed to better measure candidates’ clinical judgment and decision-making abilities through innovative item types and case-based measurement approaches (National Council of State Boards of Nursing [NCSBN], 2023a). The NCSBN Clinical Judgment Measurement Model provides a framework for measuring clinical judgment with psychometric rigor and was developed through literature review, expert input, and analysis of data from more than 200,000 NCLEX candidates (NCSBN, 2023b). This shift requires nursing programs to move beyond content coverage and toward intentional development of clinical reasoning, prioritization, cue recognition, hypothesis generation, action planning, and outcome evaluation. The JoyceU Model was reviewed with the 2026 NCLEX (NGN) update. The 2026 NCLEX -RN changes were minimal and did not force consequential changes to the JoyceU Model.

Low NCLEX-RN pass rates are rarely caused by one problem. They often reflect cumulative weaknesses in curriculum sequencing, course rigor, assessment quality, student support, faculty development, academic policies, admissions processes, and post-graduation testing support. Therefore, sustainable improvement requires a systems approach rather than a single intervention. The 51cg Comprehensive NCLEX Readiness Model (JoyceU Model) provides one example of how a nursing program can organize NCLEX improvement as an integrated ecosystem.

The 51cg NCLEX Readiness Model

51cg developed a comprehensive NCLEX readiness system to improve first-time NCLEX pass rates, reduce time-to-test, and ensure consistent and defensible readiness decisions. This work integrated several components of the Diane M. Breckenridge, Zane R. Wolf, and Mary J. Roszkowski (2012) Risk Assessment Profile and Strategies for Success framework. Dr. Johnson introduced the model to 51cg after applying and observing successful implementation at other institutions with historically lower NCLEX performance. Johnson and Rogers adapted and expanded the model for use at 51cg. The model was further tailored to address the specific needs of Joyce students through collaboration with academic leaders, including Dean Jennifer Ayotte, Dr. Becky Collins, Dr. Ashley Otto, Assistant Dean Jennifer Cowherd, Dr. Cory Myers, and Dr. David Haskell. The model is intentionally organized as an integrated ecosystem rather than a collection of isolated initiatives. It includes six interdependent domains: assessment and evaluation, faculty development, NCLEX readiness infrastructure, policy alignment, student support, and curriculum design.

The JoyceU model is grounded in a central premise: NCLEX success is designed, measured, managed, and continuously improved. This differs from traditional approaches that place responsibility primarily on students near the end of the program. In the Joyce model, readiness begins at admission and orientation, continues through course-level assessment and remediation, is reinforced through curriculum and faculty development, and is supported through operational processes that help graduates test promptly.

Assessment and Evaluation

51cg implemented a comprehensive assessment and evaluation model to ensure consistent, valid, NCLEX-aligned measurement of student readiness. The model includes centralized governance, standardized blueprinting, subject matter expert review, AI-assisted item development, unbiased item review, item piloting, and psychometric validation. Exam item piloting was planned to began in Spring 2026, with the goal of developing at least 20 validated new items per exam beginning Fall 2026. The institution also established a key performance indicator to maintain exam failure rates at or below 20% per course beginning Summer 2026.

This assessment strategy recognizes that poor exam quality can distort readiness decisions. If course exams are not psychometrically sound, students may pass courses without demonstrating readiness or fail courses because of flawed items, misaligned content, or inconsistent rigor. Valid assessment systems, therefore, protect students, faculty, programs, and the public. These Joyce-content specific exams were given, along with the standardized, nationally-normed ATI subject-specific Content Master Series examinations in select courses throughout the pre-licensure programs.

Faculty Development

The Joyce model positions faculty development as a core NCLEX readiness intervention. Faculty influence curriculum delivery, classroom rigor, assessment validity, clinical judgment development, remediation quality, and the consistency of student expectations. Joyce strengthened program-specific faculty orientation, developed NCLEX-aligned item-writing and assessment training, prepared faculty for competency-based education, and created a new faculty support and readiness model that includes onboarding, observation, mentoring, and performance monitoring.

