Attention Health Care Leaders: Literature Review ...

Attention Health Care Leaders: Literature Review Deems Baccalaureate Nurses Improve Patient Outcomes Deborah O’Brien, Mary Knowlton, and Ramona Whichello

Abstract AIM This review of studies conducted since the 2011 publication of the Institute of Medicine (IOM) report “The Future of

Nursing: Leading Change, Advancing Health” evaluates the current state of evidence showing an association between an increased ratio of BSN-prepared nursing staff and improved patient outcomes. BACKGROUND The IOM established a nationwide goal to increase the number of BSN nurses to 80 percent by 2020 to meet the challenges seen in today’s health care environment. METHOD The literature search included a five-year (2011-2016) span following the initial release of the IOM report. RESULTS Mortality, failure to rescue, and readmission rates all decrease as the proportion of BSN nurses is increased in a nursing staffing ratio. CONCLUSION It is the recommendation of this project that nurse leaders and organizations support the findings of this literature review and the IOM BSN recommendation. KEY WORDS Baccalaureate Nurses (BSN) – Cost-Effectiveness – Failure to Rescue – Length of Stay – Mortality Rates – Patient Outcomes – Readmission Rates

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he groundbreaking Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health outlined recommendations to increase the percentage of baccalaureateprepared nurses (BSN) to 80 percent by 2020. Research demonstrating improved patient outcomes with the increased use of BSN nurses has been published for more than a decade, but health care leaders have not altered hiring practices to reflect current recommendations. The American Organization of Nurse Executives (AONE) reported that 7 percent of health care organizations are reluctant to hire BSNs because of lack of evidence related to improved patient safety (Caramanica & Thompson, 2012). Therefore, the aim of this literature review is to present current evidence on the impact of nursing care provided by BSN-educated nurses on patient outcomes and quality care.

BACKGROUND Health Care Challenges Health care continues to face enormous challenges, including a growing aging population and changes brought about by the enactment of About the Authors Deborah O’Brien, BSN, is a student, Western Carolina University School of Nursing, Cullowhee, North Carolina. Mary Knowlton, DNP, RN, CNE, is director, Accelerated BSN Program, and associate professor, and Ramona Whichello, DNP, RN, NEA-BC, is director, Nurse Educator/Nursing Leadership/RN to MS(N) Early Option Programs, and associate professor, Western Carolina University School of Nursing. For more information, contact Ms. O’Brien at [email protected]. The authors have declared no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.neponline.net). Copyright © 2018 National League for Nursing doi: 10.1097/01.NEP.0000000000000303

Nursing Education Perspectives

the Affordable Care Act (ACA). Ortman, Velkoff, and Howard (2014) predict that, between 2012 and 2050, the United States will experience an exponential growth in its older population and that, by 2050, the population aged 65 and above will be 83.7 million, almost double the estimated population of 43.1 million quoted for 2012. Regrettably, the normal aging process is often associated with unrecognized atypical and complex presentation of illnesses that can lead to compromised health, function, and poor outcomes (Nunnelee et al., n.d.). The ACA aims is to transform the health care system to provide and demand safe, quality, patient-centered, accessible, and affordable care that will require a comprehensive reassessment in the role of the nursing profession (National Academies of Science, Engineering, Medicine, 2011). The ACA also calls for provisions that would improve outcomes of health care through a series of requirements proposed to ensure quality reporting for processes such as care coordination and chronic disease management (Berkowitz, 2016). The major focus of ACA quality reporting was to develop measurement sets designed to collect and report quality evidence-based clinical care within health care institutions, which would eventually affect reimbursement for institutions based on quality outcomes (Berkowitz, 2016). With the proposed changes and challenges to health care, nurses and leaders can look forward to nurses educated at higher levels, such as the BSN, who will be able to impact the quality of patient health care.

