Tuesday, 7 April 2009

Research and Degree Educated Bedside Nurses

IF YOU WANT TO GET STRAIGHT TO THE RESEARCH BIT THEN PLEASE SCROLL DOWN.Before you read the research below let me say something. I have worked with many traditional trained nurses who were intelligent, excellent and talented nurses. But their method of training allowed a lot of crap into the profession. I don't believe that the research below is the whole story. There are many factors at play here. For decades hospital bosses have used that fact that most nurses do not have degrees to shit all over the nursing profession and kill patients. For decades.

Hospital bosses have asked why they should have more nurses on the wards than health care assistants. "What does it matter as long as you have staff on the ward who is physically able to wipe ass? It's not like nurses need a degree to be qualified anyway" the bosses have always said.

And now we have research that proves that patients have better chances of survival when there are more qualified staff on the ward than untrained kiddies. HCA's and kids are okay in addition to enough nurses, not instead of god damn it. I am forced to delegate way to much to them and I don't like that.

When the nurses told the bosses that putting c-diff and MRSA patients on crowded wards with poor hygiene facilities the bosses said "why should we listen to you? It's not like you need to hold a degree to be a nurse in the way that an OT or a physio does". I have heard that line directly.

And we have this.

And when the nurses tell the bosses that the numbers of qualified nurses on the ward improves patient survival the bosses said" why should we listen to you, it's not like your professional is all degree qualified?"

How many die on wards where the usual is 1-12, 1-15,1-20 as is the norm on general wards?

When the nurses told the bosses that patients have increased complications, that they starve, that they deteriorate leading to delayed discharges and increased length expensive hospital stays when staffing levels are low the bosses said "why should we listen to you, it isn't like one needs a degree to do your job".

And we have this.

When the nurses told the hospital bosses that newly qualified staff need mentoring and assistance and cannot just be thrown straight in the bosses replied with this: "But they had 3 years at nursing school to learn how to bed bath. Why can't they just get thrown in to sink or swim. What could possibly go wrong with a newly qualified over stressed nurse? It's not like you gals are a profession that requires a degree or something".

And we have this.

The nurses have been telling their bosses these things for decades. And for decades the response from hospital management has always been the same.

Countless, countless patients have died needlessly on the wards because of these attitudes. Nursing was not respected in the least when they were all hospital trained. Not in the least. These old fashioned docs and retired nurses view the old days via rose tinted glasses. Nurses were seen and not heard. They were not seen as educated and were ignored. There were more needless deaths back in the "good ole days". I have heard stories from people who trained in the 70's that would make your toes curl. Green students left in charge of wards etc. But back then it was all swept under the rug and the devastated families accepted the BS they were told by hospital bosses.

They are not learning their lesson. Now increasingly complex 21st century patients are getting cared for by untrained kids as a direct result of cost cutting by the hospitals and an ignorant public who cannot differentiate between kiddie carers with green hair and nurses.

I think that it is good for a bedside nurse to be well educated. I think it helps her to problem solve. That essay may not be worth shit but it got the nurse thinking. The statistics class I took in nursing school is long forgotten and I do not use that knowledge on the ward. But damn did it teach me how to think and problem solve. Nurses who don't think kill. Nurses who do not understand the reasons behind what they are doing can kill.

But I also think that the bosses of hospitals that have a higher percentage of degree educated nurses staffing the wards cannot get away with the "You girlies are not degree educated like the OT's, docs, social workers and therefore we don't have to listen to you" line.

This is a very important factor. The hospitals with a higher percentage of degree educated bedside nurses also have better ratios, better working conditions for nurses etc etc.

All that plays into patient mortality rates. Dramatically so. I am not slamming older nurses with this research.

The research below is not promoting nurse practitioners. When they are talking about degree educated nurses they are talking about degree educated nurses at the fucking bedside...not in advanced roles.

Now you can look at the research.


Recognizing Differences Among Nursing Program Graduates. There is a growing body of evidence that shows that BSN graduates bring unique skills to their work as nursing clinicians and play an important role in the delivery of safe patient care.

In an article published in Health Services Research in August 2008 that examined the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery, Dr. Christopher Friese and colleagues found that nursing education level was significantly associated with patient outcomes.

