To our knowledge, this study provides the first empirical evidence that hospitals’ employment of nurses with BSN and higher degrees is associated with improved patient outcomes. Our findings indicate that surgical patients cared for in hospitals in which higher proportions of direct-care RNs held bachelor’s degrees experienced a substantial survival advantage over those treated in hospitals in which fewer staff nurses had BSN or higher degrees. Similarly, surgical patients experiencing serious complications during hospitalization were significantly more likely to survive in hospitals with a higher proportion of nurses with baccalaureate education.
When the proportions of RNs with hospital diplomas and associate degrees as their highest educational credentials were examined separately, the particular type of educational credential for nurses with less than a bachelor’s degree was not a factor inpatient outcomes. Furthermore, mean years of experience did not independently predict mortality or failure to rescue, nor did it alter the association between educational background or of staffing and either patient outcome. These findings suggest that the conventional wisdom that nurses’ experience is more important than their educational preparation may be incorrect. The improved outcomes associated with higher levels of BSNs in a hospital was found to be independent of and additive to the associations of superior outcomes in hospitals with better nurse staffing we reported previously.2
Thus, both lower patient-to-nurse ratios and having a majority of RNs educated at the baccalaureate level appear to be jointly associated with substantially lower mortality and failure-to-rescue rates for patients undergoing common surgical procedures.
In our sample of 168 Pennsylvania hospitals in which the proportion of nurses with bachelor’s degrees and mean patient-to-nurse ratios varied widely, 2% (4535/232 342) of the surgical patients undergoing the procedures we studied died within 30 days of hospital admission. Our results imply that had the proportion of nurses with BSN or higher degrees been 60% and had the patient-to-nurse ratio been 4:1, possibly 3810 of these patients (725 fewer) might have died, and had the proportion of baccalaureate nurses been 20% and had staffing uniformly been at 8:1 patient-to-nurse ratios, 5530 (995 more) might have died. While this difference of more than 1700 deaths across 2 educational and staffing scenarios is approximate, it represents a conservative estimate of preventable deaths potentially attributable to nurses’ education and RN staffing levels because our patient sample represents only about half of all surgical cases in the study hospitals.
One limitation of our analysis is the potential for response bias in the education and staffing measures derived from the nurse survey, given a 52% response rate. However, examining the Pennsylvania respondents in the probability-based National Sample Survey of Registered Nurses conducted in 2000,21
we found no evidence of overall differences between our sample and Pennsylvania hospital staff nurses at large in terms of job satisfaction or demographic characteristics, including education.
A second limitation relates to study design. Longitudinal datasets, preferably including hospitals from more than 1 state, will be essential for establishing the generalizability of these findings as well as establishing whether and how levels of baccalaureate-prepared nurses and nurse staffing in a hospital are causally related to patient outcomes. Also, as in any research drawing on administrative patient outcomes data, there is a potential for differences in completeness and consistency of diagnostic coding across hospitals to influence risk adjustment.29
A number of checks on the validity of these findings were completed. Allowing nurse education to have a nonlinear effect and testing whether the effect of education varied across levels of educational composition using quadratic and dummy variables did not significantly improve model fit, suggesting that incremental increases in more educated nurses in a hospital were associated with progressively better outcomes. Including the small proportion of nurses who checked “other” as their highest degree with nurses in the baccalaureate or higher category or in the associate degree or diploma category rather than omitting them from calculations yielded no change in the estimated associations between education and patient outcomes. In an attempt to determine whether unobserved variables that distinguished patients treated in hospitals with different levels of nurse education, we computed propensity scores30
representing the likelihood that patients with various characteristics were treated in hospitals with high and low levels of baccalaureate nurses. These scores were not a significant predictor of mortality or of failure to rescue, nor did they significantly alter our estimates of the association between education and outcomes.
Research suggests that nurse executives in university teaching hospitals prefer a nurse workforce with approximately 70% prepared at the baccalaureate level and estimate that current levels average 51%. Also, community hospital nurse executives prefer to have 55% of their RNs educated at the baccalaureate level.31
Data are not currently available to estimate the proportion of hospitals nationally that have 50% or more of their RN workforces prepared at the BSN level or higher, but since only 11% of Pennsylvania hospitals met this standard in our sample there appears to be a wide gap between the preferences of hospital executives and current staffing patterns.
Only 43% of all hospital staff nurses nationally in 2000 were prepared at the BSN level or higher. Enrollments in baccalaureate nursing programs declined by almost 10% from 1995 to 2000, although the past few years have seen an upturn.21, 32
The return of diploma- and associate degree prepared RNs to colleges and universities after their initial preparation has been an important source of baccalaureate-prepared nurses. About 22%of currently employed hospital RNs with BSN or higher degrees received them after their basic educations.21
However, the proportion of hospital nurses pursuing further studies declined from 14%in 1984 to 9% in 2000, as did the proportion of hospital nurses who received tuition assistance from their employers (from 66%in 1992 to 53% in 2000).21, 33
Meeting the demand for baccalaureate-prepared hospital nurses requires renewed support and incentives by employers to encourage nurses to pursue education to the level of baccalaureate and beyond.
In the current nurse shortage, as in previous ones, public policy discussion has centered on how to increase the supply of RNs. However, little attention has been paid to considering where investments in public funds in the 2 major educational pathways into nursing practice–associate or bachelor’s degree programs–will best serve the public good and the interests of employers. Nursing education policy reports published in the past decade concluded that the United States has an imbalance in the educational preparation of its nurse workforce with too few RNs with BSN and higher degrees.34–36
Our findings provide sobering evidence that this imbalance may be harming patients.
Our documentation of significantly better patient outcomes in hospitals with more highly educated RNs at the bedside underscores the importance of placing greater emphasis in national nurse workforce planning on policies to alter the educational composition of the future nurse workforce toward a greater proportion with baccalaureate or higher education as well as ensuring the adequacy of the overall supply. Public financing of nursing education should aim at shaping a workforce best prepared to meet the needs of the population. Finally, our results suggest that employers’ efforts to recruit and retain baccalaureate-prepared nurses in bedside care and their investments in further education for nurses may lead to substantial improvements in quality of care.