Monday, April 22, 2013

Do BSN nurses provide better care?

A paper entitled "An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality" appeared in Health Affairs in March and  generated quite a lot of buzz on the Internet.

Its major finding was that hospitals in Pennsylvania that had 10% more nurses with BSN degrees were found to have 2.12 fewer deaths per 1000 postop patients than those that did not. The authors extrapolated this, saying that if all the hospitals they surveyed had the same percentage of BSN nurses as the best performers, 500 deaths may have been avoided.

The reduction in mortality rates was not significantly affected by staffing levels, skill mix or years of experience as a nurse.

The mechanism for the decrease in death rates was not explained but assumed to be better rates of "rescue" after the development of complications which also was significantly associated with the presence of more BSN nurses and not staffing levels, skill mix or years of experience as a nurse.

The abstract concludes, "The findings provide support for efforts to increase the production and employment of baccalaureate nurses."

The math in the paper is confusing. In 2006, 25,000 nurses responded and 1/3 (presumably about 8,333) of them were staff nurses in general hospitals. The information from those 8,333 nurses was the basis of the study. They go on to say that there were 134 hospitals with an average of 48 respondents. That computes to 6,432. That's a discrepancy of over 2000.

A cliché that is often used in comments about research papers is "the study raises more questions than it answers."

Here are a few. 

Could it be that the hospitals with improved mortality and rescue rates are simply better hospitals? And maybe BSN nurses are simply more likely to work at better hospitals. 

If 2/3 of the nurses who responded to the surveys are not working as staff nurses in general hospitals, just what are they doing? Going to committee meetings?

A nurse who commented on a recent post of mine about a national organization setting up a "Transition to Practice" fellowship for graduating surgical trainees who lack confidence in their skills said,

I could say the same about nursing school. Why are there suddenly nurse residencies and nurse fellowships? Because there is too little clinical time while in school. My nursing school has a name that you would recognize. Our med-surg clinical days were one half-day per week spent at the hospital, about 26 in total over 2 semesters. Peds and maternity, about 5 half-days each. I was lucky because I was on a general medicine unit and got to see a variety of patients. We all complained that our clinical time was inadequate. The preceptorship in the last semester consists of working eight shifts one-to-one with a staff RN. No wonder, then, that hospitals are not confident in the capability of new nurses to practice safely and effectively.

Why is it that over 100 hospitals have established "nursing residency" programs? Click here to see a list of them published by the University of Pennsylvania. 

Here are quotes from two hospital websites about their nursing residency programs.

The Nurse Residency Program at Mayo Clinic in Arizona is a full-time registered nurse position with a one-year orientation program that assists you in transitioning from a new graduate to a fully competent, professional nurse at Mayo Clinic.

Children’s National Medical Center’s Pediatric Nurse Residency program provides the novice nurse with the knowledge base and skill set needed to transition to competence in clinical nursing practice.

What they are saying is that at least some graduating nurses are not competent. This meshes well with recent findings that graduating surgical residents are not ready to practice independently.

Why can't we teach nurses how to nurse in school and docs how to doctor during residency?.


Anonymous said...

I can't speak to nursing, but the reason surgeons aren't learning are because we waste years of our training doing little more than paperwork and non-operative BS ( e.g. 90+% of trauma in most institutions) so the older surgeons don't have to deal with it. Although new requirements in documentation seem to require more and more of the attendings' time. Once upon a time, the goal of a surigcal residency was to learn surgery. This just isn't the case anymore.

Anonymous said...

In many years as a doc, I have never seen much clinical difference between 2yr grads and BSN's, though obviously the latter are much more represented in administrative roles.

Many first year nurses are inadequate because they have had little nursing experience in training. Some years ago, a close friend of mine was getting her BSN and her senior courses were stuff like "Multi-Cultural Aspects of Nursing", "Sociology of Nursing", and similarly vacuous nonsense. I looked at some of her course materiel and much of it had little intellectual content.

Basically, many nurses get their first real nursing training on the job. Given that, spending 4 years getting a BSN instead of just 2 in Community College would just delay getting real clinical skills. Kinda like a surgical resident doing a year of research.

But, surgical (and non-surgical) residents have spent years actually dealing with patients prior to independent practice. New nursing grads have not.

Anonymous said...

Responding to #1:

A lot of a surgeon's medical duties involve treatment outside of the OR. Of course a surgeon should have excellent technical skills, but he/she should want to take care of perioperative problems as well. Most general surgeons are in fact excellent at this, so they must have learn some non-operative BS along the way.

But, if you are an orthopod, you can/will quickly refer any/all problems not immediately surgical. I'm not sure how this became the standard everywhere.

