BSN's deliver safer care than ADN's??

[sbic56, BSN, RN]

Now, I am all for further education, but I think this study is skewed. I truly don't see how they have come to the conclusion that taking more courses in the humanities and other such non-nursing related courses is going to produce a more competent bedside nurse. The core nursing cirriculum for most ADN and BSN programs is quite similar in my experience. I can see where the BSN nurse may have it over the ADN in managerial type roles, but as a bedside nurse? I think lots more studies need to be done before this quick conclusion is drawn. One factor that may affect nursing in this negative way is the poor economy. Maybe it is that some people are going into nursing just because it will almost guarantee them employment and don't really want to be in nursing and therefore are not as dedicated as nurses? These people may not want to go for the BSN. I don't know...that is just something I am throwing out there because this makes no sense to me. I don't want to start the old BSN vs. ADN war, but this is news and I was wondering, what do you all think?

http://www.upi.com/view.cfm?StoryID=20030923-050052-9024r

WASHINGTON, Sept. 23 (UPI) -- The ongoing nursing shortage in the United States has forced some hospitals to rely on nurses with less than a college education as they scramble to fill vacancies but new research suggests the practice can yield deadly consequences for patients.

The study, the first of its kind, reveals patients undergoing surgeries at hospitals where a greater proportion of nurses have obtained a bachelor's or higher degree experienced a lower rate of death than patients at hospitals where most nurses had only associate degrees.

Such findings have implications not only for patients but also for how nursing schools, hospitals and even the U.S. Congress should address the nursing shortage, Linda Aiken, a nurse and lead investigator of the study, told United Press International.

These institutions have made efforts to address the nursing shortage by facilitating the rapid training of nurses via associate degree programs, but the study indicates in the long-run the strategy might be worse for both patients and hospitals, said Aiken, who is director of the center for health outcomes and policy research at the University of Pennsylvania's School of Nursing in Philadelphia.

It underscores the need to find ways to increase the numbers of nurses graduating from bachelor degree programs, she said, noting some hospitals studied did not employ a single nurse with a bachelor's or higher degree.

In the study, which is published in the Sept. 24 issue of the Journal of the American Medical Association, Aiken's team examined patient data from 168 Pennsylvania hospitals over a 19-month period beginning in 1998. They found, all other factors being equal, hospitals where 60 percent of the nurses held a bachelor's degree or higher had a 19-percent lower rate of surgical patients dying within 30 days of admission or dying from complications than hospitals where only 20 percent of nurses had higher degrees.

The authors estimate if all the hospitals in the study could meet the 60-percent, bachelor's-degree-or-higher threshold, 725 patient deaths could have been prevented over the study period.

The differences in patient mortality rates "are stunning and should make people very concerned," Geraldine Bednash, a registered nurse and executive director of the American Association of Colleges of Nursing, told UPI. "One of the first questions (patients) ought to ask people in a hospital is what is the proportion of their nurses with bachelor's degrees, and if it's not 60 percent or higher, I'd be very concerned about going into that hospital," Bednash said.

The higher rate of patient deaths associated with lower education level is compounded by the fact that "all of the federal government's projections about the nursing shortage over the past decade have not only projected a shortage of nurses but a severe shortage of baccalaureate degreed nurses," Aiken said. At present, less than half of all hospital staff nurses across the nation hold bachelor's degrees or higher.

"Policymakers seem to think we just need to get nurses out fast," but that is not good for hospitals or patients, Bednash said, suggesting legislators should focus on developing ways to produce more nurses with bachelor degrees because "it makes a difference in people's care and whether or not they live or die."

President George W. Bush signed the Nurse Reinvestment Act into law in 2002 in an effort to remedy the nursing shortage and Congress will likely authorize no more than $163 million for fiscal year 2004. But this falls far short of the $250 million the American Association of Colleges of Nursing estimated would be needed to address the problem.

"To date, we've had mostly a symbolic response from Congress," Aiken said, noting the money the legislative body has appropriated is "not a sufficient amount to close the nursing shortage."

Hospitals also have a role to play in addressing the problem, however, Aiken continued. They should "subsidize continued education to the nurses because there is a return to the hospital in terms of greater productivity and better patient outcomes," she said. But many hospitals do not seem to recognize the value of more education in their nurse because many have discontinued tuition reimbursement programs to help their nurses obtain bachelor's or advanced degrees, she said.

Aiken also noted the study found nursing experience was not associated with lower mortality rates of patients. "It's the educational level that's important and experience alone cannot achieve the same level of benefit for the patient as education plus experience," she said.

Joan Hrubetz, dean of the school of nursing at Saint Louis University, said as medical treatments become even more sophisticated, hospitals "will need nurses with advanced education to be able to deal with the kinds of treatments and diagnostics" that likely would be developed in the era of genetics and molecular-based medicine. "I don't think there's any question we need better trained nurses," Hrubetz told UPI.