Faculty performance data are used to monitor course launch and closure compliance, end-of-course surveys, Content Mastery Series outcomes, predictor performance, and NCLEX pass rates. This approach reframes faculty development as an accountability and improvement system rather than a one-time orientation activity.

NCLEX Readiness Infrastructure

51cg revised its readiness infrastructure by replacing a single high-stakes predictor standard with a multi-indicator readiness model. A revised ATI Comprehensive Predictor benchmark of at least 74% raw average across two attempts replaced the prior single-attempt 95% probability-of-passing requirement. Remediation was required and guided based on each student’s individual learning needs. This change was designed to reduce high-stakes pressure while encouraging sustained preparation and allowing more students who demonstrated readiness to progress.

The ATI RN Comprehensive Predictor is designed to provide a numeric indication of a student’s likelihood of passing the NCLEX-RN and to guide remediation based on missed content (Assessment Technologies Institute [ATI], 2020). ATI’s technical documentation links percent-correct score ranges to predicted probability of passing, including a 74.0% to 74.7% range associated with an estimated 94% to 95% probability of passing the NCLEX-RN (Assessment Technologies Institute, 2020). However, Joyce’s model appropriately uses the predictor as one component of readiness rather than as a stand-alone determinant.

Joyce also incorporated VATI Greenlight requirements, weekly NCLEX data infrastructure, predictive analytics, Pearson VUE voucher incentives, and fast-track transcript processes. These strategies are designed to provide individualized readiness coaching, reduce financial and administrative barriers, and shorten the time between graduation and NCLEX testing.

Policy Alignment

The Joyce model includes systematic policy review because academic policies can either support or undermine readiness. The institution reviewed transfer credit, grading scale, dismissal and appeals, course expiration, assessment expiration, and entrance assessment policies. It also increased the weight of CMS assessments and removed reliance on an in-course exam-average requirement as the sole high-stakes determinant of progression.

The purpose of policy alignment is not to weaken standards. Rather, it is to ensure that standards are valid, equitable, evidence-informed, consistently implemented, and linked to licensure readiness. A defensible readiness system should avoid overreliance on a single high-stakes measure when multiple indicators can provide a more accurate picture of student readiness.

Student Support Systems

Joyce implemented proactive student support systems that identify risk early and intervene before failure occurs. The model includes at-risk dashboards, individualized remediation plans, key concept reviews, ATI CMS-based study plans, learning support services, re-entry safety and success plans, and redesigned new student orientation. Risk indicators include Comprehensive Predictor performance below 74%, CMS performance below benchmark, any single course examination below 80%, and course averages below 77%.

The student support model is designed to shift the institution from reactive remediation to predictive intervention. Rather than waiting until students fail a course or fail the NCLEX, the system identifies risk during the program and deploys targeted supports.

Curriculum Design

Curriculum alignment is central to the Joyce model. The institution strengthened alignment between Joyce-developed curriculum and ATI resources, improved course sequencing, mapped courses to the NCLEX blueprint, AACN Essentials, and program outcomes, and emphasized integrated learning across didactic, lab, simulation, and clinical environments.

This curricular design reflects the NGN emphasis on clinical judgment. Students must not only recall nursing content but also recognize cues, analyze data, prioritize hypotheses, generate solutions, take action, and evaluate outcomes. Therefore, NCLEX improvement requires curriculum structures that repeatedly develop and assess clinical judgment across the program.

Conceptual Figure: The 51cg NCLEX Readiness Ecosystem

Evidence Supporting the JoyceU Model

NGN and Clinical Judgment

The NGN requires programs to prepare students for complex clinical decision-making rather than content recall alone. NCSBN describes the NGN as an exam designed to better measure clinical judgment and decision-making abilities through innovative item types (NCSBN, 2023a). The NCJMM provides a framework for valid measurement of clinical judgment and decision-making within the NCLEX context (NCSBN, 2023b). These developments support Joyce’s emphasis on curriculum alignment, clinical judgment assessment, simulation integration, and progressive complexity across the program.

