Final why bsn, bl4, rev2.26.13

Why BSN?
The evidence of why patients & families need BSN nurses
Paulette C Compton, RN, MSN, MC
Program Director
MaricopaNursing-Banner Boswell MCC

Imagine…….
 SCENERIO: The principal at the new school for
your children or your nieces & nephews tells you
they have teachers with different education
preparation and degrees but there is NO difference
in their ability to teach your
children/nieces/nephews.
What do you think about this?
What questions would you have for the
principal?
2.26.13 2PCCompton Why BSN?

What do you know about ADN vs.
BSN?
 What does the concept „entry into practice‟
mean?
 Is it common to have different entry into
practice points in a specific profession?
 Do you know of any other profession who has
more than one way to enter into practice?

What is a ‘profession’?
Defining Characteristics of a Profession:
1) Established ethical standards(AZBN & ANA
Code of Ethics)
2) Widely recognized body of knowledge (ANA
Nursing Scope & Standards of Practice)
3) Use body of knowledge in the interest of
others. („helping profession‟)
4) Body of body of knowledge is derived from
research (EBP), education and training at a
university institution of higher learning.
(4 year college degree)
Adapted from SOURCE: Australian Council of Professions (2004)
http://www.qualityresearchinternational.com/glossary/profession.htm

ANA 1965 Position Paper
The 1965 ANA Position Paper recommended:
① Requirement making the baccalaureate degree
the minimum educational standard for
professional nursing practice: Registered
Nurse (RN)
② Create new license for associate degree nurses:
Registered Associate Nurses (RAN)
③ Eliminate two types of technical nursing
education programs:
 Diploma
 Practical

ANA’s Rationale for Position
Paper on Nursing Education
ANA‟s Rationale for 1965 Position Paper on
Nursing Education
1) Increasing complexity of healthcare and
nursing practice
2) Majority of nurses trained in diploma
programs, which focused on staffing hospital
with students, rather than higher education in
colleges or universities

ANA’s Rationale for Position Paper on
Nursing Education (cont.)
4) Professionals are educated in institutions of
higher learning
5) Nursing lagging behind other healthcare
professions who are increasing educational
requirements which result in nurses the „least
educated‟ healthcare professional

Nurses are the ‘least educated’ healthcare profession!
Healthcare Occupations:
Minimum Education Degree for Entry to Practice
 Associate
Registered Nurse
Respiratory Therapist Tech
Pharmacy Tech
Occupational Therapy Assistants
Physical Therapy Assistants
 Baccalaureate
Respiratory Therapist
 Masters
Physical Therapist
Occupational Therapist
Social Worker
Speech Therapist
Counselor
 Doctoral
Physician
Pharmacist

Source: HRSA 2008 National Sample Survey of Registered
Nurses
http://bhpr.hrsa.gov/healthworkforce/rnsurvey/

What is the Tri-Council for Nursing?
“The Tri-Council for Nursing is an alliance of four
autonomous nursing organizations each focused on
leadership for education, practice and research. …... These
organizations represent nurses in practice, nurse
executives and nursing educators….”
Tri-Council Member Organizations:
1) American Nurses Association
2) National League for Nursing
3) American Association of Colleges of Nursing
4) American Organization of Nurse Executives

2010 Policy Statement from Tri-
Council for Nursing
Educational Advancement of Registered Nurses:
A Consensus Position

2010 Policy Statement from Tri-
Council for Nursing
Educational Advancement of Registered Nurses:
A Consensus Position (cont)
Quote from 2010 Policy Statement:
“A more highly educated nursing profession
is no longer a preferred future; it is a
necessary future in order to meet the
nursing needs of the nation and to deliver
effective and safe care.”

Did you know……….?
Did you know…….?
① US Army, Navy, and Air Force require BSN for
RNs.
② US Public Health Service require BSN for RNs.
③ 76% of respondents to 1999 Harris Poll believe
nurses should have 4 year college degree to
practice nursing
④ AONE: American Organization of Nurse
Executives released statement in 2005 calling
for all RN be educated in BSN programs.

ANCC Magnet Hospital Recognition
Average Magnet Direct Care RN Education

Why BSN?
Why BSN??? The answer is simple. The evidence
indicates:
 Patient outcomes are better when a higher
proportion of nurses are educated with BSN.
 Patient mortality rates decrease when a higher
proportion of nurses are educated with BSN.
 Failure to rescue rates by nurses decrease as a
higher proportion of nurses are educated with
BSN.

