The nursing shortage in the United States (US) is not a new problem; and the COVID 19 pandemic exacerbated the situation. The cause of the shortage is multifaceted including the aging baby boomer nurses retiring, the number of new graduates that leave nursing after the first year, the COVID 19 pandemic that resulted in many experienced nurses leaving the profession, and the faculty nursing shortage that limits the number of qualified applicants accepted to nursing programs (Baker, 2022). In order to ameliorate some of these issues, academic institutions must be innovative in their approach to nursing education. One such approach is to create educational pathways to Registered Nursing (RN). The City University of New York is a large, urban university system in New York City (NYC) that has 11 senior colleges and seven community colleges. The LaGuardia Community College, one of the seven community colleges within the City University of New York system, developed the first and only to-date, Paramedic to RN Pathway (Associate in Applied Science-AAS) within their Nursing Programs across the 18 campuses’. This initiative is two-fold; to increase the number of students qualified to take the National Council Licensure Examination (NCLEX-RN) and to create a career pathway for Paramedics to Registered Nursing.

The decision to choose the RN career pathway can provide numerous benefits to both the community and the Paramedic themselves. The Paramedics at this urban community college reside in the communities that they serve. These communities often represent underserved populations, in which groups have limited access to resources or services. The Paramedic to RN career pathway can positively impact the individual’s socioeconomic standing, marked by an increase in salary and numerous opportunities for career advancement. The following statistics offered by the US Bureau of Labor and Statistics indicate that Paramedics would benefit significantly by upscaling their education and completing a Registered Nursing degree. The salary of Registered Nurses is significantly higher than that of a paramedic. The median annual wage for paramedics was $53,180 in May 2023. The median annual wage for registered nurses was $86,070 in May 2023 (US Bureau of Labor Statistics, 2024). Job openings for Registered Nurses will continue to be greater over the next decade (US Bureau of Labor Statistics, 2024).

Career pathways that are implemented for professional advancement, addressing societal challenges, and upscaling a profession are not unique to nursing. However, in the current healthcare climate it is important for academic institutions and health care facilities to utilize prior learning and clinical experience to facilitate the upscaling of academic degrees and licensure. The need to increase the percentage of highly qualified nurses is a priority (Nasser, 2024). A major core of the tailored career pathway is collaboration with universities, government entities, hospitals, and departments of education (New York State Board of Health, Career Pathways Training (CPT) Program, 2025).

There is a paucity in the literature regarding career pathways of Paramedics to Registered Nursing. It is unclear why the literature does not reflect this advantageous Pathway. Although career pathways are not limited to nursing, nursing has capitalized on the Pathway model. Examples include Certified Nursing Assistant (CNA) to Licensed Practical Nurse (LPN), LPN to RN, Medical Assistant (MA) to RN, and most recently, Behavioral Health Associate to LPN have facilitated the up-scaling of academic degrees and licensure to assist individuals with professional advancement. The authors also believe the literature may be sparse due to this nontraditional, pathway to Registered Nursing. Historically, most educational pathways have been within the profession. Although, Paramedic to RN pathways do exist, in the New York City (NYC) area, they are offered at for-profit colleges and universities. The Pathway implemented at, the City University of New York system provides affordable public education for underserved and disenfranchised students. The cost of the Paramedic to RN Pathway at the LaGuardia Community College is a fraction of the cost at for-profit colleges and universities offering the same degree program. A Paramedic to RN career pathway contributes to a robust and efficient healthcare system, while addressing societal challenges.

It is well-known that community colleges are in a unique position to add diversity to the workforce, as it pertains to ethnicity due to their demographics and student population. According to the American Nurses’ Association diversity in the nursing workforce provides numerous benefits for both the nursing team and patient outcomes. Nurses can learn from each other’s diverse perspectives while strengthening the quality of patient care (American Nurses' Association, 2023). The Registered Nursing profession continues to lack diversity in its workforce. The following ethnicities make up the Registered Nursing workforce in New York State (NYS): Latino or Hispanic 8%, Black African Americans 13% American Indian and Alaska Native 0.2%, Asian 14%, Non-Hispanic or Latino race 54%, Unknown 11% (Center for Health Workforce Studies, 2024). In addition to a lack of diversity in ethnicity, nursing also lacks diversity in gender. Only 13% of nurses are male (US Bureau of Labor Statistics, 2024). Paramedics have a more diverse workforce: Latino or Hispanic 27%, Black African Americans 21% American Indian and Alaska Native 0.29%, Asian 5%, Non-Hispanic or Latino race 41%. However, Paramedics are primarily males (75%) (New York City Council, 2022). A pathway program from Paramedic to Registered Nurse in this urban community college contributes to increasing diversity in the nursing program and ultimately the nursing workforce.