Predictive Analytics and Multiple Readiness Indicators

The literature supports the use of multiple predictors rather than a single readiness measure. Cummings et al. (2024) found that GPA and the ATI Comprehensive Predictor both accurately classified 86.67% of NCLEX-RN success, while performance in anatomy and physiology and pathophysiology classified 84.81% of NCLEX-RN success. ATI Medical-Surgical scores and the ATI Comprehensive Predictor were also correlated with first-time NCLEX-RN success. These findings support a multi-indicator model that includes academic performance, course-specific standardized assessments, and comprehensive predictors.

The ATI Comprehensive Predictor technical documentation states that the assessment is intended to estimate readiness and guide remediation; it also cautions that institutions using the exam are responsible for decisions based on test scores (Assessment Technologies Institute, 2020). This distinction is important. Standardized predictors can inform readiness decisions, but program leaders should avoid treating them as the only evidence of readiness. Joyce Nursing Leaders track key student performance indicators on a month-over-month basis, comparing performance to past semesters, and then they utilize the data to make real-time adjustments as needed.

Remediation and Student Support

Structured remediation is associated with improved readiness indicators. Meehan and Barker (2021) found that a prescribed remediation protocol helped high-risk students achieve the necessary Comprehensive Predictor scores associated with NCLEX success. House et al. (2021) also reported that a distance-delivered remediation course supported NCLEX-RN success among at-risk students during COVID-19 disruptions. These findings support Joyce’s use of individualized remediation plans, key concept reviews, ATI-guided remediation, and learning support integration.

Assessment Quality and Validity

NCLEX readiness decisions are only as strong as the assessments used to make them. Assessment validity requires alignment between course outcomes, program outcomes, licensure expectations, item design, administration conditions, and score interpretation. ATI’s technical manual emphasizes content validity, reliability, construct considerations, and standardized administration assumptions (Assessment Technologies Institute, 2020). Joyce’s assessment governance model, item piloting, psychometric review, and faculty item-writing development address these validity concerns at the program level.

Systems Thinking and Continuous Quality Improvement

A systems approach is necessary because NCLEX outcomes are influenced by multiple interacting variables.

NOTE:

• Curriculum alignment alone is insufficient if assessment quality is weak.
• Faculty development alone is insufficient if policies create inappropriate progression barriers.
• Remediation alone is insufficient if the risk is identified too late.
• Testing incentives alone are insufficient if students are not academically prepared.

The Joyce model addresses these interdependencies through feedback loops and shared accountability. The Feedback loops are outlined below:

Outcome Metrics and KPI Tables

A comprehensive NCLEX readiness system requires clearly defined outcome measures, operational benchmarks, and continuous performance monitoring processes. Sustainable improvement in first-time NCLEX-RN pass rates cannot be achieved through isolated interventions or retrospective analysis alone. Rather, nursing programs must establish measurable indicators that evaluate readiness longitudinally across the educational continuum.

The following outcome metrics and key performance indicators (KPIs) were developed to support continuous quality improvement, early risk identification, regulatory accountability, and evidence-informed decision-making within the 51cg NCLEX Readiness Model. These metrics intentionally combine leading indicators, such as predictor performance and CMS outcomes, with lagging indicators, such as first-time NCLEX-RN pass rates and time-to-test. This multidimensional approach reflects the understanding that NCLEX success is the product of interconnected academic, operational, instructional, and support systems rather than a single assessment event.

Importantly, these KPIs also support alignment with accreditation and regulatory expectations, including AACN Essentials competency development, CCNE outcomes assessment requirements, ACEN continuous improvement standards, and the Next Generation NCLEX emphasis on clinical judgment readiness. Collectively, these metrics allow institutions to monitor student progression, evaluate intervention effectiveness, identify curricular or assessment concerns, and ensure defensible readiness determinations through systematic and ongoing review processes. Refer to Table 1 below.

Table 1

Core NCLEX Readiness Outcome Metrics

Table 2, below, outlines the key leading, intermediate, operational, lagging, and quality indicators used to monitor and improve NCLEX-RN outcomes within a comprehensive readiness system. Together, these indicators provide a structured framework for continuous quality improvement by allowing institutions to identify risk early, evaluate intervention effectiveness, monitor operational efficiency, and assess long-term licensure outcomes. Leading indicators provide early warning signals that support proactive intervention, while lagging indicators evaluate the ultimate effectiveness of curriculum, instruction, assessment, and support systems. Operational and quality indicators further ensure that institutional processes, assessment validity, and program infrastructure remain aligned with student success and regulatory expectations. Collectively, these measures support evidence-informed decision-making, accountability, and sustainable NCLEX readiness improvement across the program.