Opinion vs. Evidence
Opinion
• Individual‟s view or perception
• Individual may or may not be an „expert‟
Evidence
• Based on scientific methods
• Levels of evidence

EFFECT of RN Educational Level
on Patient Outcomes Evidence
 Aiken, L.H., et al. (2003).Educational levels of hospital nurses
& surgical patient mortality, Journal of American Medical
Association, 290, 16-17-1623.
STUDY RESULTS: N=#232,342.
A 10% increase in the proportion of nurses holding a bachelor‟s
degree was associated with a 5% decrease in both the
likelihood of patients dying within 30 days of admission and
the odds of failure to rescue (odds ratio, 0.95; 95%CI, 0.91-
0.99 in both case).
STUDY CONCLUSION: In hospitals with higher proportions of
nurses educated at baccalaureate level or higher, surgical
patients experienced lower mortality and failure to rescue
rates.

 Aiken, L.H., et al. (2008). Effects of Hospital Care
Environment on Patient Mortality and Nurse Outcomes.
Journal of Nursing Administration, 38(5), 223-229
STUDY RESULTS: N =#232,342. Each 10% increase in
the proportion of nurses with a BSN was associated with
a 4% decrease in risk of death.
STUDY CONCLUSION: This study reaffirmed 2003 Aiken
study in JAMA which found in hospitals with higher
proportions of nurses educated with BSN, patient
mortality decreased.

 Friese, C.R., et al. (2008) Hospital nurse practice
environments and outcomes for surgical oncology patients.
Health Services Research, 43(4), 1145-1163
STUDY RESULTS: Hospitals whose nurses had more advanced
educational preparation had lower mortality rates (p<.05).
Higher education was associated with lower failure to rescue
rates (p<.01).
(By convention, a p value of 0.05 is considered a statistically
significant result)
STUDY CONCLUSION: Improvements in the quality of nurse
practice environments could reduce adverse outcomes for
hospitalized surgical oncology patients.

 Tourangeau, A.E., et al. ( 2007) Impact of hospital care on 30-day
mortality for acute medical patients. Journal of Advanced Nursing,
57(1), 32-41.
STUDY RESULTS: N=46,993. A 10% increase in the proportion of
baccalaureate-prepared nurses was associated with 9 fewer deaths
for every 1000 discharged patients. This is a similar finding of
Aiken (2003) study.
STUDY CONCLUSIONS: Evidence supports current movement to
legislate BSN as minimum requirement for RN entry to practice.
Because of impact of BSN lowering mortality rates, authors
recommend hospitals aggressively seek to hire and retain BSN
nurses to care for acute medical patients, who require the scope and
depth of knowledge attained in BSN education to provide safe
quality care to complex acute medical patients.

 Estabrooks, C.A., et al. (2005). The impact of hospital
nursing characteristics on 30-day mortality. Nursing
Research, 54(2), 72-84.
STUDY RESULTS: N= #18,142. The hospitals with a
higher proportion of baccalaureate-prepared nurse were
associated with lower rate of 30-day patient mortality
(95% CI, 0.81-0.96).
STUDY CONCLUSIONS: Hospital nursing characteristics
are an important consideration in efforts to reduce the
risk of 30-day mortality of patients.

What is rationale for opinion
opposing BSN minimal entry into
practice?
 Why do you think anyone would have the „opinion‟
BSN minimal entry into practice is not a good idea?
1) WIIFM….good or bad?
2) Unaware of clinical issues
3) Unaware of health policy issues
4) Fear of change
5) Fear of loss of job
6) Inability to obtain BSN
7) Increased tuition to obtain BSN
8) Increased cost to health care organizations
9) Fear of increased nursing shortage
10) Fear of evidenced-based practice
11) ??

Educating Nurses: A Call for Radical
Transformation Carnegie Report
 The Carnegie study on nursing education, led by Patricia
Benner, studied the current nursing education system in
the US.
 The study found ALL nurses are undereducated for the
very complex nursing practice in the health care system.
 One of the many Carnegie recommendations:
Require BSN minimum entry into practice.
 Source: Benner, Patricia, et al (2009) Educating Nurses:
A Call for Radical Transformation
 http://www.carnegiefoundation.org/elibrary/educating-nurses-highlights

Educating Nurses: A Call for Radical
Transformation Carnegie Report
http://www.carnegiefoundation.org/elibrary/educating-nurses-highlights
 Carnegie Report (2009) Recommendations on
Entry and Pathways in Nursing Education.

