Investing in Nurse Education: Is there a Business Case for Health Care Employers?

Transcription

1 Investing in Nurse Education: Is there a Business Case for Health Care Employers? Patricia Pittman, Katie Horton, Alex Keeton, and Carolina Herrera The George Washington University RWJF Grant April 11, 2012

2 TABLE OF CONTENTS 1. Overview The Human Capital Perspective Nurse Education and Retention Retention Practices Magnet Policies and Retention Barriers to Retention and Educational Progression Summary Nurse Education and Quality of Care Observational Studies Nurse Self-Reported Surveys Magnet Specific Research Summary Experiential Knowledge of Leading Healthcare Institutions The Johns Hopkins Hospital Veterans Health Administration Tenet Health Care Implications The Changing Payment Landscape Nurses and Pay for Performance Initiatives Navigators and Care Coordination Nurses and HIT Framework for Assessing the Returns on Pro-Education Policies Conclusion Investing in Nurse Education 2

3 1. OVERVIEW Business and policy leaders have long recognized the benefits of education progression for individuals and for society. Yet in health care, the debate over policies that promote nurse educational progression is still raging. Driving the lack of consensus are the difficulties faced by many registered nurses (RNs) in completing a bachelor of nursing (BSN) degree while working, and inconsistent research results about the impact of higher nurse education on patient outcomes. In this paper, we review the evidence and the experiential knowledge to date, and propose a preliminary framework for understanding the financial trade-offs that health care employers may want to consider as they determine the costs and benefits of investing in nursing education. The issue of nursing education drew national attention when the Institute of Medicine s (IOM) Committee on the Future of Nursing recommended that 80 percent of nurses should have a baccalaureate degree or higher by the year The IOM specifically suggested that (1) health care employers encourage nurses with associate and diploma degrees to enter baccalaureate nursing programs within five years of graduation, (2) employers should offer tuition reimbursement, (3) employers should create a work culture that fosters continuing education, and (4) employers should provide salary differentials and promotions to nurses who advance in their education. The IOM recommendations come at a time of upheaval in the health care market. Both the economic recession and the impending changes to provider reimbursement systems mandated by 1 Institute of Medicine The Future of Nursing. Leading Change, Advancing Health. Washington D.C. Investing in Nurse Education 3

4 the Affordable Care Act (ACA) create financial pressure on health care organizations (HCOs), making it imperative that HCOs find ways to increase organizational efficiency. 2 Health care administrators need to understand the implications of the IOM recommendations on the HCO s bottom line. The rationale for the IOM recommendations rests on two arguments: 1) better health outcomes will be achieved if nurses complete a baccalaureate degree and 2) if more nurses complete a BSN then more nurses will go on to graduate school, increasing the numbers of advanced practice nurses (e.g., nurse practitioners or nurses with PhDs) who can serve as faculty. The IOM did not recommend that a baccalaureate degree be the entry level requirement for nurse licensure. Rather, the IOM suggests that associate nursing degrees can function as a critical stepping stones in an educational ladder, especially in geographic areas in which access to four year colleges may be difficult. Currently, a continuum of organizational policies is being used by health care executives interested in pursuing these recommendations. HCO strategies range from those that generate no cost to the organization to new/continued investments in human capital. They also vary in the degree to which they facilitate or push nurses to continue their education. These policies include: 1) Preferential hiring of BSNs over ADNs when possible; 2) Compensation differentiation by degree; 3) Human resource (HR) grades requiring a BSN for promotion; 4) Requiring or encouraging RNs to complete a BSN within a stipulated period; and 5) Various forms of tuition reimbursement. 2 Belmont E, et al. A New Quality Compass: Hospital Boards' Increased Role Under the Affordable Care Act. Health Aff (Millwood) Jul;30(7): Investing in Nurse Education 4

5 In the sections below we examine the effects of HCO policies that promote nursing education. First, we summarize the human capital literature as it relates to corporate investments in employee education. We then examine the research on education benefits as a strategy to increase nurse retention in hospitals. Next, we assess the research that attempts to establish a relationship between nurses education and improved quality of care. Lastly, we describe the experiential knowledge of a set of leading nurse executives, and the reasons they believe that a nursing education degree matters. We conclude with a preliminary framework that could be used to estimate the costs and benefits of the nurse education policies for HCOs. Investing in Nurse Education 5

6 2. THE HUMAN CAPITAL PERSPECTIVE The business case for investing in education is not a new concept. As far back as 1776, Adam Smith noted that: the improved dexterity of a workman may be considered in the same light as a machine or instrument of trade which facilitates and abridges labor, and which, though it costs a certain expense, repays that expense with a profit. 3 Yet it was not until 1965 that the University of Chicago Economics professor Gary Becker expanded on earlier conceptions of human capital and argued that firms could maximize their return on investment (ROI) in their labor forces by investing in worker education. 4 Since that time, academics and businesses have spent a considerable amount of time and effort attempting to answer the following question: Under what circumstances, and up to what point, does investing in more education for their workforce yield positive economic and non-economic returns? More than four decades of research have generated enlightening, if inconclusive, results. With some caveats and qualifications, it is generally accepted that successfully completing a four year college degree is a worthwhile investment for workers. 5 Most employees that acquire college degrees earn higher wages and, over the course of a lifetime, earn almost twice the amount earned by those who have only graduated from high school. 6 Workers with bachelor degrees are more 3 Smith, A. An Inquiry into the Nature and Causes of the Wealth of Nations Book 2 - Of the Nature, Accumulation, and Employment of Stock; Published Becker, G Human Capital. Chicago: University of Chicago Press. 5 Williams, A. and Swail, W. (2005). Is More Better? The Impact of Postsecondary Education on the Economic and Social Well-Being of American Society. Washington, DC: Educational Policy Institute, Inc. Retrieved August 17, 2011 from 6 Carnevale, A., Rose, S., and Cheah, B. (2011). The College Payoff: Education, Occupation, Lifetime Earnings. Washington, DC: The Georgetown University Center on Education and the Workforce. Retrieved August 17, 2011 from Investing in Nurse Education 6