Table 2

Leading and Lagging Indicators for NCLEX Improvement

The next table, Table 3, summarizes the major domains within the 51cg NCLEX Readiness Model and translates each domain into actionable strategies that can be adopted by other nursing programs seeking to improve NCLEX-RN outcomes. The framework demonstrates that sustainable licensure success requires coordinated improvement across assessment systems, faculty development, student support, curriculum design, academic policies, and readiness infrastructure. By pairing institutional strategies with transferable program actions, the table provides a practical roadmap for implementing evidence-informed, systems-based approaches to NCLEX readiness and continuous quality improvement.

Table 3

Joyce Model Domains and Program-Level Improvement Actions

Accreditation and Regulatory Implications

CCNE Implications

All 51cg Bachelor’s degree nursing programs are accredited by the Commission on Collegiate Nursing Education (CCNE). The CCNE 2024 Standards require programs to demonstrate achievement of required program outcomes related to licensure. Programs may demonstrate licensure pass-rate achievement through several approaches, including first-time pass rates of 80% or higher for each campus/site and track for the most recent calendar year, all-taker pass rates of 80% or higher, or three-year aggregated approaches (Commission on Collegiate Nursing Education [CCNE], 2024). CCNE also expects programs to provide aggregate student outcome data, including completion rates, licensure pass rates by campus/site and track, certification pass rates where applicable, employment rates, and evidence that data are analyzed and used for ongoing program improvement (CCNE, 2024).

The Joyce model aligns strongly with these expectations because it does not treat NCLEX performance as an isolated annual statistic. Instead, it creates a continuous improvement system in which NCLEX outcomes, assessment analytics, faculty performance, and student success data inform curriculum, policy, and intervention decisions.

ACEN Implications

Our associate’s degree nursing program is accredited by the Accreditation Commission for Education in Nursing (ACEN). ACEN Standard 5 focuses on outcomes and requires nursing programs to demonstrate student learning and program outcome achievement. Although specific benchmarks and reporting structures vary by program type and accreditation context, the underlying expectation is that programs systematically evaluate outcomes, analyze data, and use findings for program improvement. For programs with declining NCLEX outcomes, an integrated model such as Joyce’s provides a stronger accreditation response than a narrow remediation plan because it demonstrates root-cause analysis, shared accountability, data-informed decision-making, and sustained monitoring.

The Joyce model is especially useful from an ACEN lens because it connects NCLEX outcomes to curriculum, faculty, students, policies, and assessment quality. This creates a defensible narrative that the program is not merely reacting to pass-rate concerns but has implemented a structured, measurable, and continuously monitored improvement system.

Board of Nursing and Public Protection Implications

Boards of nursing are concerned not only with pass rates but also with public protection and the readiness of graduates to enter practice safely. A model that strengthens assessment validity, clinical judgment development, remediation, and timely testing supports the public protection function of nursing regulation. The NGN emphasis on clinical judgment further reinforces the need for programs to align learning activities, simulation, clinical experiences, and assessments with entry-level decision-making demands.

Recommendations for Nursing Programs Seeking to Improve NCLEX-RN Outcomes

1. Conduct a Full-System Diagnostic Review

Programs should begin by examining the entire readiness ecosystem rather than assuming the problem is limited to students or a single course. The review should include admissions data, progression data, course outcomes, standardized assessment performance, faculty preparation, curriculum mapping, exam quality, remediation effectiveness, and time-to-test patterns.

2. Build a Multi-Indicator Readiness Model

Programs should avoid overreliance on a single predictor, exit exam, or course grade. A stronger readiness model includes course performance, CMS or specialty assessment performance, comprehensive predictor results, remediation completion, clinical judgment performance, faculty input, and student engagement data.

3. Establish Assessment Governance

Programs should implement standardized blueprinting, item-writing training, item review, exam analysis, and psychometric review. Assessment quality should be monitored as a program-level quality indicator rather than left solely to individual faculty preference.