Nevertheless, hospitals appear to be reluctant to make any changes based on this single study.

"Hospitals are very interested in studies such as this ... but it really needs to have further studies done because this really only represents one state," Rita Turley, president of the American Organization of Nurse Executives -- a subsidiary of the American Hospital Association -- told UPI.

The good news is although enrollment rates in baccalaureate nursing programs had been down over the past decade, they now appear to be on the rise. In addition, many schools are offering rapid training programs, in which holders of bachelor degrees in other fields can obtain a bachelor's degree in nursing in approximately one year, which may help increase the number of people joining the nursing profession.

[barefootlady, ADN, RN]

Very few BSN nurses stay at the bedside to learn through patient care. They move quickly into supervision or other paper jobs. It is a shame that some supervisors are making decisions about patient care and don't have enough time at the bedside to know what some patients really need in the way of adequate patient care. Don't say it's the floor nurse's job to point out that the patient may not be approiate for the unit. I have been there, done that, and been told you have the bed, the patient is yours.

BSN vs. ASN has been an ongoing debate for over 20 years, no answers in sight. It depends on the nursing heart/instinct of the nurse at the bedside most of the time. Administration wants only a warm body to fill a need a the present time. That is why bedside nursing is in such trouble. Too many shortcuts have been endorsed by institutions that are not in the best interest of the patient. Nurses want to give good care, when we can't we feel terrible, this leads to burn out and looking at other jobs, such as HH jobs, where we can give care and bond with out patients. Sorry this is so long but education is not the only way to judge a nurse.

[2banurse]

Considering the competition to get into an ADN program, I believe, that most ADNs have actually gone almost as long or if not longer to school. In order to get into my ADN program, you really need to have all of your prerequisites done by the time you apply for the program, so that means that the last semester before starting the nursing portion, many students will take additional classes (sciences, maths and humanities). This especially comes into play when it is the intention of students to continue on to the BSN or ADN-to-MSN program after getting their ADN.

I think that as Sbic56 stated, I too, believed that the results are somewhat skewed as well.

Kris

[bonjovigirl]

OMG, I am only a student but i heard this today on the news and was floored! I mean I really don't know what to say about this. Maybe the hospitals with over 60% bsn nurses recognize the limits of being human and staff their floors more adequatly? Less turnovers, better staff morale? I do know a nurse with a bachelor's and she works in a hospital that only hires bsn nurses(thats what she tells me) and she is well paid, and rarely works short, she absolutely loves her job. Maybe thats where these numbers are coming from??

[OC_An Khe]

This study does not surprise me in the least. Hospitals in this area have long recognized this and will hire a BSN over ADN any chance they get.

I don't see any less retention at the bedside between BSN and ADN prepared nurses. If you like direct patient care you stay in this area, if you don't then you move to other areas of nursing or out of nursing all together. Granted a BSN gives you more flexibility in moving away from the bedside and this leads to the erroneous perception that BSN nurses don't want to stay at the

bedside.

[New CCU RN]

Originally posted by 2banurse

Considering the competition to get into an ADN program, I believe, that most ADNs have actually gone almost as long or if not longer to school. In order to get into my ADN program, you really need to have all of your prerequisites done by the time you apply for the program, so that means that the last semester before starting the nursing portion, many students will take additional classes (sciences, maths and humanities). This especially comes into play when it is the intention of students to continue on to the BSN or ADN-to-MSN program after getting their ADN.

I think that as Sbic56 stated, I too, believed that the results are somewhat skewed as well.

Kris

Just FYI, most BSN programs also require you to have your prereq's done prior to getting into the actual program... for instance for my BSN program year one we had to take:

A&P one and two, Chem, Organic Chem. Psych, Child Psych, Writing one and two, and a math course. A minimum of a 3.0 was required to get in....

To get into the program, we had to interview with a few nursing professors as well the director, do some health care related community service, write a couple essays and a goal statement.

This was all after being accepted into the university...even though you were a student in the university, you still needed to be accepted into the "nursing program".

It was also quite competitive, in fact only about 30% of students that applied were accepted into the program as they only had 25 seats. There were still other core courses required while you were in the program, but the "prereq's were mandatory to be completed with a B prior to even being considered for the program.

I am not debating which is better...BSN or ADN or diploma. I just wanted to let you know the process at many universities in order to get into their programs.