7 likely to be employed and, when unemployed, are more likely to find work faster than those with only a high school diploma. 7 The benefits of higher education are also correlated with more generous employee benefit packages, higher quality health care, longer vacations, and better working conditions. 8 At a national level, productivity gains are among five positive economic returns documented by the Institute for Higher Education Policy. 9,10 Although overall productivity growth slowed during the latter part of the 20 th century, at a national level, higher levels of education attained by workers have been estimated to account for between 11 to 20 percent of the increase in productivity during the latter part of the 20 th Century over this period. 11 Even in this time of recession, worker productivity continues to grow, driven in part by the increasing level of workforce education. The exact nature of the returns to companies that invest in human capital are not as easily discerned. Demonstrating causality between education progression and corporate outcomes is a difficult task. 12 First, the amount of time that elapses between the initial investment (e.g., tuition 7 Williams (2005). 8 Ibid. 9 The other benefits, which mostly accrue to the general public, are increased tax revenues, increased workforce flexibility, and decreased reliance on governmental support 10 IHEP. (1998). Reaping the benefits: defining the public and private value of going to college. Washington, DC, The Institute for Higher Education Policy. 11 U.S. Department of Education, National Center for Education Statistics, Education and the Economy: An Indicators Report, NCES , by Paul T. Decker, Jennifer King Rice, Mary T. Moore, and Mary R. Rollefson, project officer. Washington, DC: McMahon, W. W. (1993). The Contribution to Higher Education to R&D and Productivity Growth. Higher Education and Economic Growth. W. E. Becker and D. R. Lewis. Boston, Kluwer Academic Publishers: Investing in Nurse Education 7

8 reimbursement) and the output of higher-educated workers is too long to provide accurate measurements. This lengthened time scale makes it difficult to measure impacts over short periods of time. The interplay of a variety of inputs of production makes it difficult to separate the impact of advanced research and development from the actual people who are trained to do the work and use the technology once it is applied. Randomized studies with generalizable conclusions are a challenge to design, especially when outcomes are highly dependent on organizational practices, and the interaction of large teams of workers. Yet, many U.S. businesses are strongly committed to investing in the education of their workforce. In a report assessing the economic benefits of workplace training programs, ninetyeight percent of employers interviewed reported at least one benefit gained from these programs. 13 Corporate leaders and health resource professionals point to multiple levels of benefit from education and insist that to compete globally, they must invest in the development of the current and future workforce. 14 Nike and Microsoft, for example, are investing billions of dollars a year in education. 15 In addition, states are using investments in education as a means to entice business to a certain locality and increase the benefit to local economies. 16,17 13 Bloom, M. and Lafleur, B. (1999). Turning Skills into Profit: Economic Benefits of Workplace Education Program ( RR). The Conference Board. Retrieved August 17, 2011 from 14 Scramm, J. (2008). Workplace Visions (No. 2): Alexandria, VA: Society for Human Resource Management. Retrieved August 17, 2011 from 15 Levy, G. (July 25, 2011). U.S. firms spend $3.5 billion a year on education: Business leaders seek better return on investment. MarketWatch. Retrieved August 17, 2011 from 16 America s Edge. (2011). Michigan Business Leaders Tout Economic Benefits of State Early Education Investments [Press Release]. Retrieved from Investing in Nurse Education 8

9 It is important to acknowledge the potential unintended consequences of programs that encourage educational progression. In a study of large manufacturers, employees who participated in the tuition reimbursement program had lower voluntary turnover rates. Once employees completed their degree, however, they were more likely to seek employment that recognized their enhanced skills. 18 Importantly, the study also found that employee promotion was a significant determining factor in the length of time the employee stayed with the company after receiving their degree. This observation aligns with other research that demonstrates the importance of providing career ladders to individuals who earn advanced degrees and generally encouraging positive workplace policies. 19,20 17 America s Edge. (2011). Illinois Business Leaders Tout Economic Benefits of State Early Education Investments [Press Release]. Retrieved from 18 Benson, G., Finegold, D. and Mohrman, S. "You Paid for the Skills, Now Keep them: Tuition Reimbursement and Voluntary Turnover." Academy of Management Journal 47.3 (2004): Web. 19 Duncan, K. "Student Pre-Entry Experience and First Year of Employment." Journal of Continuing Education in Nursing 28.5 (1997): Web. 20 Strachota, E., et al., Reasons Registered Nurses Leave or Change Employment Status, Journal of Nursing Administration 33:2 (2003): 115. Investing in Nurse Education 9