Defining Quality Patient Outcomes One can define quality care as the right care, at the right time, every time. It is better, more efficient, and cost-effective (Andel, Davidow, Hollander, & Moreno, 2012). Nightingale, the first nurse leader to promote quality patient care, implemented quality patient measures with the introduction of hand washing to prevent soldiers from dying of hospital-acquired infections during the Crimean

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war (Dykes & Collin, 2013). Recent literature denotes the definition of quality patient outcomes. Patient outcomes can be classified by a) patient functional status (maintained or improved), b) patient safety (protected or unharmed), and c) patient satisfaction (patient reporting of comfort and contentment) (Liu, Avant, Aungsuroch, Zhang, & Jiang 2014). Patient outcomes within the realm of the nursing discipline include metrics such as medical errors, patient falls, pressure ulcers, 30-day mortality, and nosocomial infection rates (Liu et al., 2014). Liu et al. define patient safety as the avoidance of harm that patients may encounter from nursing care received in a health care environment. For this literature analysis, mortality rates, failure to rescue rates, readmissions rates, length of stay (LOS), patient satisfaction, and health care cost reduction will be discussed as measures of quality patient outcomes.

IOM Recommendation The 2011 IOM report outlined goals to enable nurses to better meet growing health care needs in the United States (Kutney-Lee, Singh, & Aiken, 2014). A key recommendation was to increase the number of nurses with BSN degrees nationally, from 50 percent in 2010 to 80 percent by 2020 (IOM, 2011). The recommendation is supported by strong evidence-based research that stipulates patient outcomes improve when more highly educated nurses provide patient care (Kutney-Lee et al., 2014). The Robert Wood Johnson Foundation and the IOM launched a two-year study to assess and transform the current nursing profession. The IOM’s directive was to develop a nurse workforce with the necessary skill set and knowledge base to function effectively with multidisciplinary teams caring for complex patient needs (Duffy et al., 2014). An expert committee that included leaders in nursing education, nursing practice, as well as representatives from a diversity of health care, consumer, business, and research interests investigated the available research to comprise the recommendations (National League for Nursing [NLN], 2010). The IOM has created a paradigm shift with the decree to require higher levels of education for the nurse profession (Duffy et al., 2014). Since the IOM BSN announcement, further studies along with published statements from today’s health care organizations have energized the support of the IOM BSN recommendation.

METHOD An integrated review of literature data was collected through the Hunter Library of Western Carolina University, Cumulative Index of Nursing and Allied Health (CINAHL), Cochrane Database of Systematic Reviews, EBSCO’s Electronic Journal Service (EJS), Medline, and the National Library of Medicine (PubMed). The Google research engine provided further collection of data to assist with pertinent evidence-based studies and statements from the American Association of Colleges of Nursing (AACN), AONE, and the IOM. The institutional review board process was not required for this BSN literature review research study. The literature search focused on the five years following the initial release of the IOM report (2011–2016). The keywords baccalaureate, BSN, patient outcomes, mortality rates, failure to rescue, readmission rates, length of stay, patient satisfaction, and cost-effectiveness returned 135 articles; returned articles without full text, such as articles with only bibliography data or abstracts, were eliminated. Further elimination included duplicate article titles and articles that pertained to students in BSN programs. Bibliographies of reviewed articles

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and the AACN article “The Impact of Education on Nursing Practice” were searched to find other relevant articles and studies to support the IOM recommendation. The sentinel work done by Aiken, Clark, Cheung, Sloane, and Silber (2003) was included due to the significance of the study. The returned studies resulted in a total of 13 articles used for this literature review.

RESULTS This literature review evaluated evidence-based studies that focused on the impact of having BSN-educated nurses provide bedside nursing care and the resultant effects on patient outcomes. Not all patient outcomes were measured in every study, but various improved patient outcomes were found in all 13 studies. (See Table in Supplemental Digital Content, available at http://links.lww.com/NEP/A58.) The most common metrics reported to analyze patient care outcomes were mortality rates, failure-to-rescue rates, readmission rates, LOS, patient satisfaction, and cost-effectiveness.