I really don't care or even know what my coworkers education level is... so long as they are competent, a team player, and provide good patient care. Personally, I recieved an excellent education from my BSN program and would recommend it to anyone. I have no regrets about it and it was the happiest 4 years of my life thus far :)

[smk1, LPN]

I've stated this before but if "the powers that be" think all nurses should be bsn prepared, then they need to quit whining and take steps to allow a plausible way for this to happen. Most people DO NOT live near a 4 yr institution or if they do it may be private which means they can't afford it. So the state universities really need to get into some kind of co-op program with the community colleges so that you can finish your bs on the community college campus via telecourse or distance learning or something. This way people can earn their 4 yr degree from the university without actually having to set foot on the university campus. Until this happens all the studies in the world aren't going to do anything except further divide nurses/nursing as a whole. I am currently a pre-nursing student at a community college and plan to go straight to my bsn however you can't get into the bsn program without first being an RN here. (and this is the only state college that services sw washington and part of northern oregon.) Yeah the people in charge of this situation really thought it through huh?

[Cynthiann]

Correlation does not mean causation. To know how accurate this study is you have to look at all the factors. Maybe the hospitals that have more BSN nurses put more effort on better ratios and retention of their staff and also do things to be more attractive to a BSN graduate. Maybe they mostly recruit from Universities. That's why I take these kind of reports with a grain of salt.

[pama]

How sad at this point in time the division continues. Below is the response from the National Organization for Associate Degree Nurses. Seems the JAMA article left out some pretty important facts.

N-OADN

National Organization for Associate Degree Nursing

MEMORANDUM

TO:N-OADN List Serve

FROM:Sharon L. Bernier, President

SUBJECT:Update: JAMA Article "Educational Levels of Hospital Nurses and Surgical Patient Mortality", September 23, 2003

DATE:September 23, 2003

The National Office was contacted by an AP Medical Reporter last Thursday asking for our response to the above article. Carol Hodgson, Director of Public Relations, and I were at the NLN Summit in San Antonio. We shared the article with several colleagues including Libby Mahaffey and Jodi Parks for feedback. I then sent it to all of the N-OADN Board and our new consultant for Research, Dr. Art Viterito. I am going to share with you what I said to the AP reporter and some of the salient points from Dr. Viterito, Kathie Malloy from Community College of Allegany County in Pittsburgh. My response was based on collaboration with all of the above persons.

You can access the article through http://jama.ama-assn.org. Feel free to use any of the information here should you be contacted by your local media. This will be the lead piece in the October Executive Summary. Please consider sending letters to JAMA after you have read the article and formed your opinions. Please share with me if you do respond either to JAMA or to a reporter. I will share with the Board.

Response to AP Reporter Questions

1.Is there any merit to the conclusions, why or why not?

The conclusions are unsupported by the data and there are serious questions about the flawed methodology.

The real conclusions may be that:

vPatients admitted to a high tech and/or teaching hospital have a better chance of survival.

vAn older patient population would, in and of itself, result in higher mortality regardless of staff education levels. The study says that the average patient age in hospitals with larger numbers of AD nurses is 61.9 years and in hospitals with highest BSN levels it is 57.3 years.

vHospitals with the highest percent of AD nurses also have excessively high patient loads. The authors say that they controlled for this but did not say how. In fact, a small percentage of AD nurses with excessively high patient loads could greatly skew the outcome.

2.Why would educational level make a difference, assuming that all RNs need to pass the same licensing exam?

The study says that it compares AD and BS educated nurses but this is clearly not the case. The samples are far from pure:

vThe numbers of diploma and AD nurses is unclear and when clumped together give a false impression of the sample. For example, Pennsylvania has the second largest number of diploma programs in the contiguous United States.

vThe BSN and above include masters prepared nurses, who are usually nurse practitioners, and doctorally prepared nurses. For example, Pennsylvania is the 6th highest state in the nation for percentage of nurses with advanced degrees.

vThe combination of the groups is troubling since there are distinct differences in the education levels once you go beyond the AD/BS nursing education.

3.Were the researchers able to control for other factors that presumably would affect patient outcome, such as severity of the patient's condition, surgeon's skill level and educational level?

It is unclear what the positions were with regard to these issues:

vPhysician preparation seemed to conclude that if the surgeon was Board Certified then no mistakes could or would be made.

vThe article noted control of acuity level, but no explanation was given for how this was done.

vBSN/MSN nurses tended to work in the high tech/teaching hospitals and to have lower ratios of nurse to patient 4:1 as compared with the ADN at 8:1. Higher patient ratios lead to more limited ability to provide quality patient care no matter what the education level of the nurse.

Sharon L. Bernier, PhD, RN, CS-P

President

[email protected]

[email protected]

Discussion Points on the JAMA Article

Contributors

Carol Hodgson, TAC

Libby Mahaffey, HCC

Kathleen Malloy, CCAC

Jodi Parks, Florida

Art Viterito, CSM

Charlotte Warren, GPC

1.Data on hospitals is aggregated for the purpose of statistics.

-Data based on hospital statistics and not on who actually cared for the patient.