4. Align Curriculum to NGN Clinical Judgment Expectations

Programs should map curriculum to the NCLEX test plan, NCJMM cognitive operations, AACN Essentials competencies, and program outcomes. Clinical judgment should be developed progressively through didactic learning, unfolding case studies, simulation, lab, clinical, and debriefing.

5. Implement Early Alert Dashboards

Programs should identify risk before course failure or graduation. Dashboards should include academic performance, standardized assessment scores, attendance, progression history, remediation completion, and engagement with support services.

6. Standardize Remediation

Remediation should be structured, individualized, documented, and connected to missed content and clinical judgment deficits. Students should receive clear expectations, targeted resources, faculty follow-up, and accountability checkpoints.

7. Strengthen Faculty Capability

Faculty development should include NCLEX test plan updates, NGN item-writing, clinical judgment pedagogy, exam analysis, remediation coaching, and competency-based education principles. Faculty data should be used to guide support, not merely evaluation.

8. Review Policies for Validity and Equity

Programs should evaluate whether grading, progression, dismissal, transfer credit, re-entry, and standardized testing policies are evidence-informed and consistently implemented. Policies should protect academic standards while avoiding unnecessary barriers that are not predictive of licensure success.

9. Reduce Time-to-Test

Programs should examine operational delays between graduation and NCLEX testing. Transcript processing, ATT support, testing fee barriers, advising, and scheduling assistance should be reviewed and improved.

10. Create a Continuous Improvement Rhythm

NCLEX performance should be reviewed continuously through formal governance structures. Programs should establish monthly and quarterly NCLEX readiness reviews, annual curriculum variance reviews, post-exam assessment reviews, and regular reporting to academic leadership. Annual program reviews are not enough.

Discussion

The 51cg model demonstrates that NCLEX improvement is most defensible when it is framed as academic quality improvement rather than test preparation alone. This distinction matters. Programs that focus only on test preparation may improve short-term performance while leaving deeper curricular, assessment, and faculty issues unresolved. In contrast, programs that build integrated readiness ecosystems can improve NCLEX outcomes while strengthening overall educational quality.

The model also supports equity. Overreliance on a single high-stakes gate can disproportionately harm students when the gate is not sufficiently valid, when remediation is inconsistent, or when operational barriers delay testing. A multi-indicator model allows programs to maintain rigor while ensuring that readiness decisions are based on a fuller body of evidence.

Finally, the model supports accreditation defensibility. Accreditors expect programs to analyze outcomes, identify variances, implement improvements, and evaluate effectiveness. The Joyce ecosystem provides a structure for demonstrating that NCLEX outcomes are actively managed through a formal quality system.

Conclusion

NCLEX-RN outcomes are not isolated student outcomes; they are institutional outcomes produced by curriculum, assessment, faculty, policy, student support, and operational systems. 51cg’s Comprehensive NCLEX Readiness Model offers a practical and evidence-informed example of how nursing programs can improve first-time pass rates through intentional design, predictive analytics, early intervention, assessment governance, faculty development, policy alignment, and continuous feedback loops.

We have had early, clear, and measurable NCLEX_RN pass rate success with initial implementation. We will continue to test and refine this model over the next two years. Programs seeking to improve NCLEX-RN outcomes should move beyond reactive remediation and adopt integrated readiness ecosystems that work for their unique system and student demographics. Such systems are better aligned with the Next Generation NCLEX, competency-based education, accreditation expectations, and the public protection mission of nursing education.