10 3. NURSE EDUCATION AND RETENTION For healthcare organizations that employ registered nurses, the research on the benefits of educational progression have focused on improving retention rates and improving quality of care. Both, of course, have tremendous impact on financial wellbeing of health care organizations and are likely to be even more important in the future as health reform implementation advances. RN wages make up a sizable proportion of HCO operating budgets. On average, thirty percent of a hospital s total operating budget is related to RNs. 21 Controlling costs means ensuring that the nursing labor force is being utilized efficiently. RETENTION PRACTICES The first efficiency challenge is attracting and retaining nurses. High turnover rates among nursing staff and high vacancy rates cost hospitals tens of thousands of dollars, with estimates ranging from $22,000 to $64,000 per nurse turnover. 22 These costs may climb higher in the future. Experts believe that once the recession subsides, there will be a wave of retirements and a return to part time work among nurses. The combination of an aging nurse workforce, an aging U.S. population, and the expansion of health insurance coverage in 2014, are believed to be clear indications that the cyclical nature of past shortages is being replaced by a structural shortage Welton JM, Fischer MH, DeGrace S, Zone-Smith L. Hospital nursing costs, billing, and reimbursement. Nurs Econ. 2006;24(5):239-45, 262, Strachota, E et al., Reasons Registered Nurses Leave or Change Employment Status, Journal of Nursing Administration 33:2 (2003): Buerhaus, P. I., D. O. Staiger, and D. I. Auerbach. "Implications of an Aging Registered Nurse Workforce." JAMA (2000): Web. Investing in Nurse Education 10

11 Researchers estimate that in 2020, the number of nurses will be equivalent to the level today, but that this will fall 20 percent below anticipated demand. 24 As retention of RNs becomes a greater priority, HCOs will need to ado6pt new human resource policies. A recent report suggests that a large proportion of health care organizations have considerable room for improvement when it comes to their human resources policies. Restrictive management techniques that hinder the development of innovative, motivated, and creative healthcare professionals were estimated to limit productivity to 60 to 70 percent of potential. 25 The primary factor in determining whether a nurse will remain in a job is job satisfaction. The top reasons for turnover include issues with schedule, better job opportunities, and family concerns. 26 Turnover rates are sensitive to HR policies. Extending a nurse s career by only a few years can provide a significant benefit to the HCO. An empirical study of nurse retention strategies found that by far, tuition and education benefits are among the most widespread incentives offered by employers. 27 Other strategies typically used include offering signing bonuses, extensive advertising, sponsoring career fairs and community outreach programs, and providing flexible work schedules. 28 Nationwide, between 40 and 60 percent of nurses report that their employer provides tuition benefits as part of their efforts to 24 Ibid. 25 Khatri, N. et al. "Strategic Human Resource Management Issues in Hospitals: A Study of a University and a Community Hospital." Hospital topics 84.4 (2006): Web. 26 Ibid. 27 Spetz, J., and Adams, S., How Can Employment-Based Benefits Help the Nurse Shortage? Health Affairs, 25:1 (2006): Buerhaus, Peter I., et al. Trends in the Experiences of Hospital-Employed Registered Nurses: Results from Three National Surveys, Nursing Economic$, 25:2 (2007): 74. Investing in Nurse Education 11

12 attract and retain nurses. 29 In 2008, 90 percent of health care providers in New York offered tuition assistance to their nursing staff. 30 In addition to tuition-related incentives, career ladders are often used to encourage nurses in the workforce to advance their education. Some employers report using career ladder programs as the basis for a successful nurse retention strategy. Results have been mixed, but several hospital systems, including Inova in Northern Virginia, report that the costs of implementing the program are far outweighed by the benefits of high retention of the nursing staff. 31 Flexible scheduling is a third policy that has been linked to high retention and potentially helps nurses who are seeking to continue their education. 32 Nurse administrators can work with employees to develop shift schedules that facilitate employee s education progression and reduce stress and burnout from working untenable hours. MAGNET POLICIES AND RETENTION Research suggests that organizations achieving Magnet status have been highly successful in reducing turnover among nurses. 33 Hospitals seeking to attain Magnet status must demonstrate that they meet 14 forces of magnetism. 34 It is impossible to disentangle the multiple 29 Ibid. 30 Zimmerman Drenkard, K. and Swarthwout, E. Effectiveness of a Clinical Ladder Program, Journal of Nursing Administrator, 35:11 (2005): Spetz and Adams (2006). 33 Drenkard, K. The Business Case for Magnet, Journal of Nursing Administration, 40:6 (2010): American Nurses Credentialing Center, Forces of Magnetism, Available at Accessed July 26, Investing in Nurse Education 12

