Nursing Educational Levels - Op/Ed Piece

[Q.]

Following is a recent commentary that appeared in The Journal of Nursing Administration 35(1). Thought I would share since it touches on Aiken's article:

NURSE STAFFING AND OUTCOMES: DIFFERENTIATING CARE DELIVERY BY EDUCATION PREPARATION

[DEPARTMENTS: LETTER TO THE EDITOR]

Page, Jan Stapleton BSN, RN

Graduate Student, Sinclair School of Nursing, University of Missouri, Columbia, Mo ([email protected])

Lang et al 1 have presented a thorough literature review, looking at patient outcomes as they relate to nurse staffing. This issue holds great significance for nurses, especially for those who live and work in the state of California where the minimum staffing ratio has taken effect. Many key researchers have been working diligently, trying to prove, or disprove, the need for California's new mandate. While their efforts are noteworthy, many are missing the mark.

This mandate is based on the presumption that the more nurses there are, the safer the patients are. The data do not support this presumption. While staffing ratios are certainly a concern, they are not exclusive in affecting patient outcomes, staff satisfaction, or hospital goals. If positive patient outcomes, staff satisfaction, and positive hospital outcomes are the goals, then the data must include all factors affecting these issues. Research needs to focus on how nurses deliver care, rather than how many patients a nurse delivers care to.

By only considering nurse-patient ratios, researchers are not going to find the data they need. Nursing care delivery models should be researched further to establish safe practice guidelines. Care delivery needs to be designed to maximize the potential of each nurse and to appropriately utilize the nursing resources available. Many care delivery models utilize differentiated practice, utilizing the more educated nurses for critical thinking across the continuum, and the less educated nurses for the task-driven roles.

The study conducted by Aiken et al 2 revealed that the more educated the nurse, the better the patient outcomes. Thus, it is of vital importance to place the more educated nurses in positions where they can critically think, allowing these nurses to deal with the complexity of care. This will result in safe, appropriate care, excellent patient outcomes, satisfied nurses, as well as productive hospital outcomes.

The work nurses face today is too complex for any one person, or discipline, to handle effectively. Well-coordinated, interdisciplinary care is what keeps the patients safe. It is the coordination of all roles associated with each patient that will have the greatest impact on patient outcomes. With the appropriate roles working together, the patients will have their needs met, nurses will feel more satisfied about their contribution to a team, and hospitals will meet their goals.

Gow et al found that a care coordination delivery model "addresses the needs of complex patients, enhances the quality and consistency of care within a cost-effective frame-work."3(p109) Halm et al 4 show that coordination and interdisciplinary collaboration show an increased positive patient outcomes, increased job satisfaction of all roles, and increased retention of nurses. Using a differentiated nursing practice approach with well-educated, articulate nurses placed in the position to coordinate interdisciplinary care is the answer to the staffing issues facing nursing today.

REFERENCES

1. Lang TA, Hodge M, Olson V, Romano PS, Kravitz RL. A systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. J Nurs Adm. 2004;34(7/8):326-337. [Context Link]

2. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. J Am Med Assoc. 2003;290(12):1617-1623. [Context Link]

3. Gow P, Berg S, Smith D, Ross D. Care co-ordination improves quality-of-care at South Auckland health. Qual Clin Pract. 1999;19:107-110. [Context Link]

4. Halm MA, Goering M, Smith M. Interdisciplinary rounds. Impact on patients, families, and staff. Clin Nurse Spec. 2003;17(3):133-142. [Context Link]

Accession Number: 00005110-200501000-00003

[Tweety, BSN, RN]

Whew, I thought it was going to be another ADN vs. BSN article.

I agree 100% that ratios are only part of the equation in providing safe care with positive outcomes. There's a lot that goes into it. But lowing RN to patient ratios is a good place to start IMO, having 8 patients is killing me, and sooner or later a patient.

Good article. Thanks for sharing.

[begalli]

I'm not quite sure I understand what the author considers "more educated." Does this mean more experience? Because everyone knows that you can have all the book smarts in the world but you are not a critically thinking nurse until you actually have the opportunity to develop this hallmark of nursing through repeated exposure to situations that require nursing and medical intervention.

I agree that nursing should be looked at by how nursing delivers care as oppossed to how many nurses are delivering care. I also agree that the more experienced (as oppossed to using the term "educated") should be placed in patient care roles that require more critical thinking.

For example, in my ICU a new nurse will be assigned more stable patients while the experienced nurse will be assigned a very unstable patient who needs vigilant by-the-minute care that requires a thorough knowledge of hemodynamics, drugs, and equipment and how the body responds to such interventions. The less experienced nurse may be assigned to a patient who is physically close to the sicker patient so the newer nurse can watch and learn from the more experienced nurse (exposure).

The problem lies in how much time does a nurse have to really contribute the critical thinking required to properly take care of his/her patient. On a med/surg floor, there is NO WAY that a nurse with a patient assignment of 8 has time to sit down, read labs, read histories, read progress notes, consult with other disciplines, look for trends and come up with plans of care that benefit the whole patient. There is NO WAY that this nurse has time to really "know" their patient. Unfortunately for the nurse who is overburdened with too many patients, this nurse's critical thinking consists of - how do I get through this day and get the "tasks" done - as oppossed to - how can I contribute to the outcome of this patient. (please, no one take offense to that last sentence).

