Updated July 2011
Impact of Education on Nursing Practice
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The American Association of Colleges of Nursing (AACN), the national voice for baccalaureate and graduate nursing programs, believes that education has a significant impact on the knowledge and competencies of the nurse clinician, as it does for all health care providers. Nurses with Bachelor of Science in Nursing (BSN) degrees are well-prepared to meet the demands placed on today's nurse. BSN nurses are prized for their skills in critical thinking, leadership, case management, and health promotion, and for their ability to practice across a variety of inpatient and outpatient settings. Nurse executives, federal agencies, the military, leading nursing organizations, health care foundations, magnet hospitals, and minority nurse advocacy groups all recognize the unique value that baccalaureate-prepared nurses bring to the practice setting.
AACN encourages employers to capitalize on the education and experience provided by the varied educational programs leading to the registered nurse (RN) designation by using these nurses in different capacities. We also encourage BSN graduates to seek out employers who value their level of education and distinct competencies.
Different Approaches to Nursing Education
There are three routes to becoming a registered nurse: a 3-year diploma program typically administered in hospitals; a 3-year associate degree usually offered at community colleges; and the 4-year baccalaureate degree offered at senior colleges and universities. Graduates of all three programs sit for the same NCLEX-RN© licensing examination.
Baccalaureate nursing programs encompass all of the course work taught in associate degree and diploma programs plus a more in-depth treatment of the physical and social sciences, nursing research, public and community health, nursing management, and the humanities. The additional course work enhances the student’s professional development, prepares the new nurse for a broader scope of practice, and provides the nurse with a better understanding of the cultural, political, economic, and social issues that affect patients and influence health care delivery. Throughout the last decade, policymakers and practice leaders have recognized that education makes a difference.
- In October 2010, the Institute of Medicine released its landmark report on The Future of Nursing, initiated by the Robert Wood Johnson Foundation, which called for increasing the number of baccalaureate-prepared nurses in the workforce to 80% by 2020. The expert committee charged with preparing the evidence-based recommendations in this report state that to respond “to the demands of an evolving health care system and meet the changing needs of patients, nurses must achieve higher levels of education.”
- In May 2010, the Tri-Council for Nursing (AACN, ANA, AONE, and NLN) issued a consensus statement calling for all RNs to advance their education in the interest of enhancing quality and safety across healthcare settings. In the statement titled Education Advancement of Registered Nurses, the Tri-Council organizations present a united view that a more highly educated nursing workforce is critical to meeting the nation’s nursing needs and delivering safe, effective patient care. In the policy statement, the Tri-Council finds that “without a more educated nursing workforce, the nation's health will be further at risk.”
- In December 2009, Dr. Patricia Benner and her team at the Carnegie Foundation for the Advancement of Teaching released a new study titled Educating Nurses: A Call for Radical Transformation, which recommended preparing all entry-level registered nurses at the baccalaureate level and requiring all RNs to earn a master’s degree within 10 years of initial licensure. The authors found that many of today’s new nurses are “undereducated” to meet practice demands across settings. Their strong support for high quality baccalaureate degree programs as the appropriate pathway for RNs entering the profession is consistent with the views of many leading nursing organizations, including AACN.
- On September 30, 2008, the Foundation for California Community Colleges and Kaiser Permanente announced grant funding for a new program aimed at creating a better-educated nursing workforce in California through collaboration between two-year and four-year nursing programs. Funding will be used to develop demonstration models of collegiate partnerships that seamlessly provide a baccalaureate degree to nurses educated in two-year programs. The grants are an outcome of a study conducted by California Institute for Nursing & Health Care (CINHC) that called for transforming California's nursing education system. Study director Dr. Jan Boller said: "Recent studies clearly demonstrate that a higher prevalence of baccalaureate- and masters-prepared RNs at the bedside positively impact patient outcomes."
- In February 2007, the Council on Physician and Nurse Supply released a statement calling for a national effort to substantially expand baccalaureate nursing programs. Chaired by Richard "Buz" Cooper, MD and Linda Aiken, PhD, RN, the Council is based in the University of Pennsylvania's Leonard Davis Institute of Health Care Economics. In the statement, the Council noted that a growing body of research supports the relationship between the level of nursing education and both the quality and safety of patient care. Consequently, the group is calling on policymakers to shift federal funding priorities in favor of supporting more baccalaureate level nursing programs. This call was reaffirmed in a new statement released in March 2008.