13 components of Magnet. However, research has demonstrated that Magnet hospitals report higher percentages of satisfied RNs, lower RN turnover and vacancy, improved clinical outcomes, excellent nurse autonomy and decision-making capabilities, and improved patient 35, 36,37 satisfaction. Among the forces of magnetism that hospitals must demonstrate is a requirement that, at the time the facility applies for Magnet status, chief nursing officers and 75 percent of nurse managers are required to have a BSN or higher. 38 In 2013, all nurse managers and nurse leaders will be required to have BSNs or higher at the time of application. 39 As part of the standards for demonstrating transformational leadership, healthcare systems applying for Magnet status are required to have a CNO with a baccalaureate or higher degree in nursing and each component entity within the system must have a designated RN executive leader who meets the qualification requirements for a CNO. 40 To fulfill these requirements, hospitals have formed partnerships with educational institutions and pursued other creative strategies to develop a workforce that is able to meet the Magnet mandates. Some of these partnerships have led to a dramatic increase in the 35 Drenkard, K., The Business Case for Magnet, Journal of Nursing Administration, 40:6 (2010): Frellick, M. A path to nursing excellence. Trustee. 64(3):15-21, Mar Retrieved Aug 22, Magnet Status: Is it Worth it? American Hospital Association Resource Center Blog. March 22, Retrieved Aug. 22, Ibid. 39 American Nurses Credentialing Center. Organization Eligibility Requirements, Available at Accessed August 14, American Nurses Credentialing Center. System Eligibility Requirements. Available at Process/EligibilityRequirements/SysEligibilityRequirements.aspx. Accessed August 14, Investing in Nurse Education 13

14 number of BSN-educated nurses on staff. 41 Because of difficulties in accessing educational facilities, rural hospitals seeking Magnet status have also sought to develop new ways to encourage their nurses to pursue continuing education, such as detailed collaboration agreements between area colleges and universities that allow nursing students to continue working during their education and dramatically cut down on travel time to and from school. 42 BARRIERS TO RETENTION AND EDUCATIONAL PROGRESSION Expanding educational incentives for nurses to complete a BSN may be slowing as a result of the recession. A recent study reported that employers were finding it less necessary to offer hiring bonuses in the current economic climate. 43 Nurse salaries, in particular BSNs wages, appear to be declining. 44 In Vermont, only 26 percent of health care providers offer a salary differential based on a nurse s level of education, and this additional compensation is often minimal. 45 Instead of attempting to grow their own, employers seek out either newly graduated BSNs or nurses from abroad. 46 Foreign-educated nurses recruited to the United States tend to be more highly educated than U.S. nurses. 47 Regardless, a subset of leading hospitals continues to deepen 41 Russell, J. Journey to Magnet: Cost vs. Benefits, Nursing Economic$, 28:5 (2010): Murphy, M. et al. The Rural Pipeline: Building a Strong Nursing Workforce Through Academic and Service Partnerships, Nursing Clinics of North America, 46 (2011): Bacon, Donald. Results of the 2010 AORN Salary and Compensation Survey, AORN Journal, 92:6 (2010) Hader, Richard. Salary Survey 2010, Nursing Management, August 2010, Rambur, B. et al. Education as a Determinant of Career Retention and Job Satisfaction Among Registered Nurses, Journal of Nursing Scholarship, 37:2 (2005): Ibid. 47 U.S. Department of Health and Human Services, Health Resources and Services Administration (2010). The Registered Nurse Population: Initial Findings from the 2008 National Sample Survey of Registered Nurses. Investing in Nurse Education 14

15 their commitment to educational policies (see case studies below), and the Magnet program continues to grow even during these difficult economic times. 48 Tuition reimbursement and career ladder programs may not be sufficient to actually persuade most associate degree nurses to complete their BSNs. First, access to four-year colleges in rural areas may be an impediment to completing a BSN. 49, 50 Second, the evidence which suggests that, on average, BSN nurses earn more over their lifetime, is contingent on the BSN being earned early on in the nurse s career. Data from the Census Bureau, which does not include the cost of education, show that BSNs will earn $200,000 more than ADN nurses over a life time. 51 When discounted at a rate of 2.5 percent, the difference between the lifetime earnings of a BSN and an ADN drops to $96,000. On the other hand, a study analyzing National Sample Survey of RNs from 1996 and 2000 revealed that whether or not the degree paid off in the long run was influenced by other factors, the most important of which was the nurse s remaining years in the labor market. 52 For 45 percent of the nurses in the study, the lifetime benefits of investing in a BSN outweighed the cost Drenkard Brewer, C. et al. Nursing Recruitment and Retention in New York State: A Qualitative Workforce Needs Assessment, Policy, Politics, & Nursing Practice, 7:54 (2006): Megginson, Lucy. RN-BSN Education: 21 st century barriers and incentives, Journal of Nursing Management, 16 (2008): Carnevale Graf, C. M. "ADN to BSN: Lessons from Human Capital Theory." Nursing Economic$ 24.3 (2006): 135,41, 123; quiz 142. Web. 53 Ibid. Investing in Nurse Education 15

16 SUMMARY Tuition reimbursement policies, flexible work hours, and career ladder programs help attract and retain the best nurses, especially when used in conjunction with other strategies to create positive, proactive work environments. The effects on retention, of course, do not necessarily mean that nurses actually take advantage of the programs and complete their BSN. Other complementary policies may be needed to incentivize nurses, such as preferential hiring, educational requirements for promotion, and differential compensation. Investing in Nurse Education 16