This is where the ratios come in. By lowering the number of patients one nurse is responsible for, it allows nurses to use their judgement by giving them more time to get to know their patients better and recognize potential problems in a patient's course of illness/wellness. Lower the ratios and you will have more experienced, critical thinking nurses because nurses will have the time to learn about their whole patient, collaborate with other disciplines, and come up with real contributions to a patient's outcome.

Interdisciplinary teams are a must. But how often are they a reality? We have interdisciplinary team meetings for some patients where I work and the nurses are heavily involved. But many hospitals have no such thing and I think the only way different disciplines communicate is through notes in a patient's medical record. But does a floor nurse really have time to sit through meetings???

p.s. IMO, this does appear to be an opinion that a higher degree of "education" is "better."

[Q.]

The problem lies in how much time does a nurse have to really contribute the critical thinking required to properly take care of his/her patient. On a med/surg floor, there is NO WAY that a nurse with a patient assignment of 8 has time to sit down, read labs, read histories, read progress notes, consult with other disciplines, look for trends and come up with plans of care that benefit the whole patient. There is NO WAY that this nurse has time to really "know" their patient. Unfortunately for the nurse who is overburdened with too many patients, this nurse's critical thinking consists of - how do I get through this day and get the "tasks" done - as oppossed to - how can I contribute to the outcome of this patient. (please, no one take offense to that last sentence).

No offense taken.

I wonder though, if more educated nurses are able to still critically think while still accomplishing all those tasks in a crazy environment? Probably not as good, and definitely shows where ratios are one variable to the problem. But even if you have a 1:1 nurse/patient ratio, if you have a nurse who can't "critically think," is the patient going to experience the best outcome possible?

[begalli]

I think either you get it or you don't. I have worked with nurses who just don't get it or they focus on the wrong thing. They usually don't last longer than a year. But I don't think the level of education has anything to do with it. This is that age old discussion. I strongly feel that it's experience, not the level of education. Critical thinking develops, it cannot be taught without repeated exposure to problem solving and a thorough understanding of "how things work and what effects what" (for lack of a better description).

[begalli]

Also, I work with many nurses who have gotten or are in the process of getting their master's degree in cardiovascular nursing. The difference in these folks is that they have the experience to back them up from perhaps years of working (at least the ones who are NOT doing an accelerated masters). In this case, YES! They are AWESOME critical thinkers. They have a deep, deep knowledge and understand of "how things work" and I admire them tremendously. As well do I admire the knowledge and deep understanding an RN who may have graduated 20-30 years ago from a Diploma program and who has years of experience and an equal understand of "how things work." (yep! we have more than a few).

But, the MSN who comes in from an accelerated program who may have no nursing background whatsoever, is just as good a critical thinker as someone who just graduated with an ADN. With both, their critical thinking has not yet developed.

[llg, PhD, RN]

I agree that experience can be a good teacher -- but there are a lot of people who do NOT learn well from experience. Just because has many years of experience, does not mean that the person has learned a lot and/or practices at a higher level. As the saying goes ... "Sometimes, 10 years of experience is just the first year repeated 10 times."

As educational research shows (check out David A. Kolb's work on experiential learning), some people learn best through "hands-on" experience ... other people learn best through "book learning."

I believe the best learning ... and the greatest amount of expertise -- exists in people who do both. They invest in getting concrete experiences and make an effort to actively learn from those experiences ... AND ... they invest in getting the book learning that will help them make the most of those experiences.

Once again ... we nurses need to stop saying that 1 type of learning method is good and the other bad. They are both good and both should be respected.

llg

[VivaLasViejas, ASN, RN]

I'm with you, llg. I work with a few nurses who have been practicing since God was a boy, yet they're forever behind in their work and never think beyond the end of their noses! I also know a few who are only a couple of years out of school, and I'd rather have them taking care of me or my family than anyone else.

That said, I don't believe the level of formal education matters as much as having a solid set of skills and a good head on one's shoulders. When push comes to shove out there on the floor, give me a nurse who knows her stuff and doesn't freak out---and that takes time and experience, not necessarily a higher degree. :stone

[llg, PhD, RN]

That said, I don't believe the level of formal education matters as much as having a solid set of skills and a good head on one's shoulders. When push comes to shove out there on the floor, give me a nurse who knows her stuff and doesn't freak out---and that takes time and experience, not necessarily a higher degree. :stone

I agree ... but how does one develop the knowledge and skills? As I said above, the best learning comes by combining practical experience with book learning. Either one without the other is less than ideal. Instead of wasting a lot of time, energy, and resources arguing about which type of learning is better, we should be investing those resources in helping nurses get both kinds of learning.

llg (ddd is the account from my home computer, llg is my work computer)

[Tweety, BSN, RN]

llg, excellent post. The idea that experience is the greatest teacher only holds true for those with the brains to learn.

Nursing is a learning experience, we need to continually educate ourselves on new treatements, medications, illnesses, etc. through continuing education of some sort, be it reading journals, websites, CEU's, higher education, etc.

Experience is great because you see and deal with things, so the next time you'll be on your toes and can handle it. But that's only part of it.