- In March 2005, the American Organization of Nurse Executives (AONE) released a statement calling for all for registered nurses to be educated in baccalaureate programs in an effort to adequately prepare clinicians for their challenging and complex roles. AONE’s statement, titled Practice and Education Partnership for the Future, represents the view of nursing’s practice leaders and a desire to create a more highly educated nursing workforce in the interest of improving patient safety and providing enhanced nursing care.
- The National Advisory Council on Nurse Education and Practice (NACNEP), policy advisors to Congress and the Secretary for Health and Human Services on nursing issues, has urged that at least two-thirds of the nurse workforce hold baccalaureate or higher degrees in nursing by 2010. Currently, only 50.0 percent of nurses hold degrees at the baccalaureate level and above.
- NACNEP found that nursing’s role calls for RNs to manage care along a continuum, to work as peers in interdisciplinary teams, and to integrate clinical expertise with knowledge of community resources. The increased complexity of the scope of practice for RNs requires a workforce that has the capacity to adapt to change. It requires critical thinking and problem solving skills; a sound foundation in a broad range of basic sciences; knowledge of behavioral, social and management sciences; and the ability to analyze and communicate data. Among the three types of entry-level nursing education programs, NACNEP found that baccalaureate education with its broader and stronger scientific curriculum best fulfills these requirements and provides a sound foundation for addressing the complex health care needs of today in a variety of nursing positions. Baccalaureate education provides a base from which nurses move into graduate education and advanced nursing roles.
- There is a growing consensus in the higher education community that a liberal arts education should be embedded in all the professional disciplines. Graduates with a liberal education are prized by employers for their analytical and creative capacities and demonstrate stronger skills in the areas of communication, assessment, cultural sensitivity, resourcefulness, the ability to apply knowledge, and scientific reasoning. Though some arts and science courses are included in ADN programs, the BSN provides a much stronger base in the humanities and sciences.
- There are 650 RN-to-BSN and 173 RN-to-MSN programs that build on the education provided in diploma and associate degree programs and prepare graduates for a broader scope of practice. In addition to hundreds of individual agreements between community colleges and four-year schools, state-wide articulation agreements exist in many areas including Florida, Connecticut, Arkansas, Texas, Iowa, Maryland, South Carolina, Idaho, Alabama, and Nevada to facilitate advancement to the baccalaureate level. These programs further validate the unique competencies gained in a BSN program. See http://www.aacn.nche.edu/Media/FactSheets/AA.htm.
- Registered nurses today work as a part of an interdisciplinary team with colleagues educated at the master’s degree or higher level. These health professionals, including physicians, pharmacists, and speech pathologists, recognize the complexity involved in providing patient care and understand the value and need for higher education. For example, Occupational Therapists (OT) require education at the master’s level, while OT Assistants are prepared at the associate degree level. Since nurses are primarily responsible for direct patient care and care coordination, these clinicians should not be the least educated member of the health care team.
- According to a study published by Dr. Betty Rambur and her colleagues in the July/August 2003 issue of Nursing Outlook, increasing the proportion of baccalaureate prepared nurses in the registered nursing population may be essential to stabilizing the nursing workforce. Nurses prepared at the BSN level were found to have higher levels of job satisfaction which is key to nurse retention.
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 a January 2011 article published in the Journal of Nursing Scholarship, Drs. Deborah Kendall-Gallagher, Linda Aiken, and colleagues released the findings of an extensive study of the impact nurse specialty certification has on lowering patient mortality and failure to rescue rates in hospital settings. The researchers found that certification was associated with better patient outcomes, but only when care was provided by nurses with baccalaureate level education. The authors concluded that “no effect of specialization was seen in the absence of baccalaureate education.”
- 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 2008 issue of the Journal of Nursing Administration, Dr. Linda Aiken and her colleagues confirmed the findings from her 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 Journal of Advanced Nursing, a study on the “Impact of Hospital Nursing Care on 30-day Mortality for Acute Medical Patients” found that BSN-prepared nurses have a positive impact on lowering mortality rates. Led by Dr. Ann E. Tourangeau, researchers from the University of Toronto and the Institute for Clinical Evaluative Sciences in Ontario 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.
- 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, Marlene Kramer, Linda Aiken and others have found a strong relationship between organizational characteristics and patient outcomes.
- The fact that passing rates for the NCLEX-RN©, the national licensing exam for RNs, are essentially the same for all three types of graduates is not proof that there are no differences among graduates. The NCLEX-RN© is a multiple-choice test that measures the minimum technical competency for safe entry into basic nursing practice. Passing rates should be high across all programs preparing new nurses. This exam does not test for differences between graduates of different entry-level programs. The NCLEX-RN© is only one indicator of competency, and it does not measure performance over time or test for all of the knowledge and skills developed through a BSN program.