Paramedics are in a unique position to transition to Registered Nursing. Although their practice is fundamentally prescriptive, they have some of the basic skills and theoretical education that would facilitate their move to Registered Nurse. The use of evidence-based guidelines and protocols can help to improve the quality of care provided in the prehospital environment, reduce the risk of adverse events, and improve patient outcomes (Cimino & Braun, 2023). Depending on the academic background of their Paramedic license (certification vs AAS degree), Paramedics may have some of the educational prerequisites required for an AAS in Nursing. The implementation of a Paramedic to RN Pathway relies on recruitment of eligible candidates, high-quality advisement and the development of a preparatory course that would increase student success.

Paramedics are the most skilled emergency responders. The working environment in pre-hospital emergency care is fast paced, physically dangerous and highly stressful, requiring quick decision-making and action. (Bitan et al., 2019). In the context of a knowledge, skills, and attitudes framework, through educational and training activities, a person can acquire new knowledge, develop new skills, or form a new attitude. The attainment of knowledge and the acquisition of skills are the most observable and the easiest to measure. However, attitudes are the most difficult for people to develop or change, and the hardest to measure (The Peak Performance Center, 2025). The Paramedics may possess some of the knowledge, and many of the skills required for Registered Nursing, however, the attitudes regarding autonomous clinical decision-making surrounding patient care require some adjustment. Paramedics education includes the use of algorithms to provide care in emergency situations. In the United States, the National Emergency Medical Services Information System has been developed, where both physicians and paramedics act as advanced providers of emergency medical care. Paramedics primarily deliver vital information about a patient's condition/symptoms to physicians in the Emergency Room (ER) of a hospital and wait for instructions for delivering care (Kim et al., 2020).

Nursing practice is among the most diverse and interesting of all of the healthcare professions because of the variety of different capacities and environments where nurses practice (Armstrong et al., 2025). In general, Nursing can be divided into three basic workplace environments: in-patient care, out-patient care and alternative care. In-patient care is given in a healthcare environment, such as a hospital or long-term care facility. Some examples of nurses who practice in out-patient care areas are nurses who are employed by home care agencies, clinics, out-patient rehabilitation facilities and doctor’s offices. Alternative care practice areas include, but are not limited to military nursing, travel nursing and school nursing.

Nursing care can vary significantly from pre-hospital care. All nurses use the Nursing Process to assess, diagnose, plan, implement and evaluate care. The Nursing Process is “defined as a systematic approach to care using the fundamental principles of critical thinking, patient-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care” (Toney-Butler & Thayer, 2023). Attitude change can be an important starting point for behavior change. If successful, such change may be consolidated and become enduring by turning the newly formed behavior into a habit (Verplanken & Orbell, 2022). Nursing faculty need to use the Nursing Process and promote behaviors and attitudes of the Registered Nurse that result in the Paramedic student adopting a shift from algorithm-based emergency care to the use of the Nursing Process for patient care.

The implementation of a Paramedic to RN curriculum at the LaGuardia Community College is the first of its kind for the City University of New York system. Utilizing a pathway model, Paramedics have the opportunity to earn an AAS in Registered Nursing by applying for this Advanced Standing Pathway. The design of this model is congruent with the LPN to RN Advanced Standing Pathway. Students with a background in healthcare utilize academic knowledge, existing skillset and experiential learning to convert their present degree to an AAS in Registered Nursing. The LPN to RN Advanced Standing Pathway has existed at the LaGuardia Community College since 2007 and has graduated approximately 500 students.

