ADN vs. BSN - patient mortality rates

chare · Aug 3, 2013

Would this be a reference to the long-ago discredited Aiken study? If so...I don't know how it keeps turning up as current, when it was recognized as fatally flawed quite some time ago.

Discredited by whom? Please post a source for this assertion.

MunoRN, RN · Aug 4, 2013

I see a lot of nurses speak very critically about the flaws of the Aiken (2003) study. The most common cited reasons:
1. The hospitals with more BSN nurses have better staffing, more experienced nurses, and board-certified surgeons. Well, the study actually controlled for all these confounders.

The majority of criticism revolves around how these confounders were controlled, not that they were not controlled. Sometimes "controlling" reduces the confounders, sometimes it adds to them. The type of controlling we're referring to here is altering the data, which typically should be minimal even when done well, some of these data sets went through an excessive number of manipulations which by definition makes the results less reliable.

2. The study was done by biased reviewers. Well, like most research, the study was done by academically associated nurse researchers (like clinical trials are done by pharmaceutical companies). It was also extensively peer-reviewed by one of the most stringent journals in healthcare. I don't think the JAMA has a vested interest in the nursing agenda.

I hope you don't really assign absolute credibility to something because it's published in a reputable peer reviewed journal. Dr. Wakefield's now infamous study linking vaccines and autism was published in the Lancet, despite it's questionable basis even before Wakefield admitted he made much of it up. Without getting too off track there's also a whole list of peer reviewed studies that were textbook examples of how to manipulate data to sell drugs. Unfortunately "peer-reviewed" doesn't mean as much as some people think.

3. The Akien study is flawed in its design. How come there have been any other studies that have shown different results?

Other studies used the same design.

4. The study didn't account for nurses that began as diplomas or ADNs. That is an irrelevant point; the years of experience were consistent in both groups.

I'm not sure how a consistent mean years of experience makes that irrelevant, those are two completely different aspects of the study, actually the two opposing characteristics the hypothesis was comparing.

I do feel that the study had some flaws, but people rarely mention them, rather they just rehash these urban myths about the study.

I think every study ever done has "some flaws", but the flaws in these studies, mainly the over-manipulation of data that was of questionable relevance to begin with, is beyond typical. That doesn't mean that these studies aren't correct, but to imply with any certainty that they are correct, without some very clear qualifiers, is dishonest. I'm all for more education, and I'm all for supporting the argument that my BSN was worth the time and money, but given the level of accuracy of these studies combined with the significant changes in ADN curriculum that have occurred since most of the Nurses in these studies graduated, I think we're a long way from saying the level of education is and will continue to be the primary predictor of patient outcomes.

allnurses Guide · Aug 4, 2013

The majority of criticism revolves around how these confounders were controlled, not that they were not controlled. Sometimes "controlling" reduces the confounders, sometimes it adds to them. The type of controlling we're referring to here is altering the data, which typically should be minimal even when done well, some of these data sets went through an excessive number of manipulations which by definition makes the results less reliable.

The effect of nursing education on both the primary and secondary endpoints was (mortality and FtR) was significant in both the raw (unadjusted) and adjusted data. I haven't run the math myself, but I have looked through the statistics they used and all are well established and fairly conservative methods. They did use a logistical regression to predict outcomes from a 10% greater BSN+ workforce, but this was supplemental to the main findings only. Which statistical tests most concern you?

I hope you don't really assign absolute credibility to something because it's published in a reputable peer reviewed journal. Dr. Wakefield's now infamous study linking vaccines and autism was published in the Lancet, despite it's questionable basis even before Wakefield admitted he made much of it up. Without getting too off track there's also a whole list of peer reviewed studies that were textbook examples of how to manipulate data to sell drugs. Unfortunately "peer-reviewed" doesn't mean as much as some people think.

Nothing in healthcare (or life) is absolute. Stringent peer-review reduces the risk of publishing inaccurate and (sadly) dishonest/disingenuous material. If you are likening Aiken's landmark study to Wakefield's, then I would challenge where the refuting articles are, it has been over 10 years?

Other studies used the same design.

A large retrospective cohort study design? What would have been better, a double-blinded RCT? That would be ideal, albiet unethical.

If you are referring to merging of the raw data from two unrelated studies, then we are in partial agreement, and that is one of the major flaws I find with the Aiken article. Logically, errors from that type of design would favor the null, but that can't be proven. It does provide room for error regardless.

I'm not sure how a consistent mean years of experience makes that irrelevant, those are two completely different aspects of the study, actually the two opposing characteristics the hypothesis was comparing.