Mortality Rates Mortality rate is defined as deaths that occur from any cause within 30 days of a hospital admission, for patients hospitalized with one of several medical conditions or surgical procedure (American Hospital Dictionary, n.d.). Ten research studies found decreased patient mortality rates when BSN nurses provided nursing care (Aiken et al., 2003, 2011, 2014; Blegen, Goode, Park, Vaughn, & Spetz, 2013; Cho et al., 2015; Kendall-Gallagher, Aiken, Sloan, & Cimiotti, 2011; Kutney-Lee, Sloan, & Aiken, 2013; McHugh, Smith, Wu, Vanak, & Aiken, 2013; Vanak, 2014; Yakusheva, Lindrooth, & Weiss, 2014a). The improved patient outcome related to fewer patients dying did not require an inclusive BSN nursing staff but was seen with a proportional difference in staffing patterns. Improvement in patient outcomes related to patient mortality was seen when there was a 10 percent increase in the proportion of BSN nurses providing care (Aiken et al., 2003, 2011, 2014; Blegen et al., 2013; Cho et al., 2015; Kendall-Gallagher et al., 2011; Kutney-Lee et al., 2013; Vanak, 2014; Yakusheva et al., 2014a). The decrease in mortality rates ranged from 4 percent to 14 percent among the 10 studies reviewed. Variables included study design, the type of patients studied, and the types of hospitals. Similar datasets of three studies with general, orthopedic, and vascular surgery patients found a decreased mortality rate ranging from 4 percent to 6 percent with higher BSN staffing patterns (Aiken et al., 2003, 2011; Kendall-Gallagher et al., 2011). A cross-sectional analysis of outcome data in a study of 232,342 patients resulted in a 5 percent decrease in patient deaths within 30 days of hospital admission (Aiken et al., 2003). Another study of 1,262,120 patient records across 665 hospitals in the United States showed a 4 percent decrease in mortality (Aiken et al., 2011). Kendall-Gallagher et al. (2011) conducted a secondary analysis of inpatients discharged during 2005 to 2006 (n = 1,283,241) from 652 nonfederal hospitals; nurse survey data (n = 28,598) showed a 6 percent decreased odds of dying within 30 days of being admitted in a hospital. Kutney-Lee et al. (2013), in a retrospective two-stage panel design study that involved three data sources at two different time points (1999 and 2006), utilized nurse survey data, administrative patient discharge data, and the American Hospital Association Annual Survey for data analysis. The study showed an associated average

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Baccalaureate Nurses Improve Patient Outcomes

reduction in mortality of 7.47 deaths per 1,000 patients with each 10 percent increase in BSN staff. In a cross-sectional study of 21 university consortium hospitals (Blegen et al., 2013), an average reduction of 2.12 deaths for every 1,000 patients was found on general adult units and adult intensive care units; decreased mortality was specifically found in patients with congestive heart failure (R2 = .118 and .114). For a subset of patients with complications in this study, more patients lived 30 days past hospital admission with an average reduction in deaths of 7.47 deaths per 1,000 patients. Vanak (2014), in a two-stage panel-designed secondary analysis, examined nurse-specific organizational characteristics of 135 hospitals. For a population of adult oncology patients (n = 29,356), there was a reported average reduction of 5.07 deaths for every 1,000 patients when BSN-educated nurses provided bedside care. A retrospective observational patient-level analysis of electronic data of adult medical-surgical patients (n = 8526), matched with 1,477 direct care nurses from an eastern U.S. academic medical center, showed a lower mortality rate of 10.9 percent in patients cared for by a 10 percent higher proportion of BSN-educated nurses (Yakusheva et al., 2014a). Decreases in mortality related to BSN staffing have been demonstrated in studies conducted outside the United States (Aiken et al., 2010; Cho et al., 2015). An observational study of discharge data for 422,730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries reported a decrease in inpatient mortality within 30 days of admission by 7 percent (Aiken et al., 2014). A study in South Korea (Cho et al., 2015), conducted in 14 large high-technology teaching hospitals (700+ beds), linked hospital facility data with staff nurse survey data (n = 1,024) and surgical patient discharge data (n = 76,036). A 9 percent decrease in patient deaths was found. McHugh et al. (2013) analyzed the link between Magnet hospitals and patient outcomes. Patient, nurse, and hospital data were linked for 56 Magnet and 508 non-Magnet hospitals using logistical regression models to estimate differences in the odds of mortality for surgical patients. Magnet hospitals are reported to have higher proportions of nurses with bachelor’s degrees. In addition, a 14 percent decrease in the odds of dying was noted for those patients cared for at Magnet-designated hospitals. The impact of BSN staff on lives saved can be significant. Findings from Kutney-Lee et al. (2013) suggest that if all 134 hospitals in their study increased the percentage of BSN nurses by 10 percent between 1999 and 2006, about 500 deaths could have been prevented among general, orthopedic, and vascular surgery patients. If the studied hospitals’ nursing workforce were composed of 80 percent BSNs, more than 2,100 lives could have been saved.

