BSN and Associate Nurses Are Neck and Neck. Will This Change?

[allnurses]

AACN published The Impact of Education on Nursing Practice in 2015 which discussed multiple studies about ADN and BSN education. One of the more important statements is about Magnet status. Hospitals that have attained Magnet status, are recognized for nursing excellence and superior patient outcomes, have moved to require all nurse managers and nurse leaders to hold a baccalaureate or graduate degree. Hospitals in the process of applying for Magnet status must show plans to achieve the goal of having an 80% baccalaureate prepared RN workforce by 2020.

Then there are the studies that show that hospitals staffed with more BSN prepared nurses have better patient outcomes. This has been a hotly debated topic on AN. Here is one references:

In an article published in the March 2013 issue of Health Affairs, nurse researcher Ann Kutney-Lee and colleagues found that a 10-point increase in the percentage of nurses holding a BSN within a hospital was associated with an average reduction of 2.12 deaths for every 1,000 patients-and for a subset of patients with complications, an average reduction of 7.47 deaths per 1,000 patients. The study is titled "An Increase in the Number of Nurses with Baccalaureate Degrees is Linked to Lower Rates of Post-surgery Mortality."

One of the more prolific threads on AN was titled the difference between ADN and BSN nurses that was started in December 2014.

Many individual healthcare facilities have created policies that will affect the increasing number of nurses earning a BSN. Due to internal policies, the management at many hospitals across the US have been requiring currently employed LPNs and RNs with diplomas and ADNs to earn BSN degrees within a specified time frame. Many non-BSN nurses are being given an ultimatum. Is this right?

It is still being debated

So...what's your opinion? Is getting a BSN on your agenda?

How is the comparison between the number of ADN and BSN RNs at your place of work?

[OHNBJL]

But minimal clinical benefit does not assure daily competency.

[rzyzzy]

macawake said:

Also, being educated on the scientific method means that you can design and implement (after getting the required ethical approval) your own study.

BSN's don't do studies -ADN's & BSN's can participate in studies, but that educational level isn't where studies come from. And the subject of the thread is bedside nursing, and required minimum standards.

[Cowboyardee]

BostonFNP said:

Just because there is minimal direct clinical work doesn't mean there is no clinical benefit.

Have you taken part in an RN to BSN program? I understand that direct clinical work is not the only path to better clinical practice. The problem is that the non-clinical work in these programs has minimal contributions to clinical practice as well. Talk with people in RN to BSN programs and you'll hear the same complaint over and over again. Look into the research and you'll find precious little to back up RN-BSN programs' efficacy in creating better practitioners.

Ultimately, schools could easily provide classes that do focus on creating better practitioners (advanced pathophysiology or advanced pharm, anyone?). But they don't. Th quality of my clinical practice would be better improved by getting a BA in Spanish. I'm not exaggerating.

[BostonFNP, APRN]

rzyzzy said:

And the subject of the thread is bedside nursing, and required minimum standards.

The subject of the thread isn't about minimum standards, it's about nursing education, outcomes, employer demands, and Magnet status....

Cowboyardee said:

The problem is that the non-clinical work in these programs has minimal contributions to clinical practice as well.

Based on what data? I don't necessarily disagree with you on the notion but I haven't seen any data that demonstrates that. The bulk of the extant data certainly supports better outcomes for higher degrees in nursing.

[BostonFNP, APRN]

OHNBJL said:

But minimal clinical benefit does not assure daily competency.

Not sure who this was in response to, or what it means, can you elaborate for us?

[Cowboyardee]

BostonFNP said:

Based on what data? I don't necessarily disagree with you on the notion but I haven't seen any data that demonstrates that. The bulk of the extant data certainly supports better outcomes for higher degrees in nursing.

Based on the anecdotal evidence of reports from people who have taken the RN to BSN route. And based on personal experience.