17 4. NURSE EDUCATION AND QUALITY OF CARE The research on whether a BSN nurse is able to deliver better patient outcomes than an ADN/Diploma nurse includes: (1) quasi-experimental observational studies from both the U.S. and other nations that use statistical techniques such as single and multi-level regression analysis to identify correlations, and (2) descriptive analysis using nurse reported perceptions of competency. While methodological limitations prevent even the observational studies with large sample sizes from concluding that there is a definitive relationship of causation, studies are becoming more rigorous over time. Still, as discussed in the section on human capital investments, more hierarchical modeling is needed to take into account multiple layers of exogenous factors, e.g., facility and regional factors. OBSERVATIONAL STUDIES During the late1990s and early 2000s, a large number of quantitative studies explored the importance of having a sufficient number of nurses on staff, i.e., the causal relationship between nurse-to-patient ratios and health care outcomes. 54,55,56,57 Research suggesting improved patient 54 Mark, B.A., Harless, D.W., McCue, M., & Xu, Y. (2004). A longitudinal examination of hospital registered nursing staffing and quality of care. Health Services Research. 39, Pearson, S.D., Allison, JJ., Kiefe, C.I., Weaver, M.T., Williams, O.D., Centor, R.M., et al. (2004) Nurse staffing and mortality for medicare patients with acute myocardial infarctions. Medical Care, 42, Kovner, C., & Gergen, P.J. (1998). Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image, 30, Farley, D.E., & Ozminkowski, R.J. (1992). Volume-outcome relationships and in-hospital mortality: The effect of changes in volume over time. Medical Care, 30, Investing in Nurse Education 17

18 outcomes when HCOs employ RNs in direct care (as opposed to Licensed Practical Nurses) is robust. 58,59,60 Research linking higher proportions of BSNs to better patient outcomes was mixed in the early 2000s, but evidence of a positive relationship appears to be growing. If studies conducted in other countries are included in the count, a majority suggests that higher proportions of BSNs on hospital units are associated with improved health outcomes. Linda Aiken and her team at the University of Pennsylvania were among the first to examine the difference in performance between BSN and ADN nurses. 61 They found that a 10 percent increase in the percentage of bachelor-educated nursing staff was correlated with a five percent decrease in both the likelihood of patients dying within 30 days of admission and the odds of hospital staff failing to notice or respond when a patient is dying of preventable complications (known as failure-to-rescue ). 62 Since the 2003 Aiken et al. study, three additional U.S.-based studies have found that higher percentages of BSN nurses correspond to improved patient outcomes: Friese et al., 2008, found a significant relationship between the education level of 58 Silber, J.H., Kennedy, S.K., Even-Shoshan, O., Chen, W., Mosher, R.E., Showan, A.M., et al. (2002). Anesthesiologist board certification and patient outcomes. Anesthesiology 96, American Nurses Association. (2000). Executive summary: Nurse staffing and patient outcomes in the inpatient hospital settings. Washington, D.C.: Author. 60 Belgen, M.A., Vaughn, T. (1998). A multisite study of nurse staffing and patient occurrences. Nursing Economics, 16, Linda H. Aiken, et.al. Educational Levels of Hospital Nurses and Surgical Patient Mortality, Journal of the American Medical Association, 290:12 (2003): Ibid. Investing in Nurse Education 18

19 nurses and failure-to-rescue rates, 63 Chang and Mark, 2009, found decreased incidences of medication errors when BSNs comprised up to 54 percent of the nursing staff, 64 and Aiken et al., 2011, not only found that higher proportions of BSNs reduced 30-day mortality and failure-torescue rates, but also that better nurse workplace environments can magnify this effect. 65 A fifth study, drawing from the same data set as Aiken et al., 2011, provides an additional finding that specialty certification enhances the BSN-effect on 30-day mortality and failure-to-rescue rates by an additional 2 percentage points. 66 Five U.S.-based studies found no difference between an increase in the number of nurses with BSNs and improved patient outcomes. Three studies found a significant relationship between incidences of patient falls and other variables, such as the experience level of the nurses 67 and the nurse-to-patient ratio, 68,69 but not to the proportion of BSN nurses. Lake et al., 2010, only 63 Friese, Christopher R., et al., Hospital Nurse Practice Environments and Outcomes for Surgical Oncology Patients, HSR: Health Services Research, 43:4 (2008) Chang YK, Mark BA (2009) Antecedents of Severe and Non Severe Medication Errors. Journal of Nursing Scholarship. 41(1) Aiken LH, Cimiotti J, Sloane DM, Smith HL, Flynn L, Neff D The effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care, 49(12): Kendall-Gallagher, D., Aiken, L.H.., Sloane, D.M., Cimiotti, J.P Nurse specialty certification, inpatient mortality, and failure to rescue. Journal of Nursing Scholarship. 43(2): Blegen, Mary A., Vaughn, Thomas E., and Goode, Colleen J. Nurse Experience and Education: Effect on Quality of Care, Journal of Nursing Administration, 31:1 (2001) Dunton, N, et al., The Relationship of Nursing Workforce Characteristics to Patient Outcomes, ONIN: The Online Journal of Issues in Nursing, 12:3 (2007). Available online at ents/volume122007/no3sept07/nursingworkforcecharacteristics.aspx. Accessed August 13, Mark, Barbara A., et al. Exploring Organizational Context and Structure as Predictors of Medication Errors and Patient Falls, Journal of Patient Safety, 4:2 (2008) Investing in Nurse Education 19