Failure to Rescue Failure to rescue is the failure to prevent clinically important deterioration, the result of an underlying complication of an illness such as cardiac arrest in a patient with acute myocardial infarction or a complication of medical care such as hemorrhage after surgery (Jones, Bottle, & Griffith, 2011). Nurses play a key role in the early identification of patient status deterioration; therefore, failure to rescue is highly sensitive of nursing care and has been widely advocated as a potential nursing-sensitive outcome indicator (Jones et al., 2011). Four articles report that BSNs decrease failure-to-rescue rates (Aiken et al., 2003; Blegen et al., 2013; Kendall-Gallagher et al., 2011;


McHugh et al., 2013). These studies include a skill mix of nurse education and years of experience, with a 10 percent higher proportion of BSNs to reduce failure-to-rescue rates. In the Aiken et al. (2003) study, patients who were cared for by BSNs had a 5 percent greater likelihood to survive health-related complications that lead to failure to rescue. Another study (KendallGallagher et al., 2011) reported patients who were cared for by BSNs had a 6 percent reduced risk of failure to rescue. Blegen et al. (2013) reported hospitals with a higher proportion of BSN degrees were associated with lower failure-to-rescue rates. McHugh et al. (2013), in a comparison between Magnet and non-Magnet facilities, found a higher proportion of BSNs was associated with a 12 percent lower odds of failure to rescue.

Length of Stay LOS is the number of days a patient is in the hospital or the number of calendar days from the day of admission to the day of discharge (UK Healthcare, 2015). Three research studies report that BSNs contribute to a reduction in patient LOS (Blegen et al., 2013; Yakusheva et al., 2014a; Yakusheva, Lindrooth, & Weiss, 2014b). Blegen et al. (2013) reported a higher proportion of BSNs reduced LOS in patients with expected greater than LOS diagnosisrelated groups by 0.8 percent. Patients receiving ≥80 percent of care from BSN nurses had 1.9 percent shorter LOS (Yakusheva et al., 2014a). A study on nurse-valued-added (NVA) attributes stated that BSNs NVA scores were higher than NVA scores in less educated nurses, which contributed to shorter length of hospital stays (Yakusheva et al., 2014b).

Additional Outcomes Additional positive patient outcomes were noted, but the breadth of findings is not strong enough at this point. Additional research is needed in cost-benefit analysis, patient satisfaction, correlation with decreased complications, and readmission rates. To achieve a projected quality and cost-benefit analysis, the proportion of BSN-educated nursing staff must be 80 percent or higher (Yakusheva et al., 2014a). BSNs who achieved higher NVA scores were linked to a 6.5 percent reduction in hospitalization costs (Yakusheva et al., 2014b). An increase in BSN nurses correlated with an improvement in patient satisfaction scores in a study analyzing data from 181 Chinese hospitals nurses (n = 9,688) and patients (n = 5,786; You et al., 2013). A 10 percent increase in BSN staff correlated with an increase in patient satisfaction as well as willingness to recommend the hospital to others (You et al., 2013). In addition, a decrease in disease complications, such as decubitus ulcers, postoperative deep vein thrombosis, and pulmonary embolism rates, was linked to care provided by higher educated BSN nurses (Blegen et al., 2013). Lastly, readmission rates were reduced when a higher proportion of BSN nurses provided patient care (McHugh & Ma, 2013; Yakusheva et al., 2014a). Each additional 10 percent increase in the proportion of hospital nurses with a BSN-level education was associated with 3 percent lower odds of 30-day readmission for patients with a diagnosis of pneumonia (McHugh & Ma, 2013). Surgical patients receiving ≥80 percent of care from BSN nurses had lower odds of hospital readmissions (Yakusheva et al., 2014a). An estimated $5,653,022.97 of annual health care savings were related to decreased readmission

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rates with a higher proportion of BSNs in an eastern U.S. academic medical center study (Yakusheva et al., 2014a).