Advisory Board Research r/t New
Grad Practice Readiness
Advisory Board (2008) Bridging the Preparation-Practice
Gap: Volume I: Quantifying New Graduate Nurse
Improvement Needs
 Initial research identified 36 new grad competencies: 18
clinical & 18 non-clinical
 Evidence indicates only 10% of nurse practice leaders are
satisfied with new grad proficiency r/t 36 new grad
competencies.
 Evidence indicates 90% of nursing faculty are satisfied
with the new grad proficiency r/t 36 new grad
competencies.

Advisory Board Research r/t New
Grad Practice Readiness
 Evidence indicates only 10% of nurse practice
leaders are satisfied with new grad practice
readiness r/t 36 new grad competencies.
 Evidence indicates 90% of nursing faculty are
satisfied with the new grad practice readiness r/t
36 new grad competencies.
 Boswell Spr 10 data indicates

What is the IOM?
 Institute of Medicine
 Private, non-governmental, nonprofit organization
providing unbiased and authoritative advice to
decision makers and the public.
 Established in 1970, the IOM is the health arm of
the National Academy of Sciences, chartered under
President Abraham Lincoln in 1863.
 www.iom.edu
SOURCE: www.iom.edu/About-IOM.aspx

What is the purpose of the IOM?
“The Institute of Medicine
asks and answers the nation‟s most
pressing questions about
health and health care.”
“The mission of the IOM is to advise the nation
on matters of health and medicine.”

What does the IOM do?
“The IOM applies a distinct research process to
provide objective and straightforward answers
to difficult questions of national importance.”
“These leading national and international
scientists [who conduct the studies], all of whom
serve as volunteers, are asked to set aside
preconceptions and to rely on evidence in their
pursuit of knowledge and truth.”

Why are IOM Reports Essential to
Nursing Education?
 The IOM Reports:
1) provide evidence how to improve our healthcare
system
2) provide evidence how to improve the health of
Americans & improve patient outcomes in our
nursing practice
3) IOM focus is also on healthcare professions
education with goal of a consistent framework
with all healthcare professions education
emphasizing interdisciplinary care
SOURCE: Finkelman A & Kenner, C (2009) Teaching IOM: Implications of the IOM Reports for
Nursing Education. ANA: Silver Spring, MD 2.26.13 31PCCompton Why BSN?

IOM Report: To Err is Human 1999
 The report identified remarkably high incidence of errors in
health care. At least 44,000 to 98,000 people die in hospitals
each year in the US as a result of medical errors that could
have been prevented, based on estimates from two major
studies.
 Definition of „medical error‟-the failure of a planned action to
be completed as intended or the use of a wrong plan to
achieve an aim.
 The highest incidence of medical errors with serious
consequences occurs more frequently in ICUs, ORs, and EDs.
 Recommendation of need to change to blame-free
environment which does not focus on punishing individuals
for errors but changes to a root cause analysis to determine
individual practice and system problems which result in
errors.

IOM Report: Crossing the Quality Chasm 2001
 The report found our health care system is fragmented,
inefficient, and poorly organized.
 IOM 1990 definition of „quality‟-“the degree to which
health services for individuals and populations increase
the likelihood of desired health outcomes and are
consistent with current professional knowledge.”
 The report identified „quality‟ as a system property with
six important improvement aims.
◦ Health care „quality‟ should be:
◦ Safe
◦ Effective
◦ Patient-centered
◦ Timely
◦ Efficient
◦ Equitable

IOM Report: Patient Safety: Achieving a New
Standard of Care (2003)
 The report identified the need for a much broader approach to
patient safety than was first stated in To Err is Human.
 Definition of „patient safety‟-The prevention of harm to patients,
where harm can occur through errors of commission and omission.
 The report describes the need for commitment from all
stakeholders to a culture of safety and improved information
system, which us clinical data at point of care to prevent, recognize,
and recover from adverse events.
 Recommended need HHS assume lead role for establishing a
standards-based nation health information infrastructure to
support comprehensive patient safety programs to detect and
analyze adverse events and near misses.