SeaSpray said...


Tom said...

While speaking as an Australian, and realise there are some differences between nurses here and in the US, I would comment that clinical hours during University are reasonably ample at least in comparison.

In three years (or two fast tracked) there is a total of approximately six months full time clinical placement, which is around 38 hours a week of work. In the final semester it was not eight shifts, but rather eight weeks of full time shift work for clinical placements. All unpaid, obviously.

However even with this fairly large block of time dedicated to clinical placement, every single nurse graduating from University must go through a one year residency program (or "transition to practice") or they are ineligible for employment, outside aged care homes.

While I would note that nurses should learn to nurse at nurses school, you learn far more in the first six months of real working than you do in the entirety of your education.

Skeptical Scalpel said...

Thanks for all the comments.

"Multi-Cultural Aspects of Nursing" and "Sociology of Nursing" are examples of the depth of the problem. Let's spend less time on the theory of nursing and more time taking care of patients.

It appears that nursing in Australia has already given up on nursing school and admitted that the nurses need "residencies" to become competent.

I agree that doctors waste a lot of time checking boxes and doing clerical work.

NurseWriter said...

I feel very strongly that the whole push for BSN is administration driven for Magnet status. I have a BA from years ago--when I returned to school for nursing I got an ADN at a local community college with a good reputation for lots of clinical time. The floor nurses all emphasized that ADN nurses were much better prepared for patient care because of the clinical hands-on time; new BSN grads were often "lost."

I have since gotten my BSN online and while it may look better on paper it added NOTHING to my bedside practice. I think it is a shame that ADN nurses are being pushed aside for management because they don't have a BSN--when they have better patient skills than their managers! "Sounds good, doesn't work" is often the case in hospital policies.

I would not be a nurse if I did not have the less expensive ADN option--and I am a darn good nurse.

Clark Venable said...

I want to second what NurseWriter said. The push for BSNs where I work is entirely driven by Magnet status--to the extent that nurses who do not want to go back to school for their BSN have been told they will find their opportunities for advancement limited.

artiger said...

The BSN sounds like the equivalent of board certification.

Tonja Treece said...

As an ADN nurse I noticed that my program at school had far more clinical hours than the BSN nurse programs, and that BSN nurse programs were geared more towards management than clinical nursing. And hospitals should never underestimate what years of experience is worth.

Skeptical Scalpel said...

Good comments all. Some day, I hope to find out just what "Magnet status" actually accomplishes in terms of bedside care for the patients. So far, I have no clue.

Some nurses think it is BS, not BSN:

DD said...

Is critical thinking taught in the classroom? I do not think so. It combines one's inherent attributes with learned skills to facilitate an ability that improves and sharpens over time... with experience. A well-rounded educational foundation is part of the preparation in any discipline. How can you "be" something if you do not fully understand what "it" is? Hence the need for classes about Nursing Theory. And in our ever diverse society who would NOT benefit from taking a "multi-cultural" course or two? A person who endeavors to undertake a rigorous course of study (in any field) usually has innate qualities that enable success; keen intellect, good work ethic, desire to learn are a few that come to mind. A four year program takes more time, effort and study than a two year program, just as finishing medical school is a more time intensive course of study than getting a Master's (needed to be an NP or PA). However, being able to complete academic course work is not the only measure of who will be a good clinician, diagnostician, surgeon or nurse. Sometimes, intangible qualities,like being a good listener, good communicator, compassionate,or humorous result in the exceptional provider on any level. Again, these are qualities not taught but developed within.
In summary:
Nursing needs one consistent entry level degree that corresponds with other disciplines where the terminal degree is a doctorate. This is not a new debate; a 4 year degree as an entry-level requirement is necessary if Nursing is to evolve as a profession.

Anonymous said...

Those who believe this deception should also believe that someone with a PhD in nursing provides the ultimate in care.

Tom said...

""Multi-Cultural Aspects of Nursing" and "Sociology of Nursing" are examples of the depth of the problem. Let's spend less time on the theory of nursing and more time taking care of patients."

This comes back to the crux of the problem though, and one that is regularly discussed in some circles. How we define what a nurse is in the modern healthcare industry, and most importantly, how we define them with respect to their medical counterparts.

As nurses gain increased education, increased skill base and scope of practice, increased paperwork and use of technology coupled with a decrease in patient contact, the role of an experienced RN compared to a green intern is far more blurred than it was a few decades ago.

As these factors exacerbate (and they inevitably will continue to) we need to actually look at what we want from nurses and how we can get it from them. Despite some perceptions, nursing is no longer a trade, and a University education is required if we want nurses to perform higher level functions technically and be more involved in critical care/deteriorating patients and so on.