Students interested in this program meet with a qualified academic advisor to review previous transcripts (if applicable), assist students with course selection and reinforce course sequencing to avoid unnecessary course work. Although all nursing students are assigned a Nursing faculty advisor, all of the Paramedic Pathway students are advised by the Director of the Paramedic Pathway. The Paramedic Director is an Academic Manager who provides consistent advisement with the ability to substitute higher level courses for pre-requisite requirements. Students are eligible to apply for the Pathway if they are licensed Paramedics in New York State (EMT-P certification), have completed the prerequisite/pre-clinical general education courses and have met the benchmark “proficient” ATI Testing-Test of Essential Academic Skills (TEAS) exam score in all 4 categories (Math, Science, Reading, English). Prerequisite/pre-clinical general education courses include Anatomy and Physiology I & II, Chemistry, Microbiology, English, Statistics and Psychology (See Table 1). It is important to note that there are time limits on the science courses: Anatomy and Physiology-I & II (seven years) and Chemistry and Microbiology (10 years). Key courses, identified by an asterisk, (*) are those courses that must be completed before applying for candidacy into the Paramedic to RN Pathway. Key courses are used to calculate the students ranking. To qualify for candidacy students must earn a minimum of 2.75 Grade Point Average (GPA) in the four key pre-clinical courses. A GPA of 2.75 does not guarantee entrance into the nursing program as seats are competitive and limited. Thus, entrance into the nursing program is determined by a rank order scoring system utilizing the four key courses and available seats.

The LaGuardia Community College nursing programs (generic RN, Licensed Practical Nurse (LPN) to RN and Paramedic to RN Advanced Standing Pathways) are registered with the New York State Education Department (NYSED) and accredited by the Accreditation Commission for Education in Nursing (ACEN). The course selection for the Paramedic to RN Pathway is congruent with the already existing registered and accredited LPN to RN Advanced Standing Pathway. The Paramedic to RN Pathway curriculum (with credits and course/clinical hours), Syllabus for Introduction to Nursing for Paramedics and Nursing Student Handbook was submitted to The City University of New York Board of Trustees and then to NYSED for approval. Once approval was received from NYSED, students were encouraged to apply for candidacy.

Upon acceptance to the Pathway, the student is eligible to register for Introduction to Nursing for Paramedics. This nonclinical course is a truncated version of Fundamentals of Nursing and introduces the student to the roles and responsibilities of the Registered Nurse. The Introduction to Nursing for Paramedics is a two credit, four-hour class that incorporates one hour of lecture (one credit) and three hours of lab (one credit), each week of a 12-week semester. The lecture introduces the topics of the Nursing Process, physical assessment, infection control and medication administration. The lab provides skill-based education including handwashing, morning care, vital signs, use of personal protective equipment (PPE) and bladder and bowel elimination. Pathway students are exempt from the traditional Fundamentals of Nursing (six credits) and receive four credits-for-prior-learning (CPL) for their field experience as a Paramedic. After earning a grade of C or better in Introduction to Nursing for Paramedics, the student is eligible to register for the Bridge Course. The Bridge Course is the first course in the clinical phase of the Paramedic to RN Advanced Standing Pathway that leads to an Associate of Applied Science (AAS) degree in Registered Nursing.

The Bridge Course includes topics in Medical Surgical Nursing I and Pharmacology. This course has a cohort of both LPN and Paramedics on a pathway to becoming a Registered Nurse. Upon successful completion of this course, the students join the generic students (students who enter the program through Fundamentals of Nursing). During the following two semesters, students take Parent-Child Nursing, Psychiatric Mental Health Nursing and Medical Surgical Nursing II. Upon successful completion of the clinical phase coursework, students graduate and are eligible to sit for the NCLEX-RN. See Table 2 for the clinical Pathway sequence.

A new cohort of Paramedic to RN students are accepted every semester (Fall/Spring). Once a student enters the clinical phase of the Paramedic to RN Pathway, completion time is three semesters. The pre-requisite courses, including Introduction to Nursing for Paramedics can be completed in two semesters. This time frame is the same for the LPN to RN Pathway students. However, although the generic program is registered with NYSED to be completed in five enhanced semesters (includes summer and winter sessions), 91% of the students in the generic RN program take longer to complete the program. Please note, the above timeframes are for students who progress through the program/pathway continuously and without issue. Pathway students, with allied healthcare experience, progress to degree faster than generic nursing students. This supports the initiative of increasing the number of graduates eligible to join the nursing workforce in NYC.