The Commonwealth Fund
 Mirror, Mirror on the Wall: How the
Performance of the U.S. Health Care System
Compares Internationally, 2010 Update Report
 http://www.commonwealthfund.org/Content/Publications/Fund-
Reports/2010/Jun/Mirror-Mirror-Update.aspx

Click on
Interactive
Feature to
Compare
Specific
Health
Indicators:
http://www.commo
nwealthfund.org/u
sr_doc/site_docs/
slideshows/Mirror
Mirror/MirrorMir
ror.html

THE
COMMONWEALTH
FUND
Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity).
Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International
Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians;
Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for
Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).
AUS CAN GER NETH NZ UK US
OVERALL RANKING (2010) 3 6 4 1 5 2 7
Quality Care 4 7 5 2 1 3 6
Effective Care 2 7 6 3 5 1 4
Safe Care 6 5 3 1 4 2 7
Coordinated Care 4 5 7 2 1 3 6
Patient-Centered Care 2 5 3 6 1 7 4
Access 6.5 5 3 1 4 2 6.5
Cost-Related Problem 6 3.5 3.5 2 5 1 7
Timeliness of Care 6 7 2 1 3 4 5
Efficiency 2 6 5 3 4 1 7
Equity 4 5 3 1 6 2 7
Long, Healthy, Productive Lives 1 2 3 4 5 6 7
Health Expenditures/Capita, 2007 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290
Country Rankings
1.00–2.33
2.34–4.66
4.67–7.00
Overall Ranking

IOM Report (2003) Health Professions Education (2003)
 The education of health professionals is viewed
as a bridge to quality care.
 The recommendation of the report is all
organizations involved in the education of
healthcare professionals implement the five core
competencies.
1) Provide PATIENT CENTERED CARE
2) Work in INTERDISCIPLINARY TEAMS
3) Employ EVIDENCED-BASED PRACTICE
4) Apply QUALITY IMPROVEMENT
5) Utilize INFORMATICS

IOM Model 2003 Overlap Core Competencies for
Health Professionals 2.26.13 39PCCompton Why BSN?

What is QSEN?
 Quality and Safety Education in Nursing
 QSEN is a comprehensive website for quality and safety
education for nurses, funded by Robert Wood Johnson
Foundation
 QSEN is a faculty resource to learn and share ideas
about teaching-learning strategies, which promote
quality and safety competency development in nursing
 QSEN includes video presentations and annotated
bibliographies for faculty and nursing students to learn
about quality and safety in nursing
 www.QSEN.org
SOURCE: www.QSEN.org

QSEN: Quality & Safety Education in Nursing
 QSEN initial goal to describe competencies which
would apply to ALL nurses & define a competent and
qualified nurse.
 QSEN utilized IOM recommended 5 competencies for
all health professions AND created 2 competencies
for IOM Quality Improvement competency: Quality
Improvement & Safety
 QSEN identified KSAs (Knowledge, Skills, &
Attitudes) for each competency
 QSEN competencies to serve as guide for
◦ Curricular development for academic programs
◦ Transition to practice
◦ Continuing education programs.

Patient-Centered Care
 IOM Provide Patient-Centered Care:
Identify, respect, and care about patients‟ differences,
values, preferences, and expressed needs; relieve pain
and suffering; coordinate continuous care; listen to,
clearly inform, communicate with, and educate patients;
share decision-making and management and
continuously advocate disease prevention, wellness, and
promotion of healthy lifestyles, including a focus on
population health.
 QSEN Patient-Centered Care:
Recognize the patient or designee as the source of
control and full partner in providing compassionate and
coordinated care based on respect for patient‟s
preferences, values, and needs.

Interdisciplinary Teams
 IOM Work in Interdisciplinary Teams:
Cooperate, collaborate, communicate, and
integrate care in teams to ensure that care is
continuous and reliable.
 QSEN Teamwork & Collaboration:
Function effectively within nursing and inter-
professional teams, fostering open
communication, mutual respect, and shared
decision-making to achieve quality patient care.

Apply Quality Improvement (QI)
 IOM Apply Quality Improvement (QI):
Identify errors and hazards in care; understand and
implement basic safety design principles, such as
standardization and simplification; continually understand
and measure quality of care in terms of structure, process,
and outcomes in relation to patient and community needs;
design and test interventions to change processes and
systems of care, with the objective of improving quality.
QSEN Two Competencies = IOM One competency
1) Quality Improvement (QI): Use data to monitor the
outcomes of care processes and use improvement methods
to design and test changes to continuously improve the
quality and safety of health care systems.
2) Safety: Minimize risk of harm to patients and providers
through both system effectiveness and individual
performance.