A New Model of Care: Differentiated Nursing Practice
Differentiated practice models are frameworks of clinical nursing practice that are defined or differentiated by level of education, expected clinical skills or competencies, job descriptions, compensation, and participation in decision making. These practice models have been implemented in acute care inpatient settings, rural community nursing centers, and acute care operating rooms.
Differentiated practice outcomes include the opportunity for health care providers to capitalize on the education and experience provided by varied educational programs leading to RN licensure. The RN has the opportunity to practice to his or her potential, taking full advantage of educational preparation, while not being expected to practice beyond it. Often, differentiated models of practice are supported by a clinical "ladder" or defined steps for advancement within the organization based on experience in nursing, education, certifications, or other indicators of professional excellence.
- Evidence indicates that differentiated practice models foster positive outcomes for job satisfaction, staffing costs, nurse turnover rates, adverse events (i.e., patient falls and medication errors), nursing roles, and patient interventions and outcomes (Anderko, Robertson & Lewis, 1999; Anderko, Uscian & Robertson, 1999; Hutchens, 1994; Malloch, Milton & Jobes, 1990).
- Clinical settings across the country are differentiating practice and advertising positions that either require or prefer the BSN for employment. Tenet Healthcare, Kaiser Permanente, Catholic Healthcare and other large employers of registered nurses all offer positions best suited to the skill level of baccalaureate-prepared nurses. Among the job titles frequently cited as requiring or preferring the BSN are case manager, clinical care coordinator, nurse manager, infection control nurse, quality improvement coordinator, and patient care manager.
- Employers further validate the skills that baccalaureate-prepared nurses bring to the nursing workforce through higher compensation levels. According to a survey released by Nursing2005 magazine in October 2005, BSN nurses earn salaries more than 10 percent higher than ADN nurses. Higher salaries for baccalaureate-prepared nurses have also been recorded in surveys conducted by RN magazine and HRSA’s National Sample Survey of Registered Nurses.
- Differentiated practice plans have been created and advanced by coalitions of nurse educators from all types of entry-level RN programs in many states including North Carolina, Colorado, Arizona, New Mexico, Washington, Indiana, and the District of Columbia. These educators understand that different educational paths prepare students for different roles.
Public and Private Support for BSN-Prepared Nurses
The federal government, the military, nurse executives, health care foundations, nursing organizations, and practice settings acknowledge the unique value of baccalaureate-prepared nurses and advocate for an increase in the number of BSN nurses across clinical settings.
- In the interest of providing the best patient care and leadership by its nurse corps officers, the U.S. Army, U.S. Navy and U.S. Air Force all require the baccalaureate degree to practice as an active duty Registered Nurse. Commissioned officers within the U.S. Public Health Service must also be baccalaureate-prepared.
- The Veteran's Administration (VA), the nation's largest employer of registered nurses, has established the baccalaureate degree as the minimum preparation its nurses must have for promotion beyond the entry-level.
- Based on a nationwide Harris Poll conducted in June 1999, an overwhelming percentage of the public – 76% – believes that nurses should have four years of education or more past high school to perform their duties.
- The Pew Health Professions Commission in a 1998 report called for a more concentrated production of baccalaureate and higher degree nurses. This commission was an interdisciplinary group of health care leaders, legislators, academics, corporate leaders, and consumer advocates created to help policy-makers and educators produce health care professionals able to meet the changing needs of the American health care system.
- The Helene Fuld Health Trust, the nation’s largest private foundation devoted exclusively to student nurses and nursing education, announced in November 2001 that it would give funding preference to programs that offer BSN and higher degrees in nursing. The foundation cited “the increased complexity of and sophisticated knowledge required for health care delivery” as reasons for setting its funding priorities at the baccalaureate level.
- Countries around the world are moving to create a more highly educated nursing workforce. Canada, Sweden, Portugal, Brazil, Iceland, Korea, Greece and the Philippines are just some of the countries that require a four-year undergraduate degree to practice as a registered nurse.
Fact Sheet References
Aiken, L.H., Clarke, S.P., Sloane, D.M., Lake, E.T. & Cheney, T. (2008, May). Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration, 38(5), 223-229.
Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., & Silber, J.H. (2003, September 24). Educational levels of hospital nurses and surgical patient mortality, Journal of the American Medical Association, 290, 1617-1623.
American Association of Colleges of Nursing (2008). 2006-2007 Enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, DC: Author.
American Association of Colleges of Nursing, American Organization of Nurse Executives, & National Association of Associate Degree Nursing (1995). A model for differentiated practice. Washington, DC: American Association of Colleges of Nursing.
