Educational Levels of Hospital Nurses and Surgical Patient Mortality A Newsmaker Interview With Linda H. Aiken, PhD, RN

Maine Nurse,  Nov 2003-Jan 2004  by Yox, Susan

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Sept. 25, 2003 - Editor's Note: Hospitals that employ a higher proportion of nurses with at least a bachelor's degree have lower rates of death for surgical patients, according to a study published in the Sept. 24 issue of The Journal of the American Medical Association (JAMA). The authors compared the three types of basic nursing education programs (RN diploma, associate degree, and baccalaureate) and found a significant relationship between the education of nurses and patient deaths. "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 bachelors or higher degrees," the authors write.

The researchers adjusted the outcomes for patient characteristics, board certification of surgeons, and hospital structural characteristics, as well as for nurse staffing and nurse experience. The findings indicated that 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," a term indicating deaths in patients with serious complications. These findings challenge the commonly held view that nurses' experience is more important than their educational preparation.

Medscape's Susan Yox, RN, EdD, interviewed the lead author of the JAMA study, Linda H. Aiken, PhD, RN, from the Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, in Philadelphia, to learn more about these important findings.

Medscape: Please review the three types of programs that provide a basic nursing education in the U.S. today. In light of that variability, please offer the context for this study. Why did you choose to examine this particular issue? Were you surprised by these differences in patient outcomes?

Dr. Aiken: Registered nurses in the U.S. receive their basic education in one of three different types of programs that all qualify graduates to take the registered nurse licensing exam: hospital-sponsored three-year diploma schools, community college associate degree programs of approximately two years, and four-year baccalaureate programs in colleges and universities. In 1950, 92% of new RNs graduated from hospital diploma schools; now only 3% do. In the meantime, baccalaureate education for nurses has grown significantly, now accounting for 36% of new graduates. Associate degree programs, which did not exist in 1950, now account for 60% of new RN graduates. These three different educational pathways into nursing have led to large variation between hospitals in the educational mix of nurses. In Pennsylvania hospitals in 1999, the proportion of bedside RNs with baccalaureate degrees varied from 0 to 77%. We thought it was important to determine whether that level of variation in nurses' educational qualifications was an important factor in determining patient outcomes. We were surprised that the...nurses' education [levels] varied so widely between hospitals. However, we were not surprised by the findings [regarding mortality] since educational qualifications of physicians have been linked to patient outcomes in many studies.

Medscape: These study findings indicate that hospitals employing a greater proportion of nurses with BSN degrees or higher have lower rates of death for surgical patients as well as lower "failure-to-rescue" (deaths in patients with serious complications) rates. As your article in JAMA says, "each 10% increase in the proportion of nurses with higher degrees decreased the risk of mortality and of failure-to-rescue by 5%." That is certainly impressive. Can you elaborate on this?

Dr. Aiken: This paper builds upon a paper we published in JAMA last year showing that each patient added to a nurses' workload increased mortality by 7%. In this research, we found that nurse staffing (workload) and the educational composition of the hospital nurse workforce are equally important in their association with mortality rates following common surgical procedures. Hospitals in which nurses care for the fewest patients each and the proportion of staff nurses with baccalaureate degrees is 50% or greater have the lowest mortality for common surgical procedures. Additionally, we find that a more educated nurse workforce is associated with better patient outcomes even at slightly higher nurse workloads.

Medscape: Why did the study not look at outcomes for RNs with associate degrees and diplomas separately, as it did with nurses with BS degrees and higher?

Dr. Aiken: We did examine the impact of diploma and associate degree education of nurses separately and found that the particular type of educational credential for nurses with less than a bachelor's degree was not a factor in patient outcomes.

Medscape: In addition to looking at nurses' educational backgrounds and workload, this research also measured nurses' experience as a factor in patient outcomes. Certainly many nurses (and perhaps others) have always believed that nursing experience has as much of an effect on patient outcomes as education. How does this research begin to question that long-held belief?