-A hospital that is deemed BSN in nature could in reality have different care data internally i.e. an ADN could have taken care of the patients who did not die or were rescued.

2.Data already show that there is lower mortality and better rescue with high tech larger facilities than small rural facilities.

-This article correlates this type of hospital to BSN staffing.

-There is no distinction with regard to who is caring for the patients. Are BSNs caring for the patients who survive or are rescued 24/7?

3.RN highest credential

-Classification determination (page 1618) was decided based on the RNs higher credential at the time of the survey.

-It does not indicate whether the initial nurse education was at diploma, ADN or BSN. Many ADNs have gone on for a BSN/MSN/PHD.

-Assumes that the impact of decreased mortality is only due to the BSN and does not address any basic education impact.

4.Pennsylvania

-The opening statements of the article are misleading regarding the breakdown of the types of education in the state: 15.3% of PA nurses are diploma graduates, 20.9% are AD nurses. So there is an almost even distribution of these two types in PA.

-The percentage of nurses with advanced degrees exceeds the number of ADNs in PA.

-A much larger proportion of ADNs-16.4% work in rural areas.

-Only 11.4% of BSN and 11% of nurses with higher degrees work in rural areas.

-Much of rural PA is very poor.

5.General

-The comparisons of BSN workload at 1:4 in a teaching hospital and the ADN at a non high tech/teaching hospital at 1:8 is faulty methodology.

-The data and the research design are faulty and misleading.

-Conclusions based on this study are misleading and damaging to the profession as well as irresponsible.

[Katnip, RN]

Without being able to see the actual study, nobody can say where it's flawed or exactly where the flaws are. All we're seeing is a report about it, and the media tends to skew things their own way.

So we really can't know what the study said, or how accurate and reliable it is.

[RNMBA]

I'll also reserve judgement until I can read the actual study.

However, there is no difference in the clinical skills of a recent graduate of any RN program (ADN, BSN, Diploma). Once students have been out of school for about a year you can't tell which is which. The management preperation of most BSN programs is laughable and does not contribute to meaningful performance in the real world.

I started my career with an ADN and completed a BSN enroute to a graduate degree. I've worked in many challenging and competitive environments over the years. Your choice of program types should be dictated by your future plans and not by any perceived intrinsic benefit of the progam in isolation.

[NRSKarenRN, BSN, RN]

Vol. 290 No. 12, September 24, 2003 Featured Link

Educational Levels of Hospital Nurses and Surgical Patient Mortality

Linda H. Aiken, PhD, RN; Sean P. Clarke, PhD, RN; Robyn B. Cheung, PhD, RN; Douglas M. Sloane, PhD; Jeffrey H. Silber, MD, PhD

JAMA. 2003;290:1617-1623.

http://jama.ama-assn.org/cgi/content/abstract/290/12/1617

Context Growing evidence suggests that nurse staffing affects the quality of care in hospitals, but little is known about whether the educational composition of registered nurses (RNs) in hospitals is related to patient outcomes.

Objective To examine whether the proportion of hospital RNs educated at the baccalaureate level or higher is associated with risk-adjusted mortality and failure to rescue (deaths in surgical patients with serious complications).

Design, Setting, and Population Cross-sectional analyses of outcomes data for 232 342 general, orthopedic, and vascular surgery patients discharged from 168 nonfederal adult general Pennsylvania hospitals between April 1, 1998, and November 30, 1999, linked to administrative and survey data providing information on educational composition, staffing, and other characteristics.

Main Outcome Measures Risk-adjusted patient mortality and failure to rescue within 30 days of admission associated with nurse educational level.

Results The proportion of hospital RNs holding a bachelor's degree or higher ranged from 0% to 77% across the hospitals. After adjusting for patient characteristics and hospital structural characteristics (size, teaching status, level of technology), as well as for nurse staffing, nurse experience, and whether the patient's surgeon was board certified, a 10% increase in the proportion of nurses holding a bachelor's degree was associated with a 5% decrease in both the likelihood of patients dying within 30 days of admission and the odds of failure to rescue (odds ratio, 0.95; 95% confidence interval, 0.91-0.99 in both cases).

Conclusion In hospitals with higher proportions of nurses educated at the baccalaureate level or higher, surgical patients experienced lower mortality and failure-to-rescue rates.

Author Affiliations: Center for Health Outcomes and Policy Research, School of Nursing (Drs Aiken, Clarke, Cheung, and Sloane), Leonard Davis Institute of Health Economics (Drs Aiken, Clarke, and Silber), Department of Sociology (Dr Aiken), Population Studies Center (Drs Aiken, Clarke, and Sloane), and Departments of Pediatrics and Anesthesia, School of Medicine (Dr Silber), University of Pennsylvania, Philadelphia; and Center for Outcomes Research, Children's Hospital of Philadelphia (Dr Silber).