References

American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. Author.
Assessment Technologies Institute. (2020). Technical manual for the RN Comprehensive Predictor 2019. Assessment Technologies Institute.
Breckenridge, D. M., Wolf, Z. R., & Roszkowski, M. J. (2012). Risk assessment profile and strategies for success instrument: Determining prelicensure nursing students’ risk for academic success. Journal of Nursing Education, 51(3), 160–166.
Commission on Collegiate Nursing Education. (2024). Standards for accreditation of baccalaureate and graduate nursing programs. American Association of Colleges of Nursing.
Cummings, J. A. F., Kennard, D., Egan, J., Aryal, S., & McVey, C. (2024). An exploratory study: Indicators of NCLEX-RN success. Teaching and Learning in Nursing.
Giddens, J. F. (2022). The revised AACN Essentials: Implications for nursing regulation. Journal of Nursing Regulation, 13(1), 53–56.
House, S. K., Hubbard, J., & Bacus, R. (2021). Adapting NCLEX-RN remediation during the COVID-19 pandemic. Teaching and Learning in Nursing, 17(1), 74–78.
Lewis, L. S., Willard, V., & Staudt, C. (2023). Effect of a commercial NCLEX-RN preparation product on first-time pass rates. Nursing Reports, 13(3), 1141–1150.
Meehan, C. D., & Barker, N. (2021). Remediation for NCLEX-RN success in high-risk nursing students. Teaching and Learning in Nursing, 16(3), 254–257.
National Council of State Boards of Nursing. (2023a). Next Generation NCLEX.
National Council of State Boards of Nursing. (2023b). Clinical Judgment Measurement Model.
National Council of State Boards of Nursing. (2026). NCLEX pass rates.

Appendix A

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In a 2025 survey of 1,000 registered nurses across the United States, we heard firsthand how emotional exhaustion, skipped breaks, and sleepless nights continue to shape their professional lives.

Nearly three in four nurses surveyed (74%) say they feel emotionally drained from work multiple times each week, underscoring a growing concern that extends beyond long shifts and heavy workloads. 

This growing wave of burnout is more than a workforce challenge. It’s a call to action to care for the caregivers who keep the healthcare system running.

Key Survey Findings:

• 74% of nurses have felt emotionally exhausted from work multiple times a week in the past month. 
• Among early-career nurses, 28% of Gen Z nurses have felt burnt out from work every day over the past month. 
• 55% of nurses skip breaks or meals on most shifts or more because they’re too busy.
• Among Gen Z nurses who represent the newest entrants to the workforce, 25% reported having access to employer-provided mental-health resources but choosing not to use them because of confidentiality or career-impact concerns. 
• 47% of nurses have trouble sleeping due to work-related stress most or all nights. 
• 40% of women nurses are uncomfortable discussing burnout or mental health concerns with their direct supervisor, compared to 26% of male nurses.
• 53% of nurses have seriously considered leaving the nursing profession monthly or more in the past 6 months. 
• 49% of nurses have been worried, once a week or more, that they might make a medication error or other mistake due to fatigue or being overwhelmed.
• 49.5% of nurses have felt unsafe due to verbal or physical aggression from a patient or a patient’s family member in the past year.
• 74% of nurses have worked mandatory overtime 3 or more times in the past month.

Nearly 3 in 4 Nurses Surveyed Feel Emotionally Exhausted Each Week

In our 2025 survey, 74% of nurses say they have felt emotionally drained from work multiple times a week in the past month, reflecting a high level of self-reported strain among participants and echoing within the nursing workforce.

This strain comes as hospitals across the country face a historic staffing shortage. Federal projections show the United States will be , leaving current staff to shoulder heavier patient loads and longer shifts. 

Despite these conditions, nurses continue to serve on the frontlines of care, driven by their commitment to their patients and communities.

Young Nurses Are Reportedly Burning Out Faster Than Older Cohorts

Survey data suggest that younger nurses may be experiencing higher levels of daily emotional strain. A national published by the American Nurses Association examining generational differences in burnout and turnover risk found that early-career nurses consistently report higher levels of stress, fatigue, and intent to leave, particularly during periods of heightened workforce strain.

Our survey reflects a similar pattern. While not nationally representative, Gen Z respondents reported the highest rate of daily emotional exhaustion (28%), compared with 25% of Millennials, 22% of Baby Boomers, and 17% of Gen X respondents. Together, these findings align with broader research indicating that younger and early-career nurses may face elevated burnout and turnover risk relative to older cohorts.

With an as older nurses retire, new graduates are entering a field already under significant pressure. This underscores the importance of supporting nurses early in their careers through mentorship, manageable workloads, and environments that encourage open conversations about well-being.