Nurses prepared at the baccalaureate-level were linked with lower mortality and failure-to-rescue rates. The authors conclude that “moving to a nurse workforce in which a higher proportion of staff nurses have at least a baccalaureate-level education would result in substantially fewer adverse outcomes for patients.”

In a study released in the May/June 2008 issue of the Journal of Nursing Administration, Dr. Linda Aiken and her colleagues confirmed the findings from their landmark 2003 study (see below) which show a strong link between RN education level and patient outcomes. Titled “Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes,” these leading nurse researchers found that every 10% increase in the proportion of BSN nurses on the hospital staff was associated with a 4% decrease in the risk of death.

In the January 2007 issue of the Journal of Advanced Nursing, a new study is titled “Impact of Hospital Nursing Care on 30-day Mortality for Acute Medical Patients” found that baccalaureate-prepared nurses have a positive impact on lowering mortality rates. Led by Dr. Ann E. Tourangeau, a research team from the University of Toronto and the Institute for Clinical Evaluative Sciences in Ontario, Canada, studied 46,993 patients admitted to the hospital with heart attacks, strokes, pneumonia and blood poisoning. The authors found that: "Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."

In a study published in the March/April 2005 issue of Nursing Research, Dr. Carole Estabrooks and her colleagues at the University of Alberta found that baccalaureate prepared nurses have a positive impact on mortality rates following an examination of more than 18,000 patient outcomes at 49 Canadian hospitals. This study, titled The Impact of Hospital Nursing Characteristics on 30-Day Mortality, confirms the findings from Dr. Linda Aiken's landmark study in September 2003.

In a study published in the September 24, 2003 issue of the Journal of the American Medical Association (JAMA), Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level. In hospitals, a 10 percent increase in the proportion of nurses holding BSN degrees decreased the risk of patient death and failure to rescue by 5 percent. The study authors further recommend that public financing of nursing education should aim at shaping a workforce best prepared to meet the needs of the population. They also call for renewed support and incentives from nurse employers to encourage registered nurses to pursue education at the baccalaureate and higher degree levels.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level. These findings are consistent with findings published in the July/August 2002 issue of Nurse Educator magazine that references studies conducted in Arizona, Colorado, Louisiana, Ohio and Tennessee that also found that nurses prepared at the associate degree and diploma levels make the majority of practice-related violations.

Chief nurse officers (CNO) in university hospitals prefer to hire nurses who have baccalaureate degrees, and nurse administrators recognize distinct differences in competencies based on education. In a 2001 survey published in the Journal of Nursing Administration, 72% of these directors identified differences in practice between BSN-prepared nurses and those who have an associate degree or hospital diploma, citing stronger critical thinking and leadership skills.
Studies have also found that nurses prepared at the baccalaureate level have stronger communication and problem solving skills (Johnson, 1988) and a higher proficiency in their ability to make nursing diagnoses and evaluate nursing interventions (Giger & Davidhizar, 1990).

Research shows that RNs prepared at the associate degree and diploma levels develop stronger professional-level skills after completing a BSN program. In a study of RN-to-BSN graduates from 1995 to 1998 (Phillips, et al., 2002), these students demonstrated higher competency in nursing practice, communication, leadership, professional integration, and research/evaluation.

associate degree doesn't exist in England. It is a 2 year junior college qualification...Anne

Data show that health care facilities with higher percentages of BSN nurses enjoy better patient outcomes and significantly lower mortality rates. Magnet hospitals are model patient care facilities that typically employ a higher proportion of baccalaureate prepared nurses, 59% BSN as compared to 34% BSN at other hospitals. In several research studies, Drs. Marlene Kramer, Linda Aiken and others have demonstrated that a strong relationship exists between organizational characteristics and patient outcomes.


Baccalaureate-Prepared Nurses are Key to Patient Safety, Preventing Deaths
WASHINGTON, D.C., September 23, 2003 The American Association of Colleges of Nursing (AACN) applauds a landmark new study released today which finds that surgical patients have a ''substantial survival advantage'' if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level. In the study, Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Wooohoooo..............Nurse Anne

''Dr. Aiken's research clearly shows that baccalaureate nursing education has a direct impact on patient outcomes and saving lives,'' said Dr. Kathleen Ann Long, president of AACN. ''Nurses with baccalaureate and higher degrees are particularly well-suited to meeting the demands of today's complex health system, reducing patient risk, and lowering mortality rates.''