This is where we, and most of the opponents of the study, do not agree. The primary null hypothesis of the study was that there was no difference in risk-adjusted mortality for hospitals with higher proportions of BSN-educated nurses working at the bedside. The secondary null was that hat there was no difference in failure to rescue for hospitals with higher proportions of BSN-educated nurses working at the bedside.

This study, and a previous study by Aiken, demonstrate that nursing experience is an significant and independent variable in mortality and FtR outcomes. It is important that mean years of nursing experience is consistent across both groups to minimize the effect a previously-demonstrated independent variable.

This study, simply, shows that increasing the education of both new and experienced nurses is associated with a reduction in mortality and FtR in post-surgical patients. It was never designed to test "new grads" or "entry-to-practice" though it provides some evidence in support of it.

I think every study ever done has "some flaws", but the flaws in these studies, mainly the over manipulation of data that was of questionable relevance to begin with, is beyond typical. That doesn't mean that these studies aren't correct, but to imply with any certainty that they are correct, without some very clear qualifiers, is dishonest. I'm all for more education, and I'm all for supporting the argument that my BSN was worth the time and money, but given the level of accuracy of these studies combined with the significant changes in ADN curriculum that have occurred since most of the Nurses in these studies graduated, I think we're a long way from saying the level of education is and will continue to be the primary predictor of patient outcomes.

We disagree about the "manipulation" of the data, as the raw data shows the same significance as the adjusted data. We agree that nothing is absolute/certain. I concede the point that (hopefully) ADN programs have continued to evolve to prepare nurses even better than in the past (though I would argue that BSN programs also have continued to evolve); I do think many ADN programs now approach the credit-hours and distributions of BSN programs and those students should receive the BSN they deserve rather than an ADN only.

Most importantly, in no way do I (or the vast majority of others), think that level education is the "primary predictor" of outcomes; this very study shows that nursing experience and staffing levels are as significant as nursing education.

BlueLightRN · Aug 4, 2013

As an ADN nurse I do not believe that the patient death rates increase just because their nurse doesn't have a BSN. I respect the BSN. I am finishing mine. But I have learned NOTHING and I mean ABSOLUTELY NOTHING clinically from the BSN program that will impact patient's safety or physical well-being. I have learned research methodology, I have learned to write papers on opinions, I have learned some things about different cultural groups (which was touched on in my ADN) but NOT ONE SINGLE SAFETY MEASURE OR CARE PRACTICE that will affect patient outcomes as far as mortality or safety. I am just as good a nurse as a BSN nurse. PERIOD. Take the same test, learned the same skills, do the same care.

westieluv · Aug 4, 2013

I am a diploma RN of 23 years who graduated from a well-respected, hospital-based RN program. I have never, in all these years of working on Med/Surg and Stepdown units, had a patient code or crash, because I always knew when to get the appropriate help and/or get them transferred to a critical care unit.

About a year ago, because both of our kids were in college pursuing Bachelors degrees and because I thought it would be a nice thing to do since I already have around 100 undergrad college credits under my belt (but not in nursing), I decided to look into getting my BSN. Both universities that I looked into had a list of the few classes that I still needed to complete the degree, and none of them had anything to do with delivering care in a clinical setting or patient safety and mortality rates, it was mostly nursing management type of stuff. With zero desire to go into management and the expense of helping put two kids through college, I dropped the plans for the BSN.

I am currently an inpatient dialysis nurse who loves my job and has absolutely no regrets about not having my BSN. I get job offers via phone or email pretty much weekly, even though I am not looking, and to date I still haven't "lost" a patient.

As the PP said, I respect the BSN degree, and is pretty much necessary these days if someone wants to climb the clinical ladder and/or get away from the bedside, but I have yet to see a BSN who is a "safer" nurse, simply because he/she has a BSN degree.

manusko · Aug 4, 2013

I have my ADN degree, the college I graduated from is highly regarded and better prepares their students than the BSN program down the road. Also, the ADN program I graduated from does far more clinicals than BSN program down the road, and in my opinion that is better at preparing student nurses for starting their career. I am not speaking for all the other ADN or BSN programs in the country. I just thought this would make an interesting topic and would like to hear everyone's opinion on this subject.

I've heard this argument over and over again. Everyone went to a well respected school which is better than the other school nearby. I heard this same thing when I was in my BSN program and when I worked with the local (better prepared) ADN students I was not impressed. When I worked in my first hospital I was equally impressed/not impressed with the local BSN and ADN students. It's a matter of every program having good and poor clinicians. Given enough time you will see both.