20 examined the relationship between the proportion of BSN nurses and a hospital unit s fall rate and found no significant relationship. 70 Sales et al., 2008, found that unit nurse-staffing ratio, but not nurse education level, was significantly associated with reduced inpatient mortality among non-icu patients. 71 Three international studies have found an inverse relationship between the proportion of BSNs and adverse patient outcomes, while a fourth found no relationship. The methodology used in Aiken et al., 2003, was replicated using data from Canadian hospitals in Estabrooks et al., 2005, and Tourangeau et al., Both reported findings similar to their U.S. counterpart. 72,73 Van den Heede et al., 2011, utilized administrative data from Belgian hospitals and found that while nursestaffing levels were not related to in-hospital mortality, the proportion of BSN nurses was. 74 The one international study to find no education-effect on patient outcomes, Sasichay- 70 Lake, Eileen T., et al., Patient Falls: Association With Hospital Magnet Status and Nursing Unit Staffing, Research in Nursing and Health, 33 (2010) Sales, Anne, et al., The Association Between Nursing Factors and Patient Mortality in the Veterans Health Administration: The View From the Nursing Unit Level, Medical Care, 46:9 (2008) Estabrooks, C.A., Midodzi, W.K., Cummings, G.G., Ricker, K.L, and Giovannetti, P. (2005). The Impact of hospital nursing characteristics on 30-day mortality. Nursing Research, 54, Tourangeau, A. E., D. M. Doran, L. McGillis Hall, L. O'Brien Pallas, D. Pringle, J. V. Tu, and L. A. Cranley Impact of hospital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing 57 (1) (Jan): Van den Heede, K., Lasaffre, E., Diya, L., Vleugels, A., Clarke, S.P., Aiken, L.H., Sermeus, W The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: Analysis of administrative data. International Journal of Nursing Studies, 46(6): Investing in Nurse Education 20

21 Akkadechnanunt et al., 2003, found that nurse-to-patient ratio was the best predictor of inhospital mortality. 75 Table 1 summarizes this literature in the United States, while Table 2 summarizes research in non-us settings. While BSN education is similar in Canada, Belgium and Thailand, we separate them from US studies because the percent participation of BSNs in the workplace in at least two of those countries is very high (Thailand and Belgium have over 95 percent BSNs), and there was no information on the lesser educational degree to which BSNs were compared. Studies that found a significant relationship between increased nurse education and patient outcomes are highlighted in blue. 75 Sasichay-Akkadechnanunt, T., Scalzi, C. and Jawad, A. The Relationship Between Nurse Staffing and Patient Outcomes, Journal of Nursing Administration, 33:9 (2003) Investing in Nurse Education 21

22 Table 1: Observational studies of nurse education and quality of care in the U.S. Title Author; Year; Journal Research Question Findings Sample Size Study Design Hospital units with more Study 1: 42 inpatient units Studies the relationship experienced nurses had from one large tertiary-care Belgen, Vaughn, and 1. Nurse Experience and between quality of care fewer medication errors and hospital during one fiscal Single-level Goode; 2001; Journal Education: Effect on provided and the nurses lower patient fall rates. year. regression of Nursing Quality of Care education and Differences in units with Study 2: 39 patient care analysis Administration experience more BSN-prepared nurses units in 11 hospitals for 2.5 were not significantly better years 2. Educational Levels of Hospital Nurses and Surgical Patient Mortality 3. The Relationship of Nursing Workforce Characteristics to Patient Outcomes Aiken, Clarke, Cheung, Sloane, and Silber; 2003; Journal of the American Medical Association Dunton, Gajewski, Klaus, and Pierson; 2007; Online Journal of Issues in Nursing Whether the proportion of BSN-prepared nurses is associated with riskadjusted mortality and failure to rescue rates Literature review of studies relating to nursing outcomes research and reports a National Database of Nursing Quality Indicators study A 10 percent increase in the proportion of BSN nurses was associated with a 5 percent decrease in both 30- day mortality and failure to rescue rates Total nursing hours per patient day, percentage of hours supplied by RNs, and years of experience in nursing were all found to be significantly related to patient falls, but the percent of BSNs on the unit were not Data from 232,342 surgery patients discharged from 168 Pennsylvania hospitals National Database of Nursing Quality Indicators, over 1,100 hospitals and over 175,000 nurses responded to the survey. Single-level regression analysis Multi-level regression analysis 4. Exploring Organizational Context and Structure as Predictors of Medication Errors and Patient Falls Mark, Hughes, Belyea, Bacon, Chang, YunKyung, and Jones; 2008; Journal of Patient Safety To examine the relationship between nursing unit environment and effectiveness (medication errors and falls) in acute care hospitals Nursing unit characteristics (which include the proportion of BSNs) have limited effects on medication errors and falls 278 med-surg units at 143 hospitals that participated in the Outcomes Research in Nursing Administration Project II Single-level regression analysis