In Spring of 2024, a Paramedic to Registered Nursing Pathway was implemented at the LaGuardia Community college in NYC. In collaboration with the Paramedic Program Director, students were recruited from the Colleges’ Paramedic Program. High quality academic advisement of the interested students resulted in a class of six Paramedics registered for Introduction to Nursing for Paramedics. The course was taught by a Nursing faculty. Of the six students, four students passed the course and moved on to the first semester of the clinical phase of the RN Advanced Standing Pathway. The four students who entered the clinical phase of the RN Pathway passed the Bridge Course and have moved on to the second semester of the Pathway (Parent Child Nursing and Psychiatric Mental Health Nursing). Of the two students who did not pass, one student returned in Fall 2024 and passed the course on the second registration. The other student who did not pass the course initially, decided not to return to the program. In Fall 2024, a class of 10 students were registered for Introduction to Nursing for Paramedics. Of the 10 students registered, two students did not pass the course and plan to repeat the course in Spring 2025. Eight students moved on to the clinical phase of the RN Advanced Standing Pathway. In Spring 2025, 16 students are registered for Introduction to Nursing for Paramedics, including the two students repeating the class from Fall 2024. Despite the small number of students in the Pathway so far, the rate of students completing the Introduction to Nursing for Paramedics course (see Table 3), is similar or exceeds that of the generic students completing Fundamentals of Nursing course (see Table 3).

While this paper imparts a constructive understanding into the transition process of Paramedic student’s pathway to become a Registered Nurse, it is also necessary to identify several limitations that warrant further discussion. Although Paramedics and Registered Nurses may share in the capacity to stay calm and focused while providing emergency medical care in different health care settings, Paramedics may find adjusting their approach to patient-centered nursing practices challenging. Paramedics who were previously trained to respond rapidly with algorithms now require a broader, more comprehensive patient communication approach to their existing professional skillset. This therapeutic communication gap encompasses diverse areas such as, prolonged emotional bedside support, patient education, on-going preventive care, management of multiple patients, interprofessional collaboration and more detailed documentation adherence. Though this list of limitations may seem extensive it nonetheless needs to be thoughtfully considered and included when designing a pathway program to optimize successful outcomes for the Paramedic to Registered Nursing Student (Duffee & Willis, 2023; Mangan et al., 2022).

Although the statistics on the percentage of Paramedic to RN pathway students who work while attending school is limited, firsthand inquiries by nursing educators teaching the class, say that of all the students in the program admit to working full-time or part-time while attending school. Some pathway programs advertise their program stating that students can work while pursuing your nursing degree, others strongly advise against it due to its demanding and challenging time commitment (Gamboa, 2024; Karimi et al., 2024; Zheng, 2022). A discussion with the students who did not achieve a passing grade revealed that all the students were working full-time and had difficulty managing work-school-life balance. All four of the students that did not pass the course worked the nightshift and arrived at class after working all night. Presently, the Paramedic to RN Pathway Director is exploring offering the course in the evening to better accommodate the nightshift students.

After identifying the challenges with the program and to best assist the Paramedic student with the transition to Registered Nurse, several changes to the course content has been adapted. Enhancing communication skills through the addition of course content on active listening, empathy, and by increasing classroom role-playing scenarios and simulation activities have been valuable in building confidence and developing skills. Through the use of the College’s ePortfolio, weekly self-reflective journaling, has been implemented to support and enhance communication skills, allowing the students to verbalize their feelings and monitor their personal progress. Paramedic students have been encouraged to join the Nursing Club, to facilitate peer-support where experienced nurses, nursing faculty and upper-class generic nursing students interact with the Paramedics to help them feel more comfortable and confident in the transitional process to become a registered nurse.

In order to facilitate student success and assess the effectiveness and outcomes of the Paramedic to Registered Nurse Pathway, future research is necessary. Program completion data needs to be assessed on an ongoing basis and the causes of attrition should be monitored closely. Curricular changes and resources should be allocated to improve course completion and graduation rates. NCLEX-RN pass rates will be monitored, and the Paramedic cohort NCLEX results will be extrapolated from the aggregate, first-time pass rate data to evaluate the Paramedic to RN Pathway course and program outcome effectiveness. As with the generic RN program, a graduate survey (sent out electronically at 6 months post-graduation) will obtain information about graduate employment, types of employment and the students continued education, among other data points. The above information will be used to implement changes to program courses and design as appropriate.