The Hidden Stigma: Fear Keeps Young Nurses From Seeking Help

suggest that even when mental-health resources exist for nurses, utilization may remain low, and stigma (such as concerns about confidentiality or career impact) continues to be a barrier among many in the workforce. 

This pattern also appeared in our findings, particularly regarding new nurses entering the field: one in four Gen Z respondents (25%) with access to employer-provided mental health support said they chose not to use it due to these same concerns.  

This reluctance comes at a time when hospitals are placing greater emphasis on retention, resilience, and workplace well-being. National workforce studies have found that stress and burnout continue to influence nurses’ decisions to leave the profession. In the , 41.3% of RNs who plan to leave or retire within five years cited stress and burnout as a contributing factor, second only to retirement itself. Workload and understaffing were also cited frequently, underscoring the ongoing impact of workplace pressures on long-term career decisions.

Together, these findings highlight that emotional strain is only part of what nurses are navigating; many also face barriers to accessing the support intended to help them cope. Reducing stigma, strengthening confidentiality protections, and promoting psychological safety are essential steps in creating environments where nurses can seek help without hesitation. As the broader workforce continues to face high demands, addressing these cultural and structural barriers is critical to supporting long-term well-being and retention of nurses.

Skipped Meals, Skipped Breaks: Daily Survival Over Self-Care

Physical strain is also a significant part of a nurse’s day-to-day routine. More than half of the nurses surveyed (55%) say they regularly skip meals or breaks on most shifts because they are too busy. For many respondents, basic needs are set aside to keep pace with workload demands, leaving little time for rest, recovery, or self-care routines.

These findings occur against the backdrop of ongoing staffing shortages that continue to stretch healthcare systems across the country. In states facing some of the such as California, Georgia, and Washington, reports of heavy patient ratios and high workloads are common, making consistent breaks difficult to sustain.

While many nurses continue to show remarkable endurance and compassion for those in their care, they are likely to still face burnout if appropriate measures aren’t taken to create a more sustainable work environment.

The Systemic Roots of a Workforce Crisis 

The forces shaping today’s nursing shortage extend beyond long hours and emotional fatigue. National experts point to several structural barriers that limit the number of new nurses entering the field each year. 

Educational capacity remains a major bottleneck. In 2023, U.S. nursing schools turned away 65,766 qualified applications to baccalaureate and graduate programs, largely due to shortages of faculty, clinical placements, classroom space, and other resource constraints, according to the . 

At the same time, the , increasing retirements among experienced nurses and the lasting impacts of the COVID-19 pandemic. Together, these pressures have narrowed the pipeline of new graduates at a moment when the healthcare system needs them most.

Addressing these systemic factors requires long-term investment in educational capacity, faculty development, and clinical training opportunities. Institutions across the country are beginning to respond by expanding access to high-quality nursing education, developing flexible pathways into the profession, and building clinical partnerships that bring training closer to where students live. 

Hybrid learning models and innovative simulation technologies are helping widen the pipeline for future nurses while preserving rigorous, hands-on skill development. These efforts by emerging universities, represent an important step toward strengthening the workforce and supporting the profession’s long-term stability.

Sleepless Nights: Work Stress Follows Nurses Home

For many nurses, the stress does not end when the shift does. Nearly half of survey respondents (47%) say they struggle to sleep most or all nights because of work-related anxiety.

Additionally, 49% of respondents also say they worry weekly that exhaustion could lead them to make a medication error or another grave mistake. The fear of harming a patient because of fatigue adds another layer of emotional strain, creating a feedback loop that endangers both caregivers and those they serve.

As national shortages deepen, this risk may increase. Fewer nurses on duty mean higher patient loads and thinner margins for safety, a reality that places both staff and patients in jeopardy.

Chronic sleep disruption is one of the most consistent predictors of fatigue-related errors, emotional exhaustion, and long-term attrition in nursing. Research shows that tired nurses are or miss care tasks and that nurse fatigue and reduced alertness are . 

Shifting the conversation from individual stamina to systemic safeguards such as fatigue-risk management, optimized scheduling, workload controls, protected rest periods, and institutional support, acknowledges that sleep and alertness are core safety issues for both nurses and patients.