The trend in Universities is still based on the idea that medical staff do medical things, and nurses provide the care. While care may best be taught in practical environments, the University is caught between a rock and a hard place and can't simply absolved themselves of teaching for sake of clinical placements.

The result is that University curriculums must involve teaching care and the historical components of nursing, and that involves analysing and being more aware of things like sociological constructs. If your job is to shower and wipe faeces from a persons rear, I can assure you that an understanding of their cultural background is imperative. Religions, nationalities, tribes and more all have distinct rules and taboos regarding personal contact and if your job is personal contact then you can't disregard the importance of being aware of it. A broad study of a variety of cultures is better than learning by insulting people on a daily basis as you "learn from your mistakes".

That being said, the healthcare industry needs to take a good hard look at where we are going in the future, and we can't rely on old structures to provide appropriate management in this ever changing world.

Skeptical Scalpel said...

Thanks for the interesting comments. Some points that need more discussion were raised.

Does nursing really need to "evolve"? If so, evolve into what? I'm not sure how studying another culture will help a nurse understand how to wipe a backside. Are they going to study every culture in the world? While they're at it, maybe they should learn the more than 200 different languages that are spoken. Is that really necessary or practical?

I want a nurse who can take care of a patient. I want him to know what the patient's problems are. Since, in theory, he spends a lot more time with the patient than I do, I encourage him to tell me what his observations are.

Many floor nurses don't seem to know what their patients' diagnoses are, what meds they are on and what their current vitals signs are.

Let's spend less time worrying about the evolution of nursing and more time with the patients, please.

Or let nursing evolve into a philosophical discipline full of PhDs who sit in offices or walk around carrying clipboards, and let's create a new category of healthcare worker who takes care of patients.

frustrated surgeon said...

Come on this is not a nurisng issue, this is a society and health care issue.

We have become so politically correct that we have frozen in our tract and can not function like our mentors. WE HAVE DEVELOPED A PHOBIA TO CONFLICT.
Look at the article about physicians -academic surgeons sound alarm about training deficiencies presents the findings from a new survey of the nation’s subspecialty fellowship program directors presented at at the annual meeting of the American Surgical Association.
the failure rate on the American Board of Surgery’s oral exam has climbed steadily from 16% to 28%. At present the percentage of examinees who fail either the oral or written ABS exam the first time around is in the mid-30s.

We have lost the ability to train people we spend more time teaching philosophy, doing personality asessments and fearing reprecussion of students and residents. We as educators are being judged and in the face of losing money or even worse for poor evaluations so we allow subpar students and residents to go forward. In the same judgemental fish bowel we do not judge our nurses instead we rally on the idea that more years of education/training will fullfill the deficit , instead of 2 or 4 years of hard labor as a resident or nursing student we do fellowships , training sessions after being hired or simply accept poor care as the norm.

Accepting poor care has become the standard: honest and critical feed back has been replaced with terms like bullying , " safe work environment" and 360 degrees of evaluation. the pendullum has swung so far that we fear our students, residents and nurses. This has led to an environment of apathy , poor critical thinking and lack of ownership.

I will give you an example, my mid level resident scrubbed a case with me, when asked about the case. He did not know why we where doing the case, did not read the chart or about the technial aspects of the case. During the case he was lightly pimped about the disease and surgery. Stuff straight out of surgical recall for students, he knew nothing. In response to all this he was told he can only hold sticks. In the next morning I was called in the chair's and the program director's office . The response was that the residents have the right to do the cases when they scrub and the rest does not matter. Here is where the problem lays in our educational system. students, resident who feel entitled rather than honored to be in health care.

Skeptical Scalpel said...

Frustrated, I feel your pain. Been there myself. You have summarized a lot about what is wrong with medicine today. I'm glad I'm not trying to run a program now.

As for the residents, I think it has a lot to do with entitlement. Some of them feel that it is their right to do a case regardless of whether or not they've examined the patient or read about how to perform the operation. I've seen it countless times. Before the work hours restrictions, they claimed they had no time to read.

What's the excuse now? Papers have shown that they don't spend their time away from work reading.

Anonymous said...

Question for frustrated surgeon and Skeptical Scalpel: why has the older generation let the younger one get away with murder? Who made that decision? Why has common sense not prevailed? Why are we multiplying degrees and theories and cr*p and paying no attention to where the rubber meets the road?

DD said...