Flimsy, you might say. Sure. But here's the thing - the data that supports better outcomes for higher degrees in nursing...

a) has never actually studied the difference between ADNs and diploma nurses who do not go the BSN route vs nurses who go the RN to BSN route controlling for experience - this subgroup has not been isolated, AFAIK

and

b) are so seriously flawed in terms of poorly controlling their variables that they appear to be deliberately misleading (and, in truth, I suspect they are to some extent). The methodology to use statistics to accurately study a single variable in complex systems is not newly discovered, radical, unfeasible, or particularly controversial. And yet studies tying patient outcomes to RN education levels assiduously avoid proper methodology. Why?

In short, personal lived experience is better than fatally flawed 'scientific' analysis.

[BostonFNP, APRN]

Cowboyardee said:

Based on the anecdotal evidence of reports from people who have taken the RN to BSN route. And based on personal experience.

In short, personal lived experience is better than fatally flawed 'scientific' analysis.

I understand. You experienced something personally and it sounds like you were frustrated. You heard others express the same. And so you disagree with the myriad of studies on the topic. Everyone is entitled to their opinion. I just cringe a little when it devolves into calling studies "fatally flawed" because you don't agree with the results; that's pseudoscience.

And by no means do I consider personal experience paramount to any published data. That again, is pseudoscience.

Cowboyardee said:

But here's the thing - the data that supports better outcomes for higher degrees in nursing...

a) has never actually studied the difference between ADNs and diploma nurses who do not go the BSN route vs nurses who go the RN to BSN route controlling for experience - this subgroup has not been isolated, AFAIK

Again, why is this important. It's a talking point that was put out by the OADN because it superficially sounds like a great point, but I have yet to have anyone tell me why it is important. I have stated before, I think it is actually a strength of the study as it demonstrates that advancing education throughout the career improves outcomes not just at the entry.

Cowboyardee said:

b) are so seriously flawed in terms of poorly controlling their variables that they appear to be deliberately misleading (and, in truth, I suspect they are to some extent). The methodology to use statistics to accurately study a single variable in complex systems is not newly discovered, radical, unfeasible, or particularly controversial. And yet studies tying patient outcomes to RN education levels assiduously avoid proper methodology. Why?

Cite some specific examples. What exactly concerns you about their statistical analysis? This is another common talking point but I have never seen anyone actually cite anything in particular. It passed a rigorous peer-review process in a major medical journal.

Additionally, a half-dozen international studies have replicated the outcome using different methods.

[vettechgrl]

As a new grad that's been job searching for 4 months I agree. The hospitals and staff say they are so short handed, yet here I am a new grad with 3.9 GPA 1st time Nclex passing potential employee willing to work nights and weekends with a stable 16 year previous job history and all I hear are crickets. Now I'm nervous to incur more student loan debt to get my BSN as I have had such a tough time in this job market. It's very discouraging!!

[MunoRN, RN]

BostonFNP said:

Kutney-Lee, A., Stimpfel, A. W., Sloane, D. M., Cimiotti, J. P., Quinn, L. W., & Aiken, L. H. (2015). Changes in patient and nurse outcomes associated with Magnet hospital recognition. Medical care, 53(6), 550-557.

Friese, C. R., Xia, R., Ghaferi, A., Birkmeyer, J. D., & Banerjee, M. (2015). Hospitals in Magnet's program show better patient outcomes on mortality measures compared to non- Magnet's hospitals. Health Affairs, 34(6), 986-992.

McHugh, M. D., Kelly, L. A., Smith, H. L., Wu, E. S., Vanak, J. M., & Aiken, L. H. (2013). Lower mortality in magnet hospitals. Medical care, 51(5), 382.

That's a misleading answer to a misleading question, which was "No(t) quite sure if magnet desire for BSN and above really improves patient care".

There is no BSN requirement for Magnet in terms of staff nurses, only for management, and the studies you linked don't establish or even suggest that transitioning staff to BSN's improve outcomes, they looked at Magnet status and outcomes.

[Susie2310]

Cowboyardee said:

Based on the anecdotal evidence of reports from people who have taken the RN to BSN route. And based on personal experience.

