Does this article prove that BSN nurses are safer than ASN?

Published

What would be some of your criticism of the author's methodology? I am doing a review of this article for a statistics class and am looking for some fresh perspectives.

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.

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).

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it could point to a correlation within this study but you need replication, you need more clearly defined settings (there are too many unintended variables). Are they picking patients that all have similar medical histories when going in for chemo or surgery? What if some have multiple disease processes going on? What is the support staff level? I was nice to see that they "controlled" for ratios and technology, but that is not enough. What are the hospital philosphies? Are they mixing primary nursing situations with group nursing? etc... In my opinion the only way to check this type of thing is to pick hospitals with similar technology, staff in all levels and capacity. then you do a blind sutdy where no one knows the study is being done, and you give the BSN nurses the same "type" of patient as the ADN nurses. (you need to use nurses with the same experience level and who have ONLY the degree requirements for BSN or ADN as well)., You would have to replicate this situation MANY MANY times across the country, and then see if you get similar results either way each time. (there would still be issues with this set up as well)

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Specializes in Critical Care, Pediatrics, Geriatrics.

totally agree with SMK...too many unnamed variables to form an opinion on this study, and one study does not prove nor disprove anything.

The patients must have similar history/current illness which I can guarantee you that they do not.

The ADNs/BSNs being studied must be entry-level to provide a true outcome because experience will skew the results. A new BSN grad has nothing on a 20yr ADN and vice versa regardless of degree.

Hospital protocol/assistive staff/training program attendend/etc. etc. etc. all add to the variables. The study claims that all this was adjusted for? I am afraid that it is not that simple...one of many things I learned in statistics was not to trust them.:uhoh21:

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What would be some of your criticism of the author's methodology? I am doing a review of this article for a statistics class and am looking for some fresh perspectives.

No, Roland, the article does not prove that BSN prepared nurses are safer; it merely proves that in nursing with enough "political" stroke one can take a weak study, make totally unfounded conclusions and still be published in a prestigious journal. :angryfire

No sense in reinventing the wheel though. There are plenty of "criticisms" out there. One good place to start would be the noadn.org web site.

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Specializes in Med-Surg.

That's an old study that has some problems. VickyRN did a very good analysis of that study and there are flaws. I don't have much time right now to find the counter-articles to this study.

One thing when reading research is to approach if with a critical eye, looking for bias, flaws, etc.

Also one study does not prove anything. It must be replicated and can not be generalized.

So no, it doesn't prove anything.

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Specializes in Gerontological, cardiac, med-surg, peds.

Everyone has made excellent points so far concerning this study. I will add my :twocents: before I go off to work this morning.

One thing to remember with research, is that research never proves anything. Research is valuable, however, in that it can lend evidence in support of or not in support of a particular premise or hypothesis. Therefore it is very important that one critically appraise the design and methodology of a research study before accepting the results as "gospel." Also remember that statistics can be manipulated in so many ways.

I have posted this information before (at least twice on the bulletin board), but will repeat:

Probably one of the most controversial research reports of all times in the great BSN versus ADN entry level debate among nursing academia is the Aiken study. This one research study was the major catalyst for the Institute of Medicine (IOM) calling for a ratio of 60% BSN and 40% ADN/ diploma in the North Carolina nursing workforce.

Study Design: quantitative, observational study with cross-section design

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).

Purpose: "We tested whether hospitals with higher proportions of direct-care RNs educated at the baccalaureate level or above have lower risk-adjusted mortality rates and lower rates of failure to rescue (deaths in patients with serious complications). We also examined whether the educational backgrounds of hospital RNs are a predictor of patient mortality beyond factors such as nurse staffing and experience. These findings offer insights into the potential benefits of a more highly educated nurse workforce."

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.

"Our findings indicate that surgical patients cared for in hospitals in which higher proportions of direct-care RNs held bachelor's degrees experienced a substantial survival advantage over those treated in hospitals in which fewer staff nurses had BSN or higher degrees. Similarly, surgical patients experiencing serious complications during hospitalization were significantly more likely to survive in hospitals with a higher proportion of nurses with baccalaureate education."

"Nursing education policy reports published in the past decade concluded that the United States has an imbalance in the educational preparation of its nurse workforce with too few RNs with BSN and higher degrees. Our findings provide sobering evidence that this imbalance may be harming patients."

Sampling plan:

Cross-sectional analyses of outcomes data for 232,342 general, orthopedic, and vascular surgery patients discharged from 168 non-federal 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.

The authors analyzed outcomes data derived from hospital discharge abstracts that were merged with information on the characteristics of the treating hospitals, including unique data obtained from surveys of hospital nurses. The institutional review board of the University of Pennsylvania approved the study protocol.

Voluntary, anonymous survey: Questionnaires sent to 50% random sample of RNs residing in Pennsylvania and on the rolls of the Pennsylvania Board of Nursing; surveys completed by 10,184 nurses, a 52% response rate (which averaged more than 60 nurses per hospital).

Random selection of participants with 52% response rate.