Agree: Nurses and residents should know their patient's diagnosis and pertinent aspects of the case.
Disagree: You are incorrect that multi-cultural awareness is not relevant to providing optimal, holistic patient care. This article points to the need for such training for residents:
Many studies show positive outcomes are associated with culturally sensitive care. It goes beyond being politically correct.
Just because you can cut someone open while they are asleep doesn't mean you should not understand how that patient perceives their disease or diagnosis,the meaning of health or how they express pain; you needn't speak their language to evaluate them in their cultural context (most health systems have translators available to help). Not every patient (or provider) is a white middle-class American.
Furthermore, the work of nurses entails far more than "how to wipe a backside". I would hope that anyone who has one (a backside) also knows how to wipe it--no training required.

Skeptical Scalpel said...

Anon, I can't speak for frustrated surgeon, but I tried my best to become involved with the organizations that run surgical education. I thougth I had a shot at one of them but I was rejected for being "too outspoken." Can you imagine that? I'm not taking any of the blame for the current state of affairs. Don't accuse me of second guessing either. I was fighting with the RRC for surgery as far back as 1985.

DD, I understand your point. I have no quarrel with being sensitive to other cultures. I've worked in an inner city hospital. I will bet I've dealt with people from places you've never even heard of. You can't learn every culture in a classroom. If you have a modest amount of common sense, you can find out from the patient or the family what cultural issues might arise.

Regarding the "backside" comment, I was simply referring to a comment made by Tom above. And perhaps you know this, but there are some patients who are physically and/or mentally incapable of wiping their own backsides.

Anonymous said...

Of course, cultural sensitivity and all is important, but do we really need senior level college courses for that?

It's been a few years, but the course material I have seen for BSN classes are trivial, and do not foster critical thought. They are similar to Communication courses for football jocks - completely useless for future employment and require little intelligence. If it is critical thought we are aiming for, I would suggest that a BA in EngLit or History followed by 2 years of Nursing.

Tom said...

Agree with basically everything being discussed here. I think a large part of the cultural awareness/sociological education is very similar to a lot of other University education in that they are trying to teach common sense and critical thinking.

Some may think that you either have these qualities or you don't and it can't be taught, but I suppose the education faculty at large believe there is merit in teaching it.

The idea that a ward nurse isn't aware of a patients diagnosis, medications and vitals are is worrying but perhaps more a reflection on the idea that "nurses should spend more time with their patients". You understand their physical condition, medication regime and so on from reading the notes, medication charts, doing some additional research. Spending time with the patient for a nurse means emotional care, practising hygiene, helping occupy their time.

I don't think that you can have nurses who are completely on the ball in a medical sense, and that are also completely engaged with a patient in a more traditional sense. You can have a balance of the two, but one inherently detracts from the other.

With regard to the residents scrubbing in with no know prior knowledge of the case, the American hospital system sounds wackier by the day. No offense intended.

Anonymous said...

I am a new grad in a busy ER, I have an ADN. I chose my ADN program over the 2 other BSN programs in my area. Why? Cost was a big option my ADN cost 5-6K compared to 10-20k for a BSN. The main reason however was I wanted the best education and in my area the ADN program had the best reputation in the area. One BSN program's students always looked like they had pulled their laundry out of the dirty clothes hamper and were clueless about basic stuff (like taking a manual blood pressure). One school's dean of nursing told me at an information session before that "ADN programs prepare you to nurse at the bedside, a BSN prepares you to be a nurse leader"

My point is that I would take a strong ADN program graduate over a random BSN school graduate. Just like I would take a BSN candidate over an ADN candidate from a school with a bad reputation.

The dean from the BSN school was wrong. The goal of any nursing program granting licensure (LPN, ADN, BSN, MSN) should be to prepare a nurse for the bedside. Most BSN programs do not add anything significant to bedside practice.

Skeptical Scalpel said...

Anon, thanks for the interesting and provocative comments. This post is a little old, but I'd love to hear from some BSN grads.

Anonymous said...

The March 2013 paper by Kinda Aiken at the center of this discussion was nothing more than an updated rehash of her 2003 study which through bias and severely flawed methodology tried to conclude that hospitals staffed with more nurses with BSNs experience lower mortality rates. This study was nothing more than a written infomercial whose sole purpose was to get nurses to run back to the schools in order to increase revenue. The study was backed by people organizations committed to the BSN being the entry level education for all nurses and who would benefit monetarily by having large numbers of nurses spend thousands for something that no one has proved will have nay bearing on patient care.

Every two to three years sine 2003 she publishes a paper to try to give a booster shot to her cause.

Skeptical Scalpel said...

Anon, I completely agree. She turns out a paper like this every few years and it's all about escalating the amount of educational requirements for nursing.

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