DISCUSSION The call for a higher proportion of BSNs providing patient care comes from the response to the health care system being in a state of rapid change. Current research has linked data that report that a higher percentage of RNs with BSN degrees can be key stakeholders in the future of complex quality patient care. A combined approach of increasing the hospital-level BSN proportion to 80 percent and ensuring a high BSN dose through individual patient-level staffing assignments is needed to achieve projected quality and costs benefits (Yakusheva et al., 2014a). An annual cost savings of approximately 5.6 million dollars was equated to reduced readmissions by roughly 248 days when the proportion of BSN-prepared nurses was increased to 80 percent or more (Yakusheva et al., 2014a). The body of evidence demonstrates improved patient outcomes when nursing care is provided by BSN-educated nurses. Mortality, failure to rescue, and readmission rates all decrease as the proportion of BSN nurses is increased in a nursing staffing ratio. There is beginning evidence that higher BSN ratios may affect other areas such as LOS, patient satisfaction, and costs, but there are only a few studies reporting these findings (Yakusheva et al., 2014b; You et al., 2013). National nursing organizations have published position statements supporting this recommended goal. AACN and AONE both published position statements that advocate for the BSN degree to become the minimum educational requirement for professional nurse practices. AACN reports that education has a significant impact on the knowledge and competencies of nurse clinicians, who are valued and respected for their skills in critical thinking, leadership, case management, and health promotion. Nurse executives, federal agencies, the military, nursing organizations, health care foundations, Magnet hospitals, and minority nurse advocacy groups all recognize the unique value that BSNs bring to the practice of patient care (AACN, 2015a). In May 2010, the Tri-Council for Nursing issued a statement that calls for all RNs to advance their education in the interest of enhanced patient quality and safety. In a statement titled “Education Advancement of Registered Nurses,” the Tri-Council presented consensus insights where a highly educated nurse workforce will be critical to meet the nation’s unbridled demand to deliver safe and effective patient care (AACN, 2015b). In addition, the call to promote academic progression within nursing is consistent with the NLN’s mission and with its core values of caring, integrity, diversity, and excellence (NLN, 2011). Magnet hospitals are recognized for nursing excellence, and superior patient outcomes required all nurse managers and nurse leaders to hold a BSN or graduate degree in nursing by 2013 (AACN, 2015b). Furthermore, hospitals that apply for Magnet recognition must outline plans on how to achieve the IOM recommendation by 2020. The BSN-in-10 proposals in New York and New Jersey were introduced by state nursing associations to require graduated entry-level RNs to obtain a BSN degree 10 years from graduation. Other states are considering similar proposals to ensure a higher-educated nurse workforce (AACN, 2015b). There is a movement nationally to preferentially hire BSN-prepared nurses. AACN conducted an online survey of 718 deans of nursing schools who offered BSN and graduate nursing degree programs. Valid responses (n = 582) were received with an 81.1 percent response rate. Responses indicated that 47.4 percent of hospitals

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and other health care settings require new hires to hold a BSN, with 83.5 percent of employers expressing a strong preference for BSN program graduates. Per the studies and statements from this literature review, the IOM recommendation is supported by an array of evidence-based research and health care organizational leaders. However, even though there is a plethora of evidence-based research that correlates staffing with a higher proportion of BSNs and decreased mortality and failureto-rescue rates, literature that supports decreased readmission rates, LOS, and health care costs, as well as increased patient satisfaction and likelihood to recommend, is currently scant. Research in these quality measures could increase support for the IOM recommendation. In addition, current research does not explain which attributes of the BSN nurse relate to improved patient outcomes, which could further support the IOM recommendation.

CONCLUSION The current state of the evidence shows significant improved patient outcomes when nursing care is provided by BSN-educated nursing staff. A 10 percent increase in the proportion of BSNs providing bedside care decreases the likelihood of patient mortality and failure to rescue. Research is needed to provide a stronger base of knowledge to support the correlation between BSN-educated staffing and reduction in readmission rates, LOS, patient satisfaction scores, and willingness of patients to recommend to others. Therefore, it is the recommendation of this project that nurse leaders and organizations support the findings of this literature review and the IOM BSN recommendation.

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Baccalaureate Nurses Improve Patient Outcomes

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