Flimsy, you might say. Sure. But here's the thing - the data that supports better outcomes for higher degrees in nursing...

a) has never actually studied the difference between ADNs and diploma nurses who do not go the BSN route vs nurses who go the RN to BSN route controlling for experience - this subgroup has not been isolated, AFAIK

and

b) are so seriously flawed in terms of poorly controlling their variables that they appear to be deliberately misleading (and, in truth, I suspect they are to some extent). The methodology to use statistics to accurately study a single variable in complex systems is not newly discovered, radical, unfeasible, or particularly controversial. And yet studies tying patient outcomes to RN education levels assiduously avoid proper methodology. Why?

In short, personal lived experience is better than fatally flawed 'scientific' analysis.

I think this is the best post on this thread.

[Cowboyardee]

BostonFNP said:

I understand. You experienced something personally and it sounds like you were frustrated. You heard others express the same. And so you disagree with the myriad of studies on the topic. Everyone is entitled to their opinion. I just cringe a little when it devolves into calling studies "fatally flawed" because you don't agree with the results; that's pseudoscience.

Hold on there - I called studies fatally flawed because of their methodology and flawed assumptions. Be a good 'scientist' yourself - wait to hear my reasoning before making assumptions about my conclusions.

And by no means do I consider personal experience paramount to any published data. That again, is pseudoscience.

That's not pseudoscience either. I admitted readily that I was speaking from personal experience and made no claims to science at all. It was non-science.

Again, why is this important. It's a talking point that was put out by the OADN because it superficially sounds like a great point, but I have yet to have anyone tell me why it is important. I have stated before, I think it is actually a strength of the study as it demonstrates that advancing education throughout the career improves outcomes not just at the entry.

It's important for several reasons:

1 - Because it is entirely possible that even if BSN education has some general benefits over ADN or even diploma programs, that those same benefits are not true of some or most RN to BSN programs. Perhaps these programs are simply lower quality. This would more closely match my experiences and those of the RN to BSN students I've talked to.

2 - Because it is entirely possible that even if BSN education has some real benefits toward patient outcomes among nurses who recently graduated, that these benefits would evaporate after some amount of practice.

3 - Because when you want to convince practicing nurses (i.e. your peers) to spend ~$20,000 and hundreds to thousands of hours on additional education to bridge a 'gap

that appears invisible in the workplace, you should probably have a tiny bit of demonstrated efficacy. Like, something... anything... that actually addresses those whose time and money are apparently up for grabs.

Cite some specific examples. What exactly concerns you about their statistical analysis? This is another common talking point but I have never seen anyone actually cite anything in particular. It passed a rigorous peer-review process in a major medical journal.

Additionally, a half-dozen international studies have replicated the outcome using different methods.

I addressed some parts of your post above (bold, underlined, in the quote), but I'll cite an example here. In truth, I have neither the time nor the inclination to address every single study that has ever been printed on the matter. So if you feel as though there is a study that more adequately controls its variables, you are welcome to post it here.

I will refer to the 2013 study correlating nursing education levels with patient mortality, for a few reasons. For one, it is one of the easier studies to find in full without access to one database or another. For another, it is one of the most cited studies on the topic, and perhaps the one most strongly linking RN education levels to patient outcomes. Here is a link to the study itself:

http://www.aacc.nche.edu/Resources/aaccprograms/health/Documents/Health%20Aff-2013-Kutney-Lee-579-86.pdf

First, a brief summary. The study in question looked at hospitals in Pennsylvania at two different time periods, recording hospital-reported patient mortality for surgical patients and RN-reported educational levels, staffing levels, and years of experience. The study found that an increase in the percentage of BSN educated nurses within a hospital was associated with lower mortality rates. The study attempted to isolate and control for those other variables (staffing levels, years of experience, and 'skill mix' for nurses), though the authors admitted that staffing levels and skill mix did not change enough in most of the hospitals tested for the results to be statistically useful. Fair enough so far?

So what are my criticisms? Mainly the following:

1) The study authors assumed they had shown that nursing education was a causative factor with respect to patient mortality when in fact they had only shown it to be correlative. This is just bad science. Often, media and various institutions make this mistake when reporting the results of a study, but study authors should know better, and frankly it makes me question the objectivity of their research. What's more, the authors even go on to make some ill-considered statements about the nature of the causative effect of RN education. I'll quote below.

