Building the Case for More Highly Educated Nurses

Nursing is the only health profession with multiple pathways to entry-level practice. Three leading health scientists affiliated with the Robert Wood Johnson Foundation (RWJF) are among those who have shown that pathways that lead to the bachelor’s degree in nursing (BSN) and higher may improve patient outcomes.

Hospitals that employ larger numbers of BSN-prepared nurses have lower patient mortality rates, according to Linda Aiken, PhD, RN, FAAN, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing. A 10-percent increase in the proportion of nurses with BSNs was associated with a 7-percent decrease in patient deaths, she found in a study published in February in the Lancet.

“Is there any reason to believe that the proportion of nurses with bachelor’s degrees is associated with better outcomes? The answer is ‘Yes,’” Aiken said in an interview.

And she has more than a decade of research to prove it. In 2003, Aiken found that patients in hospitals in Pennsylvania had “a substantial survival advantage” if they were treated in hospitals with higher proportions of BSN-prepared nurses. That groundbreaking study, published in the Journal of the American Medical Association, found that a 10-percent increase in the number BSN-prepared nurses reduced the likelihood of patient death by 5 percent.

The link between nurse education and patient outcomes was confirmed in 2011, when Aiken published a study in Medical Care that found that a 10 percent increase in the proportion of BSN-prepared nurses reduced the risk of death by 5 percent. In 2013, Aiken co-authored a study in Health Affairs that found that hospitals that hired more BSN-prepared nurses between 1999 and 2006 experienced greater declines in mortality than hospitals that did not add more BSN-prepared nurses. “We’ve established this association over and over again,” she said. “If hospitals really want to improve care, they should hire more nurses with bachelor’s degrees.”

Aiken is a research manager supporting the Future of Nursing: Campaign for Action, a joint effort of RWJF and AARP that is working to transform health care through nursing. It is grounded in evidence from a landmark report on the future of the nursing profession by the Institute of Medicine (IOM), which recommended that 80 percent of the nation’s nurses hold bachelor’s degrees or higher by 2020 in order to meet increasingly complex patient needs.

Experts recognize the tremendous contributions made by registered nurses prepared at the associate-degree and diploma levels but say more highly educated nurses are needed to navigate an increasingly complex health care system and ensure that patients—who are living longer, and sicker, often with multiple chronic conditions—have access to highly skilled, patient-centered care across the entire care continuum.

Aiken is also a National Advisory Committee member of the Interdisciplinary Nursing Quality Research Initiative (INQRI), an RWJF-supported program that supports researchers from various fields who are studying the effects of nursing on patient outcomes. Two INQRI researchers—Richard Lindrooth, PhD, an associate professor at the School of Public Health at the University of Colorado, and Olga Yakusheva, PhD, an associate professor of economics at Marquette University—are also exploring the link between nurse education levels and patient outcomes.

Putting the Results to the Test

“The body of evidence that we have now is pretty convincing that there is a correlation” between higher nurse education levels and better patient outcomes, Lindrooth said. “What we’re doing now is putting this correlation to the test.”

For one study, Lindrooth and Yakusheva are examining the effect of nurse education levels on individual patients—as opposed to entire hospital systems. In a sense, it’s like zooming in on the system-wide studies Aiken has done to determine whether patients who happen to be cared for by higher numbers of nurses with bachelor’s degrees have better outcomes.

Like Aiken, Lindrooth and Yakusheva have found positive correlations. Patients who are cared for by a higher proportion of BSN-prepared nurses were less likely to die, stayed in the hospital for shorter periods, and faced lower health care costs, they said. “We can be pretty sure that it is the BSN degree that is causing the result and not some unmeasured factor that leads to both higher quality and more BSN nurses,” Lindrooth said. The study was presented at the AcademyHealth meetings in 2013.

In another study, Yakusheva and Lindrooth are trying to tease out the effects of modern management practices and higher levels of BSN-prepared nurses on patient outcomes. The goal is to determine whether hospitals can improve outcomes by adopting modern management practices or by hiring more BSN-prepared nurses—or by doing both. They found that both factors are needed to improve outcomes, but that hiring more BSN-prepared nurses alone may be enough to improve nurse-dependent outcomes.

Yakusheva compares the findings to improving health at the individual level. “If you want to be healthy, do you eat better or exercise more? Marginally, it may be better to do one or the other, but if you want to be a lot healthier, you should do both. That’s the way I see this paper.”

More research is needed to persuade employers to spend precious resources to hire more BSN-prepared nurses, Aiken said. Still, the evidence is beginning to have an effect. “The tide is turning,” she said, noting that more nurses are getting their BSNs, and more employers are preferentially hiring nurses with bachelor’s degrees.

About the Robert Wood Johnson Foundation

For more than 40 years the Robert Wood Johnson Foundation has worked to improve the health and health care of all Americans. We are striving to build a national culture of health that will enable all Americans to live longer, healthier lives now and for generations to come.

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