The study, titled ''Educational Levels of Hospital Nurses and Surgical Patient Mortality,'' is published in this week's issue of the Journal of the American Medical Association. Key findings include:

In hospitals, a 10 percent increase in the proportion of nurses holding Bachelor of Science in Nursing (BSN) degrees decreased the risk of patient death and failure to rescue by 5 percent.. Patient mortality and failure to rescue would be 19 percent lower in hospitals where 60 percent of nurses had BSNs or higher degrees than in hospitals where only 20 percent of nurses were educated at that level..

If the proportion of BSN nurses in all hospitals was 60 percent rather than 20 percent, 17.8 fewer deaths per 1,000 surgical patients would be expected..

At least 1,700 deaths could have been prevented in Pennsylvania hospitals alone if BSN prepared nurses had comprised 60 percent of the nursing staff and the nurse to patient ratios had been set at 4 to 1..

(They mean one qualified degree educated nurse to every 4 patients. HCA's and kiddies do not improve survival rates. Just thought I would add that in for those who still do not get it.)

(And I thought that I would again remind you that these studies are talking about degree educated nurses at the bedside, NOT in advanced practice roles)


Zarathustra said...

Good post. I agree wholeheartedly.

Vicky Pollard said...

Wowsah - excellent excellent post. The kind of post I should be producing to defend my views on nurse education. Now all I have to do is link here! Thanks Anne!!!

Anonymous said...

I am currently in nursing school in a 2 year associate degree program. Today, I had a clinical at the local hospital (community based, non-profit, ~400 beds). The RN to whom I was assigned had 5 patients. The norm on that floor (mostly post orthopedic surgery) is 4 patients to 1 RN. The nursing assistants are usually assigned 10 patients - they do ADLs (bathing, dressing, changing bed linens, helping to the toilet, etc), vital signs, glucose finger sticks, and other repetitive tasks. The RNs are assessing, giving meds, changing dressings, educating patients - in other words doing tasks which can't be delegated. There are a few LPNs working on the floor, but RNs seem to be much more common. LPNs are more common in long term care and doctor's offices.
(BTW I found you by reading NHS Blog Doctor - Dr. Crippen is obviously an unhappy man.)
Also, many of my classmates already have university degrees and are going to nursing school as a career change. Hardly anyone is straight out of high school.


rosmarina said...

Hi - this is a great blog, and this particular entry is fantastic. Why people would want less well-educated nurses in positions of such responsibility is mind-boggling, and it comes as no surprise that the results are better with degree educated nurses overall. Not to say, of course, that nurses with other training aren't valuable - research also shows that results and quality of care also depends on how many years of experience nurses have.

Since you have worked as a nurse in the US and UK, I wonder what you think of this book: Gordon, Suzanne,
Nursing against the odds : how health care cost cutting, media stereotypes, and medical hubris undermine nurses and patient care?
It's well researched, and the author has written quite a lot about nursing and health care. She's very critical of many of the trends you identify, but since she's US based, she doesn't comment on the NHS.

Mr Ian said...

This research all seems to measure different levels of current nurse training with outcomes - ie: it has no specificity to compare any previous vocational training with more modern university education; only those of AD, Dip or BSN.
I have a certificate, I think.
It may even be an 'attendance certificate' - but I do remember sitting down for 3 hours and writing a care plan at some stage and having to hand it in for marking.

Nurse Anne said...

Yes Mr. Ian it is a US study. Hard to quantify for over here.

They don't have a cert program in the USA. It has been diploma level since the 1930's or so. The closest thing to a certificate nurse that they have is the LPN.

Nurse Ratchet said...

I have been nursing for 20 years.There are shit nurses, there are good nurses. No-one I have ever seen is a better nurse because of having a degree - or not.It's not about that.( I'm only 40 so not an old fart by the way)
Can we stop putting ourselves down?

Nurse Anne said...

No one has put down traditional trained nurses on this blog post.

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