American Organization of Nurse Executives. (2005). Practice and education partnership for the future. Washington, DC: American Organization of Nurse Executives.
Anderko, L., Robertson, J. & Lewis, P. (1999). Job satisfaction in a rural differentiated-practice setting. Journal of Nursing Connections, 12(1), 49-58.
Anderko, L., Uscian, M. & Robertson, J.F. (1999). Improving client outcomes through differentiated practice: a rural nursing center model. Public Health Nursing, 16(3), 168-175.
Benner, P., Sutphen, M., Leonard, V. & Day, L. (2009). Educating Nurses: A Call for Radical Transformation. Carnegie Foundation for the Advancement of Teach. San Francisco: Jossey-Bass.
Delgado, C. (2002, July/August). Competent and safe practice: a profile of disciplined registered nurses. Nurse Educator, 27(4), 159-61.
Estabrooks, C.A., Midodzi, W.K., Cummings, G.C., Ricker, K.L. & Giovanetti, P. (2005, March/April). The impact of hospital nursing characteristics on 30-day mortality. Nursing Research, 54(2), 72-84.
Fagin, C.M. (2001). When care becomes a burden: Diminishing access to adequate nursing. Millbank Memorial Fund, New York, NY.
Friese, C.R, Lake, E.T., Aiken, L.H., Silber, J.H. & Sochalski, J. (2008, August). Hospital nurse practice environments and outcomes for surgical oncology patients. Health Services Research, 43(4), 1145-1163.
Giger, J.N. & Davidhizar, R.E. (1990). Conceptual and theoretical approaches to patient care: Associate versus baccalaureate degree prepared nurses. Journal of Advanced Nursing, 15(9), 1009-1015.
Goode, C.J., Pinkerton,S., McCausland, M.P., Southard, P., Graham, R. & Krsek, C. (2001). Documenting chief nursing officers' preference for BSN-prepared nurses. The Journal of Nursing Administration, 31(2). 55-59.
Graff, C., Roberts, K., & Thornton, K. (1999). An ethnographic study of differentiated practice in an operating room. Journal of Professional Nursing, 15(6), 364-371.
Hutchens, G.C. (1994). Differentiated interdisciplinary practice. JONA, 4(6), 52-58.
Institute of Medicine. (2010). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press.
Johnson, J. (1988). Differences in the performance of baccalaureate, associate degree and diploma nurses: A meta-analysis. Research in Nursing and Health, 11, 183-197.
Kendall-Gallagher, D., Aiken, L., Sloane, D.M. & Cimiotti, J.P. (2011, January). Nurse specialty certification, inpatient mortality, and failure to rescue. Journal of Nursing Scholarship, 43(2), 188-194.
Kramer, M. & Hafner, L.P. (1989). Shared values: Impact on staff nurse job satisfaction and perceived productivity. Nursing Research, 38, 172-177.
Kramer, M. & Schmalenberg, C. (1988). Magnet hospitals: Part I, Institutions of excellence. Journal of Nursing Administration, 18(1), 13-24.
Malloch, K.M., Milton, D.A. & Jobes, M.O. (1990). A model for differentiated nursing practice. Journal of Nursing Administration, 20(2), 20-26.
Milton, D., Verran, J, Murdaugh, C. & Gerber, R. (1992). Differentiated group professional practice in nursing: A demonstration model. Nursing Clinics of North America, 27(1), 23-29.
National Advisory Council on Nurse Education and Practice (1996). Report to the Secretary of the Department of Health and Human Services on the basic registered nurse workforce. Washington, DC: United States Department of Health and Human Services, Health Resources and Services Administration.
National Council of State Boards of Nursing (2002). 2001 Employers survey. Chicago: Author.
Phillips, C.Y., Palmer, C.V., Zimmerman, B.J. & Mayfield, M. (2002). Professional development: Assuring growth of RN-to-BSN students. Journal of Nursing Education, 41(6), 282-283.
Rambur, B., Palumbo, M.V., McIntosh, B. & Mongeon, J. (2003). A statewide analysis of RNs’ intention to leave their position. Nursing Outlook, 51, 182-88.
Tourangeau, A.E, Doran, D.M., McGillis Hall, L., O'Brien Pallas, L., Pringle, D., Tu, J.V. & Cranley, L.A. (2007, January). Impact of hospital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing, 57(1), 32-41.
Tri-Council for Nursing. (2010, May). Educational advancement of registered nurses: A consensus position. Available online at http://www.aacn.nche.edu/Education/pdf/TricouncilEdStatement.pdf.
Last Update: July 15, 2011
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