23 Table 1, continued Title Author; Year; Journal Research Question Findings Sample Size Study Design Relationship between Patient-to-nurse ratio and nurse staffing, the the proportion of BSNprepared nurses were 5. Hospital Nurse proportion of BSNprepared nurses, and the Patient sample of 24,618, Single-level Friese, Lake, Aiken, Practice Environments Silber, and Sochalski; significantly associated with and Outcomes for practice environment on 164 nursing organizations regression 2008; Health Services improved patient outcomes. Surgical Oncology the odds of 30-day (at the hospital-level) analysis Research After controlling for patient Patients mortality, and hospital characteristics, complications, and so was practice environment failure to rescue rates 6. The Association Between Nursing Factors and Patient Mortality in the Veterans Health Administration: The View From the Nursing Unit Level 7. Antecedents of Severe and Non Severe Medication Errors Sales, Sharp, Li, Lowy, Greiner, Liu, Alt-White, Rick, Sochalski, Mitchell, Rosenthal, Stetler, Cournoyer, and Needleman; 2008; Medical Care Chang; 2009; Journal of Nursing Scholarship Determine what relationship exists, if any, between RN staffing/ skill mix and in-patient hospital mortality Determine the association between, among other things, RN hours, nurse expertise, and nurse education and experience RN staffing was significantly associated with a decrease in mortality among non-icu patients, but not for patients with an ICU stay. Did not find that RN education was significantly associated with mortality Nurse education level was found to have a sig. nonlinear relationship with medication errors only (As the % of BSNs increase, medication errors fell until % BSN reached 54 %) Administrative data from 129,579 patients from 453 nursing units in 123 VHA hospitals 6 months of data from 279 nursing units in 146 randomly selected hospitals in the U.S. Multi-level regression analysis Single-level regression analysis 8. Patient Falls: Association With Hospital Magnet Status and Nursing Unit Staffing Lake, Shang, Klaus, Dunton; 2010; Research in Nursing and Health Examine the relationship among nurse staffing, RN composition, Magnet status, and patient falls Higher proportions of BSNs were not found to be statistically related with a hospital units fall rate Retrospective, crosssectional observational study of 5,388 nursing units in 636 hospitals (2004 data from the National Database of Nursing Quality Indicators) Single-level regression analysis Investing in Nurse Education

24 Table 1, continued Title Author; Year; Journal Research Question Findings Sample Size Study Design Determine the Increasing the proportion of 9. Effects of Nurse conditions under which BSN nurses decreased the 665 hospitals in four states, Staffing and Nurse the impact of hospital Aiken, Cimiotti, Sloane, odds of 30-day impatient 1,262,120 patient discharge Single-level Education on Patient nurse staffing, nurse Smith, Flynn, Neff; mortality by 4 percent. The abstracts, and a random regression Deaths in Hospitals with education, and work 2011; Medical Care impact of reducing nurse sample of 39,038 nurse analysis Different Nurse Work environment are workload depends on nurse surveys Environments associated with patient work environment outcomes Investing in Nurse Education

25 Table 2: International observational studies of nurse education and quality of care Country/ Title Author; Year; Journal Research Question Findings Sample Size Study Design 1. THAILAND The Relationship Between Nurse Staffing and Patient Outcomes 2. CANADA The Impact of hospital nursing characteristics on 30-day mortality 3. CANADA Impact of Hospital Nursing Care on 30-day Mortality for Acute Medical Patients Thitinut Sasichay- Akkadechnanunt; 2003; Journal of Nursing Administration Estabrooks, Midodzi, Cummings, Ricker, and Giovannetti; 2005; Nursing Research Tourangeau, Doran, Hall; 2006; Journal of Advanced Nursing Measured the association b/w RN-topatient ratio, the proportion of RNs to total nursing staff, average years of RN experience, and the percentage of RNs with a BSN and in-hospital mortality Determine what relationship exists, if any, between RN education, skill mix, continuity of care, and quality of the work environment and 30- day mortality Attempted to explain variance in the riskadjusted 30-day mortality rates for acute medical patients. RN-to-patient ratio was the best predictor of in-hospital mortality. No relationship found between proportion of RNs to total nursing staff, year of experience, or percentage of BSN nurses. Authors speculates that the high percent of BSNs (over 95%) in all the hospitals could reduce the ability to see differences Higher proportions of BSNprepared nurses significantly associated with lower rates of 30-day patient mortality, as were higher proportions of RN-to-non- RN staff A 10 percent increase in the proportion of BSN nurses was associated with a 0.9 percent reduction in mortality rate. Data from 2,531 patients admitted to seven medical units and ten surgical units at a 2,300 bed hospital Outcome data from 18,142 patients discharged from 49 acute care hospitals Data from the Ontario Discharge Abstract Database (46,993 patients), nurse data from the Ontario Nurse Survey 2003 (5,980 nurses), and staffing data from the Ontario Hospital Reporting System Single-level regression analysis Single-level regression analysis Single-level regression analysis Investing in Nurse Education

26 Table 2, continued Country/ Title Author; Year; Journal Research Question Findings Sample Size Study Design 4. BELGIUM 2003 The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: Analysis of administrative data Van den Heede, Lasaffre, Diya, Vleugels, Clarke, Aiken, Sermeus; 2009: International Journal of Nursing Studies Determine the association between nurse-staffing levels and the in-hospital mortality of patients While not the primary objective, results found a significant relationship between the proportion of RNs with a BSNs and inhospital mortality on general units, but not ICUs 9,054 patients admitted to a Belgian acute hospital for a coronary artery bypass graft in 2003 Single-level regression analysis Investing in Nurse Education