EBP Evidenced-Based Practice
 IOMEmploy evidenced-based practice:
Integrate:
1) Best research results
2) Clinical expertise
3) Patient values
to make patient care decisions.
-Participate in learning and research activities to the extent feasible.
 QSEN Evidenced-based practice:
Integrate:
1) Best current evidence
2) Clinical expertise
3) Patient/family preferences and values
for delivery of optimal health care

Utilize Informatics
 IOM Utilize Informatics:
Communicate, manage knowledge, mitigate
error, and support decision-making using
information technology.
 QSEN Informatics:
Use information and technology to
communicate, manage knowledge, mitigate
error, and support decision-making.

Evidence New Grad Knowledge Gaps in
Quality Improvement Education
Kovner, C.T., et al. (2010) New Nurses’ Views of Quality
Improvement Education. The Joint Commission Journal
on Quality and Patient Safety. 36(1), 29-35.
STUDY RESULTS: N=436 (38.6%) newly licensed RNs thought
they were “poorly” or “very poorly” prepared about or had
“never heard of QI.” BSN grads reported significantly higher
levels of preparation in EBP, evidenced-based practice;
assessing gaps in practice, teamwork, collaboration; and
many research skills.
STUDY CONCLUSIONS: RN educational programs need to
improve education about and application of QI concepts and
to consider focusing QI content into a separate course to
assure it is taught.

Evidence New Grad Knowledge Gaps in
Quality Improvement Education
Sullivan, D. T., et al. (2009). Assessing quality and safety
competencies of graduating prelicensure nursing
students.Nursing Outlook. 57, 323-331.
STUDY RESULTS: N= 565. Only 49% newly licensed RNs reported
curriculum included reliable resources for locating evidence-based
reports and clinical guidelines. Students believed they were most
prepared to perform skills in core competencies patient-centered
care & informatics. Students felt least prepared for skills in
evidenced-based practice & quality improvement tools and
evaluating the effects of practice changes.
STUDY CONCLUSIONS:
Due to gaps between theoretical presentation of quality and safety
information and demonstrated application in practice, need to focus
on redesign of curriculum content to include quality and safety
education/practices. Special attention is needed to develop student
competency in quality improvement.

EBP Resources for Clinical
Practice
What have you learned in our program about
EBP & Quality Improvement?
What are the EBP resources you use in the
clinical to obtain current evidence for your
nursing practice?
What are your thoughts about your EBP
preparation in our program?

IOM-RWF 2010 Forum on the
Future of Nursing: Acute Care
“Many unknowns about health care remain as the
country pushes forward with health care reform.
But one thing is certain. The US cannot adequately
address the challenges facing its health care system
without addressing the challenges facing the
nursing profession. Nurses are the largest segment
of the heath care workforce and are essential to
providing quality care…….The goal of this initiative
is to help transform nursing as part of far-reaching
reforms in the health care system.”
SOURCE: Preface to Summary of October 2009 Forum on the Future of Nursing:
Acute Care

Conclusions & Plan
① Nursing practice continues to be extremely
complex and increasing in complexity.
② Carnegie Report states we are under-educating all
nurses….. both ADN & BSN….and recommend
requirement BSN minimum entry into practice.
③ Advisory Board research indicates major gap
between academia and practice…..only 10% of
nurse practice leaders are satisfied with the new
grad proficiencies on 36 competencies.
④ Nurses are the least educated health professional.

Conclusions & Plan (cont)
⑤ Nurses need to be educated in ALL of the IOM-
QSEN core competencies.
⑥ BSN education provides the comprehensive
nursing education required to teach quality
improvement, safety, evidenced-based nursing
practice, team collaboration, informatics, and
patient centered care.
⑦ Research indicates patient mortality and failure to
rescue rates decrease with higher percentage of
BSN nurses.
⑧ Our US Healthcare System has poor patient
outcomes & ranks 7th compared to six other
industrialized countries.

Conclusions & Plan (cont)
⑨ Nurses are patient advocates and therefore
must support expectation of requirement for
BSN in nurses in order to improve patient
outcomes.
⑩ Short-term approach: Regulation/legislation
requiring BSN in 3 years post Associate Degree
graduation.
11 Long-term approach: Regulation/legislation
requiring BSN minimal entry into practice.

Final why bsn, bl4, rev2.26.13

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