I also had people get defensive when I was accepted to a big name university an decided to go there over going to the local BSN or ADN program. They argued over how these schools were so highly respected in the area. My question was always "if I leave this area who will know these schools of nursing?" I didn't care either way, I choose the school that allowed me to finish sooner and get to work. My first job didn't care either. They hired 2 nurses: me and one from the local ADN program. They hired the 2 that interviewed the best not by which school we went to.

lind68 · Aug 4, 2013

I have my ADN. quite frankly I do not see a difference in the care that is given. We all get paid the same. I have been contemplating going back to school. however I'm 43 and have no intention of pursuing management. therefore I don't see an incentive.

Katniss88 · Aug 4, 2013

Where I am from there is no difference in pay between an ADN and BSN nurse. I want to earn my BSN to broaden my knowledge and be able to take other opportunities if they came along. I believe that if ADN nurses were hazardous to a patient's health and well being as this article suggests, then having a BSN would by now have became a requirement.

allnurses Guide · Aug 4, 2013

I am sure each and every one of you is the world's best nurse as a diploma or ADN education, I don't doubt your competence or your fabulous outcomes. I see people post the same things over and over about running circles around more educated nurses and PA and even docs.

My question is: do you really think investing in furthering your own education is going to make you a worse nurse? It can only make you better. It by no means implies that the person next to you is better than you simply because of their degree; it does Suggest that you might be better than the prior version of you.

Maybe a BSN won't help you. Maybe you are already the greatest. But the data shows that in aggregate, nursing does a better job with higher overall education.

MunoRN, RN · Aug 4, 2013

The effect of nursing education on both the primary and secondary endpoints was (mortality and FtR) was significant in both the raw (unadjusted) and adjusted data.... Most importantly, in no way do I (or the vast majority of others), think that level education is the "primary predictor" of outcomes; this very study shows that nursing experience and staffing levels are as significant as nursing education.

The raw data was based on different patient ratios, support, and technologies for reducing complications, so I hope you're not putting more faith in the raw data than it deserves.

You seem to be arguing that there's a good chance the 2003 study demonstrated some difference, which I don't think anyone is arguing any different, what we can't say is that we know with reasonable certainty this is true, particularly 10 years later. As a result of this and similar studies, there has been a significant shift in ADN programs and most now have some sort of affiliation with a BSN program, essentially becoming satellite programs of BSN programs and largely adopting their curriculum.

We never isolated the specific cause of the differences these studies suggested, if it was the curriculum then there is likely much less difference today. So while it's probably likely that graduates of many diploma and ADN programs 25 years ago received an education that was significantly different than today's BSN programs, although they were also significantly different than today's ADN programs.

The only realistic way of changing the entry to practice requirement is to simply rename ADN programs as BSN programs, which is unlikely to produce the sorts of significant differences suggested by Aiken's studies.

RHope · Apr 13, 2017

I think that study on patient safety decreasing when there are less BSN prepared nurses working is seriously flawed and should have gone right into the shredder. It seems to be more of a gimmick to bring in more money to 4 year universities. The future of nursing education seems to be taking a downward spiral. Learning research and how to write papers is good in its place, but assessment, procedural, bed side nursing skills are still needed. How can someone really be a safe effective RN if they can't assess? Its really a pity. Nursing is becoming more corporate and less patient centered. I cannot wait to be done with this circus of a profession. The only problem is that someday I may have to be a patient again. What a scary thought for the future.

RHope · Apr 13, 2017

I am a diploma RN of 23 years who graduated from a well-respected, hospital-based RN program. I have never, in all these years of working on Med/Surg and Stepdown units, had a patient code or crash, because I always knew when to get the appropriate help and/or get them transferred to a critical care unit.
About a year ago, because both of our kids were in college pursuing Bachelors degrees and because I thought it would be a nice thing to do since I already have around 100 undergrad college credits under my belt (but not in nursing), I decided to look into getting my BSN. Both universities that I looked into had a list of the few classes that I still needed to complete the degree, and none of them had anything to do with delivering care in a clinical setting or patient safety and mortality rates, it was mostly nursing management type of stuff. With zero desire to go into management and the expense of helping put two kids through college, I dropped the plans for the BSN.
I am currently an inpatient dialysis nurse who loves my job and has absolutely no regrets about not having my BSN. I get job offers via phone or email pretty much weekly, even though I am not looking, and to date I still haven't "lost" a patient.
As the PP said, I respect the BSN degree, and is pretty much necessary these days if someone wants to climb the clinical ladder and/or get away from the bedside, but I have yet to see a BSN who is a "safer" nurse, simply because he/she has a BSN degree.

This is so true. I have encountered some BSN prepared nurses who have NO CLUE what they're doing and they graduated from the prestigious schools. I'm not exaggerating. Trust and believe.