Staffing pressures can exacerbate fatigue, as fewer staff leads to longer shifts and greater pressure. Creating workplace environments that prioritize rest and mental wellness is essential to breaking this cycle.

From Burnout to Bedside: Nearly Half of Nurses Fear Fatigue Puts Patients at Risk

Burnout affects not only nurses but also the quality and safety of patient care. from the Agency for Healthcare Research and Quality (AHRQ) shows that hospitals with adequate nurse staffing and manageable patient ratios experience lower mortality, fewer adverse events, and shorter lengths of stay. When staffing levels become strained, whether due to vacancies, high turnover, or persistent fatigue, evidence shows that patient outcomes can suffer. The effects of burnout reach far beyond the workforce. 

These findings underscore that supporting the well-being of nurses is also essential to maintaining patient safety. Ensuring that teams are adequately staffed, especially as demand for qualified nurses continues to rise, helps alleviate many of the stressors nurses experience, from heavier patient loads to reduced recovery time between shifts. 

Expanding pathways into the profession can further strengthen staffing by ensuring that aspiring nurses have access to the high-quality education and training needed to enter the workforce. Reducing barriers to education not only supports a more stable, well-prepared nursing workforce but also reinforces the safe, reliable care that patients depend on. Supporting staff well-being is not only a matter of workforce stability but of patient safety. Healthy nurses make healthier communities, and when the profession thrives, patients receive safer, more consistent care.

Violence at Work: A Growing Threat

Violence toward healthcare workers remains a persistent and troubling reality in many care settings. Nearly half of nurses surveyed (49.5%) reported that they have felt unsafe in the past year because of verbal or physical aggression from patients or their families. Encounters like these can heighten stress, erode morale, and compound the fatigue nurses are already navigating. Facing workplace hostility adds another layer of strain to an already overburdened profession.

National safety organizations have long identified , and health systems across the country are responding with measures such as de-escalation training, clearer reporting pathways, enhanced security protocols, and zero-tolerance policies. This reflects a growing recognition that protecting nurses from harm is essential for a sustainable workforce.

Mandatory Overtime and Intensifying Pressure

Roughly three out of four nurses surveyed (74%) report working mandatory overtime three or more times in the past month. Such demands can magnify existing strain: fewer nurses on shift mean heavier workloads, longer hours, and rising fatigue. As some nurses leave due to exhaustion, the burden intensifies for those who remain. 

published in the International Journal of Public Health (2024) confirms that high rates of mandatory overtime and extended scheduling contribute to job dissatisfaction and a greater intent to leave.  

With staffing shortfalls deepening, many in the field are calling for serious reforms and stronger recognition of nurses’ role in keeping the health system afloat. has raised concerns that a proposed federal change to how nursing degrees are classified for financial aid eligibility could affect access to advanced training, underscoring the importance of expanding educational pathways into the profession. 

A Profession Worth Protecting

Across this survey, respondents reported experiencing multiple factors commonly associated with burnout, including emotional exhaustion, fatigue, staffing pressure, and safety concerns. While this survey represents a non-representative sample, the patterns observed reflect challenges widely documented in national research on the nursing workforce. Together, these findings suggest that aspects of nurse well-being, safety, and workforce sustainability may be under strain, reinforcing the importance of continued attention to how nurses are supported within the healthcare system. 

Many states, health systems, and educational institutions are beginning to respond to mounting workforce pressures by expanding capacity, strengthening training opportunities, and piloting initiatives that support nurse well-being and retention.  

51cg has taken steps aligned with these priorities, including regional expansion to broaden access to accredited nursing programs, flexible hybrid learning models that blend online coursework with hands-on training, and partnerships with clinical sites across the U.S. to bring education closer to where nurses live and work. Together, these efforts contribute to strengthening the nursing pipeline at a time when staffing shortages are placing increased strain on nurses already in the field.

Methodology

To understand the state of nurse burnout in 2025, 51cg commissioned a survey of 1,000 nurses across the United States. Participants answered questions about their emotional well-being, workloads, mental-health resources, and workplace experiences. Responses were analyzed by demographic group to identify patterns in stress, burnout, and professional satisfaction.

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