Very large achieved sample: 10,184

Researchers indicated no response bias from the relatively low 52% response rate achieved sample. "Demographic characteristics of the respondents paralleled those of Pennsylvania hospital nurses in the National Sample Survey of Registered Nurses" in terms of average ages, working full-time, and having a BSN degree (30% and 31% respectively).

Descriptive statistics (means, SDs, percentages, chi-square, and F tests) were used to compare groups of hospitals that varied in terms of their educational composition on hospital characteristics, including nurse experience and nurse staffing, and patient characteristics.

Logistic regression models were used to estimate the effects of a 10% increase in the proportion of nurses who had a bachelor's or master's degree on patient mortality and failure to rescue, and the estimate the effects of nurse staffing, nurse experience, and surgeon board certification.

The probabilities of poor outcomes were calculated for patient in hospitals assuming that 20%, 40%, and 60% of the hospital RNs held bachelor's or master's degrees and under various patient-to-nurse ratios.

Possible confounding variables and biases:

Selection bias: BSN, MSN, nurses with doctorates all grouped together; ADN's and diploma nurses grouped together (Pennsylvania has one of the highest populations of diploma nurses in the US).

This factor alone seriously compromises the study's generalizability to a target population of just ADNs and just BSNs and produces flawed methodology for the study conclusions.

It was not known how many nurses in the sample were originally ADN nurses who went back to get their BSN's (the BSN sample likely has nurses with more education and experience than the ADN's).

Need to factor out the experience variable.

Aiken 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.

This is flawed methodology, because many BSN nurses were originally ADN nurses who went back to get their BSN's. The opposite is not true- BSN's don't go back to get their ADN. For an accurate comparison, need to compare strictly new ADN graduates with BSN graduates and patient outcomes.

Another possible confounding variable:

Patients admitted to a high tech and/or teaching hospital by virtue of the type of hospital have a better chance of survival. These hospitals often employ higher percentages of BSN and higher degree nurses than smaller outlying hospitals.

Are the researchers adequately controlling for patient acuity level?

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

Nurse patient ratios:

BSN/ 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.

This highlights the danger of institutions making practice recommendations on the basis of the findings of one, unreplicated study, especially if the study involved has serious biases and flaws in methodology.

References

Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., & Silber, J.H. (2003). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association (JAMA), 12, 1617-1623.

Bernier, S. (2003). N-OADN update: JAMA Article "Educational Levels of Hospital Nurses and Surgical Patient Mortality."

North Carolina Institute of Medicine (IOM). (2004, March). Executive summary: Final report of the Task Force on the North Carolina Nursing Workforce.

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This is flawed methodology, because many BSN nurses were originally ADN nurses who went back to get their BSN's. The opposite is not true- BSN's don't go back to get their ADN. For an accurate comparison, need to compare strictly new ADN graduates with BSN graduates and patient outcomes.Vicky, ITA. This point especially stands out to me. If the BSN degree was superior (I have one and am originally an ADN grad), then the ADN's would be LPN's as they tried to do so many years ago. The fact is in many circumstances, the ADN's emerge from school better prepared for the NCLEX and bedside care. I didn't say all cases. I mean to say the BSN has never been proven to be superior across the board. Hence the debate goes on. I would love to see the BSN actually mean more NURSING education and BETTER preparation, not merely more gen eds and a management course, sometime at the expense of time at the bedside. Having a BSN mean a better more prepared nurse elevates the whole profession. We are just not there yet. I don't know if we ever will be. Mydaughter is looking at nursing schools and they are diploma and ADN. That is fine w/ me because the ones she is looking at prepare you to function at the bedside which is what you need to do as a beginning practitioner. You need experience period before you can handle a leadership role. A generic BSN grad is an entry level practitioner no more or no less than a diploma or ADN grad.

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Specializes in Med-Surg.

Thanks VickyRN for posting your article again. (I was hoping you'd come along and take the hint. )

It amazes me how one study has stuck around and a myth created around it.

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Specializes in Pediatrics.

i agree with the most of the above posts. i would not, however, make a blanket statement and say "yes, education does matter", or "adn nurses are just as good as bsn". i have my own opinions based on what i've seen in the field (and my own educational experiences as well).

i did a pseudo-research paper on this topic for one grad class this semester, and am hoping to expand on it when i take research next sem. so needless to say, at this point, i know squat about research.

they talk about all of the 'adjusted' variables in this article (don't have it in front of me, so can't remember specifics, but one was pt. age). would love to know how they adjust these things (i guess i'll find out next sem).

i honestly think it's a good start, but imho, the study was too narrow: adult surgical patients in penn. does not mention variety of yrs experience of the nurse, prior experience of the nurse, co-morbitities of the pts (were these pts gonna die anyway- not to be so blunt).

i would love to see this study replicated in multiple specialties (icu, er, peds, whatever). take nurses with the same amount of exp. (new grads would have to be the best way, as 'experience is so subjective), train them to a new specialty the same way, and then see who fails to rescue.