Quote

"If all of the study hospitals had moved to a nursing workforce containing 80 percent of nurses with baccalaureate, more than 2,100 lives might have been saved—which is equivalent to 60 percent of the observed deaths in 2006... we assumed that the coefficient associated with a ten-point increase in the percentage of baccalaureate-prepared nurses was linear. That is, the number of deaths prevented would be the same for hospitals increasing their percentage of nurses with baccalaureates from 20 percent to 30 percent as it would be for hospitals moving from 70 percent to 80 percent."

Seeing as they had no business assuming they had found a causative relationship in the first place, this is doubly ill-considered.

2) They omit discussion (to say nothing of measurement) of any outside factors that might contribute to the correlation they found. This is somewhat more egregious since some of these factors are fairly obvious and also quite measurable. Pages earlier in this thread, Dogen mentioned the likelihood that hospitals increasing their BSN-prepared workforce might also acquire state of the art facilities (cath labs, differentiated specialized ICUs, advanced therapies, more in-house specialists). Most of these things can be measured. All of them can be discussed. The study did neither.

I'll go a step further and propose a couple scenarios that might explain the correlation found.

I suggest that any hospital significantly increasing its proportion of BSN prepared nurses is either finding itself in a job market where it can afford to be picky and/or looking to improve its reputation and selling points to the general public (which may include pursuing some of those specialized services outlined in the paragraph above). I think it should be easy for any intelligent person familiar with healthcare to see how either one of those things might lead to lower patient mortality without the additional education for nurses having any causative effect at all.

I also suggest that in some cases, higher level of services (and the accompanying lower patient mortality) may attract BSN-prepared nurses, as BSNs are more likely to want to pursue a higher degree, and experience in well-equipped high tech hospitals is seen as advantageous for the admissions process.

It's very late, and this has been a long post, so I'm going to call it a day. Hopefully, my point is loud and clear. The study above is one of the centerpieces of the argument for a BSN education. But it's significantly flawed, and the authors' willingness to conflate correlation with causation is unscientific and unprofessional enough that I truly question the motives and objectivity of those who participated.

[rzyzzy]

If we're trying to prove or disprove a theory based on education, perhaps we should start small & work our way up first. Rather than trying to correlate for something as big & full of variables like "patient mortality" & "BSN prepared" nurses, knowing that there are multiple failures outside of nursing that can affect "patient mortality" & multiple paths to getting "BSN prepared"...

Let's start with something "education related" that doesn't have nearly as many moving parts & already has lots of well-studied data - I dunno, maybe first-time NCLEX pass rates for adn vs. bsn new grads. How is it possible for many adn programs to have first-time nclex pass rates that are the same or better than bsn programs? If the nclex is somehow irrelevant to patient care & mortality rates, and our goal is actually to improve patient care & mortality rates, then don't you think we should "fix" the nclex first?

When you can prove a convincing link to something as small & easy as that, then you can build on the theory. My problem - (admittedly 100% biased & self-serving) is, looking at nclex pass-rates for my local "mail-order adn-bsn mills" , who also pump out bsn's who didn't get an adn first, is seeing that their first-time nclex pass rates for their entirely in-house bsn's are 10%+ lower than the adn's from our local community college.

Any theory that requires me to believe that the bsn's who pass the nclex at a lower rate than the adn's are somehow "better" nurses out-of-the-gate relies on "magic beans", not science. Like it or not, the nclex is the measure we have, and it shows - pretty convincingly, that my adn is superior to a BSN from a mill - but somehow dropping $30k on an adn-BSN from the exact same mill (with a lower nclex pass-rate) makes me a "better" new-grad nurse.

Either the adn-BSN mills are getting a "free ride" based on junk science, or the nclex is completely irrelevant to "minimum entry standards" - and if you're going to argue that the nclex is irrelevant, you're trying to piss up a rope. (Scientifically speaking, of course).