27 NURSE SELF-REPORTED SURVEYS The nursing survey literature has consistently found that BSN nurses self-report a set of competencies that surpass ADN nurses. Pellico, et al., followed a cohort of nurse graduates over time to track their personal experiences as RNs. Nurses with BSN degrees reported greater confidence, teamwork, and collaboration than nurses with associate and diploma degrees. 76 Similarly, in work by McGrath, RNs who obtain BSNs including RNs who saw themselves as experts in the field even before receiving a BSN report seeing a difference in the quality of their patient care and practice, with enhanced critical thinking and leadership skills. 77 Studies have also found that having a baccalaureate degree increases critical thinking skills 78, ethical reasoning 79, and professional behavior. 80 Table 3 summarizes the literature regarding the self-reported effects of earning a BSN on the practice of nursing. 76 Pellico, L. H., C. S. Brewer, and C. T. Kovner. "What Newly Licensed Registered Nurses have to Say about their First Experiences." Nursing outlook 57.4 (2009): Web. 77 McGrath, J. Why Would I Want to Do That? Motivating Staff Nurses to Consider BSN Education, Journal of Perinatal and Neonatal Nursing, April-June 2008, Shin, K., Lee, J.H., Ha, J.Y., & Kim, K.H. (2006) Critical thinking dispositions in baccalaureate nursing students. Journal of Advanced Nursing, 56(2), Callister, L.C., Luthy, K.E., Thompson, P., & Memmott, R.J. (2009). Ethical reasoning in baccalaureate nursing students. Nursing Ethics, 16(4), Goode, C.J., Pinkerton, S., McCausland, M.P., Southard, P., Graham, R., & Kresek, C. (2001) Documenting chief nursing officers preference for BSN-prepared nurses. Journal of Nursing Administration, 31(2),

28 Table 3: Qualitative nurse surveys, by publication date Study Author; Year; Journal Research Question Findings Sample Size Study Design Comparison of scores on the California BSN students scored higher on both critical The California Critical Critical thinking Critical Thinking thinking examinations Thinking Disposition Shin, Ha, and Kim; dispositions in Disposition Inventory than ADNs or RN- Inventory was 2006; Journal of baccalaureate nursing and California Critical BSNs. The differences administered to a Advanced Nursing students Thinking Skills test were statistically convenience sample of Qualitative nurse survey between ADN, BSN, and RN-BSN programs significant 60 nursing students Why Would I Want to Do That? Motivating Staff Nurses to Consider BSN Education McGrath; 2008; Journal of Perinatal & Neonatal Nursing Examines the perceived benefits and barriers described by nurses when considering returning to earn their BSN Nurses who obtain their BSN report a significant difference in the quality of their patient care, including enhanced critical thinking and leadership skills Reviews the nurse survey literature with respect to the attitudes of ADN-BSN students Qualitative nurse survey Ethical Reasoning in baccalaureate nursing students Callister, Luthy, Thompson, and Memmott; 2009; Nursing Ethics BSN nursing students were asked to reflect on their clinical experiences. A framework was developed to evaluate the level of reflection that the student demonstrated in their responses BSN nursing students responses indicate a high level of ethical reasoning and critical thinking skills 70 nursing students who voluntarily participated in a qualitative descriptive study Qualitative nurse survey

29 Table 3, continued Study Author; Year; Journal Research Question Findings Sample Size Study Design Secondary data analysis Developed a framework from a nationwide to understand comments Nurses with BSNs What Newly Licensed survey of newlylicensed registered offered by nurses about report greater Registered Nurses have Pellico; 2009; Nursing their view of nursing confidence, teamwork, Qualitative nurse survey to Say about their First Outlook nurses. A random, and their experiences in and collaboration than Experiences nationally representative the profession ADNs sample of 612 nurses was selected. New Nurses Views of Quality Improvement Education Kovner, Brewer, Yingrengreung; 2011; Joint Commission Journal on Quality and Patient Safety Survey in which new nurses reported changes in clinical skills BSN nurses self-report higher levels of preparation than ADNs in measures such as evidence-based practice, assessing gaps in practice, and research competencies 436 newly-graduated nurses responded to a mail survey Qualitative nurse survey Investing in Nurse Education

30 MAGNET SPECIFIC RESEARCH Tangentially relevant to this brief are those studies mentioned in the previous section that have found Magnet status has resulted in improved outcomes for patients, 81,,82,83 although, as indicated above, isolating the education policies in the context of the full set of 14 forces of magnetism is difficult. One study did find that while Magnet status had resulted in a decrease in patient falls, RN education level and certification were not associated in a meaningful way with the decrease. 84 Further, while many Magnet hospitals have sought to hire more nurses with advanced degrees, studies of Magnet hospitals have not found the percentage of nurses with advanced degrees to be higher at Magnet hospitals than at non-magnet hospitals. 85 SUMMARY While descriptive studies suggest that BSNs self-report higher skill levels, to date, the quasiexperimental research on whether higher proportions of BSNs in a hospital improves patient outcomes is still mixed and does not permit definitive conclusions. 81 Linda H. Aiken, et al., Organization and Outcomes of Inpatient AIDS Care, Medical Care, 37:8 (1999) Linda H. Aiken, Julie Sochalski, and Eileen Lake, Studying Outcomes of Organizational Change in Health Services, Medical Care 35:11 (1997) NS6-NS Aiken, Linda H., Smith, Herbert L., and Lake, Eileen T. Lower Medicare Mortality Among a Set of Hospitals Known for Good Nursing Care, Medical Care, 32:8 (1994) Lake, Eileen T., et.al., Patient Falls: Association With Hospital Magnet Status and Nursing Unit Staffing. 85 Ulrich, Beth T., et al., Magnet Status and Registered Nurse Views of the Work Environment and Nursing as a Career, Journal of Nursing Administration, 37:5 (2007)