this topic is near and dear to me, b/c i am an adn-bsn- soon to be msn nurse, and am currently teaching in an adn program. so my thoughts on the topic are very conflicted :confused:

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Specializes in Pediatrics.
thanks vickyrn for posting your article again. (i was hoping you'd come along and take the hint. )

it amazes me how one study has stuck around and a myth created around it.

one more post to the big 20,000!!! i just noticed under your name. wow!!! (you really are avoiding that housework)

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Specializes in Med/surg,Tele,PACU,ER,ICU,LTAC,HH,Neuro.

okay i decided i had to go play with numbers because the study protocol was too full of the conclusions and not the actual variables or percentages.

i am tired it is late .

i went to jama to get them.

http://jama.ama-assn.org/cgi/reprint/290/12/1617?maxtoshow=&hits=10&hits=10&resultformat=&fulltext=educational+levels+of+hospital+nurses+and+surgical+patient+mortality&searchid=1&firstindex=0&resourcetype=hwcit

results the proportion ofhospital rns holding a bachelor's degree or higher ranged from 0% to 77% across the hospitals. after adjusting for patient characteristics andhospital 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 ofnurses holding a bachelor's degree was associated with a 5% decrease in both the likelihood ofpatients 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 ofnurses educated at the baccalaureate level or higher.

kathy’s study protocol

bsn/ 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.

in the jama article we note this:

nurse understaffing is ranked by the public and physicians as one of the greatest threats to patient safety in us hospitals.1 last year we reported the results of a study of 168 pennsylvania hospitals showing that each additional patient added to the average workload of staff registered nurses (rns) increased the risk of death following common surgical procedures by 7%, and that the risk of death was more than 30% higher in hospitals where nurses' mean workloads were 8 patients or more each shift than in hospitals where nurses cared for 4 or fewer patients.

so i stop right there all flustered thinking. why are we wasting money on research at this point in time (healthcare crisis) to discredit 50% of the profession that the doctors and population say are understaffed to the point of being “ greatest threats to patient safety in us hospitals.”

the research done last year on this is showing what percentages of death. per patient increase’s

wisdom is crying in the streets does nobody hear ?

are we too busy smacking our lips in academia to stop and see we are dying. gaw…

this stupid disrespected adns results go like this

jama here are my results:

you are jama doe and i am your nurse

today pt jama doe i have 5 patients so your chances of dying is 7% higher than you and i would like but.

today pt jama doe i have 6 patients so your chances of dying is 14% higher than you and i would like but.

today pt jama doe i have 7 patients so your chances of dying is 21% higher than you and i would like but.

today pt jama doe i have 8 patients so your chances of dying is 28% higher than you and i would like but.

today pt jama doe i have 9 patients so your chances of dying is 35% higher than you and i would like but.

today pt jama doe i have 10 patients so your chances of dying is 42% higher than you and i would like but.

today pt jamadoe i have 11 patients so your chances of dying is 49% higher than you and i would like but.

today pt jama doe i have 12 patients so your chances of dying is 56% higher than you and i would like but.

today pt jama doe i have 13 patients so your chances of dying is 63% higher than you and i would like but.

today pt jama doe i have 14 patients so your chances of dying is 70% higher than you and i would like but.

today pt jama doe i have 15patients so your chances of dying is 77% higher than you and i would like but.

today pt jama doe i have 16 patients so your chances of dying is 84% higher than you and i would like but.

today pt jama doe i have 17 patients so your chances of dying is 91% higher than you and i would like but.

today pt jama doe i have 18 patients so your chances of dying is 98% higher than you and i would like but.

today pt jama doe i have 19 patients and you were gonna die , but now your chances of living are 5 % because i have a bsn.

what jama doe?

why do i have so many patients?

well….cause ..i am so smart …better than all the rest.

i forced the states shut down all those silly associate nurse and diploma nurse facilities. you know? those archecturally inncorrect buildings that teach stupid folks things they shoulda learned in high school? they didn’t even have a sigma rama fifi…jama?

i striped them of their licenses too, cause they were not professional jama. they didn't go to a university.

what jama?

get them??

you don’t need them you have me….

besides told them where to move. i am just the smartest thing.

a vast desert full of cactus juice…it is a wonderful place called las vegas.

why they open up a new facility there every week. plenty of fancy jobs and water down there to recycle. the benefits are great cause most those fancy casino’s are forbes 100 company voted top places to work.

all they need is a food handler’s permit and a course or 16 in spanish.

oh dear jama? jama doe jama doe oh no

……….code blue >>>>code blue…………

get the code team in here stat i am a new grad!!!!!

what??

when …….cause jama doe be dying?….

at oh ………………….your coding my other 19 patients???

shucks.

note these are statistics not facts. it is the stupid disrespected conclusion of a probated adn.

dying + crisis= action

decreased patient ratios should be our focus in a crisis not difficulty controlled and poorly conducted waste of money disputing who is better than who in the name of experience and education levels.

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we have so many nurses that come to this county with a work visa

what kind of schooling or experience do they have.

why are we so critical of the nurses educated in this country.

give us a break!

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