Aiken Study Supports Pro-BSN Stance
By Lisette Hilton
A new study makes it official: A more educated hospital nursing workforce is associated with better patient outcomes, according to research by Linda H. Aiken, RN, PhD, FAAN, and colleagues, published in the September 24, 2003, Journal of the American Medical Association (JAMA). And its in the interest of the public and employers to invest more in enabling nurses to achieve a higher level of education consistent with trends for other health professionals.
Study author Robyn Cheung, RN, PhD, a postdoctoral research fellow at the Center for Health Outcomes and Policy Research in the School of Nursing, University of Pennsylvania, Philadelphia, PA, says that this study was a logical step to an Aiken study published in 2002 in JAMA that showed that lower nurse-patient ratios led to higher mortality and failure-to-rescue rates in hospitals.
Aiken is Claire M. Fagin Leadership Professor of Nursing and professor of sociology and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania. She and colleagues did a cross-sectional analysis of outcomes data for 232,342 general, orthopedic, and vascular surgery patients. The patients were discharged from 168 nonfederal adult general Pennsylvania hospitals between April 1, 1998, and November 30, 1999. Researchers looked at risk-adjusted mortality rates, hospital mortality rates, and failure-to-rescue rates.
The researchers found that for every 10% increase in the proportion of nurses prepared at the BSN or MSN level, the odds of dying or experiencing failure to rescue decreased by 5%. Cheung says these are hospital level rates for nurses reporting that they were giving bedside care. The study did not include administrators, managers, clinical nurses specialists, or others. Another way to look at the results, according to Cheung, is that in a hospital where the proportion of BSN or higher nurses is 60% compared with one where it is 20%, there would be 14 fewer deaths from complications per 1,000 surgical patients.
The authors reported that experience was not a factor in computing the odds of dying or experiencing failure to rescue; they noted that the effect of education on the odds of dying is independent of experience. They also found that combining findings from the two studies leads to a more powerful result. In other words, hospitals that have higher nurse-to-patient ratios plus greater levels of nurses with BSNs or higher degrees are in the best position to provide high-quality care for their patients.
Says Cheung, We believe strongly that hospitals need to invest more in their nursing workforces and need to provide encouragement incentives financial and otherwise so that nurses with diplomas or associate degrees who want to return to school can.
According to Aiken, solutions lie in making advanced education possible for nurses and in creating work environments that facilitate a high level of professional practice.
Data suggests that baccalaureate programs throughout the country are turning away qualified applicants because of capacity limitations, says Aiken, adding that RNs seeking advanced education and prospective nurses seeking a BSN face big financial barriers.
Assistance from federal and state governments and employers is warranted to achieve a more highly educated workforce, she says. Community colleges are important to accessible and affordable education for nurses and others. Better models of integrating community college and baccalaureate nursing programs in four-year colleges and universities into a seamless and efficient trajectory of nursing education are needed. Nurses work environments, particularly in hospitals, are poor and undermine nurses best intentions to provide care of high quality.
The take-away message from the study, Aiken adds, is that it provides more evidence that nurses make a difference in patient outcomes. The findings can be used by nurses to gain better working conditions, more favorable patient-to-nurse ratios, and greater support for career mobility and advancement, she says This study is positive for all nurses of all educational backgrounds.
Sharon L. Bernier, RN, PhD, director of the nursing program at Montgomery College, Takoma Park, MD, isnt convinced of the impact of the findings. Bernier, who is also president of the National Organization for Associate Degree Nurses, says that the study compared associate degree and diploma nurses to BSN and higher degreed nurses. A fairer representation, she says, would have compared the two lesser degrees with BSN nurses only.
But in a statement responding to that charge, the American Association of Colleges of Nursing (AACN) notes that proportions of RNs with different levels of education were analyzed separately associate degree, diploma, baccalaureate, and baccalaureate plus masters degrees. The particular type of educational credential for nurses without baccalaureate degrees was not a factor in patient outcomes, and thus, the findings were reported in aggregated form. The average proportion of staff nurses with baccalaureate plus masters degrees was very small, only 1.7% of staff nurses. The effect of baccalaureate education with and without nurses with masters preparation was examined, and there were no differences in the results, providing no rationale for excluding some staff nurses with baccalaureate degrees from the study. The few masters-prepared staff nurses do not account for the baccalaureate education effect.
Bernier, a diploma graduate who went on to get her bachelors, masters, and doctoral degrees, has taught at baccalaureate and postgraduate educational levels for about 18 years. She says that she believes associate degree nurses are as prepared and capable as nurses with BSNs. That isnt to say that I dont think there is something to be gained by continuing education, says Bernier. But at the point of entering into the practice and talking only about basic nursing education, I believe that theyre prepared at the same level.
The added pressure for higher education during a nursing shortage might have a negative effect, says Bernier. Associate degree nursing programs [represent] 60% of all the registered nurses every year. If we didnt have them, wed be in dire straits.
Geraldine Bednash, RN, PhD, FAAN, executive director of the American Association of Colleges of Nursing, Washington, DC, says the findings should come as no surprise. The study says nothing about the value of either provider, Bednash claims. It just validates that education does make a difference in the skills.
This sort of thing is obvious to her nonnurse colleagues who wonder why nursing has had to prove it in studies, says Bednash, adding that to question Aiken or JAMA on the quality of the study is ridiculous.
Bednashs message to associate degree and diploma RNs? The study reinforces the importance of more education. Associate degree and diploma nurses, she says, are an important part of the health delivery system but this validates that going on and getting the additional education helps you become a better nurse and helps you have a bigger impact on patient care.
Aiken and colleagues continue to study how the features of nurses practice environments affect outcomes. Were undertaking these studies in the US and in other countries to determine whether the problems in hospital nursing are generic in that they are seen in differently organized and financed healthcare systems, she says. If so, we could implement similar solutions to begin to solve global nursing shortages.
Lisette Hilton is a freelance healthcare reporter.