Volume 43, Number 2, pp 89-94
Copyright B2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Baccalaureate Education in Nursing
and Patient Outcomes
Mary A. Blegen, PhD, RN, FAAN
Colleen J. Goode, PhD, RN, FAAN
Shin Hye Park, PhD, RN
Thomas Vaughn, PhD
Joanne Spetz, PhD, FAAN
OBJECTIVES: The aim of this study was to examine
the effects of registered nurse (RN) education by de-
termining whether nurse-sensitive patient outcomes
were better in hospitals with a higher proportion of
RNs with baccalaureate degrees.
BACKGROUND: The Future of Nursing report rec-
ommends increasing the percentage of RNs with bac-
calaureate degrees from 50% to 80% by 2020. Research
has linked RN education levels to hospital mortality
rates but not with other nurse-sensitive outcomes.
METHODS: This was a cross-sectional study that, with
the use of data from 21 University HealthSystem Con-
sortium hospitals, analyzed the association between RN
education and patient outcomes (risk-adjusted patient
safety and quality of care indicators), controlling for
nurse staffing and hospital characteristics.
RESULTS: Hospitals with a higher percentage of RNs
with baccalaureate or higher degrees had lower con-
gestive heart failure mortality, decubitus ulcers, failure
to rescue, and postoperative deep vein thrombosis or
pulmonary embolism and shorter length of stay.
CONCLUSION: The recommendation of the Future
of Nursing report to increase RN education levels is
supported by these findings.
The Institute of Medicine’s report on the Future of
has been followed by a campaign to imple-
ment its recommendations. The 2nd recommendation
in the report focuses on increasing the proportion of
registered nurses (RNs) with a baccalaureate degree
to 80% by 2020. The report also recommends that
educational associations, colleges, delivery organiza-
tions, governmental organizations, and funders de-
velop the resources necessary to support this goal. These
recommendations are consistent with other policy
initiatives currently underway; for example, legisla-
tion requiring that nurses receive a baccalaureate degree
within 10 years of initial licensure has been considered
in New York, New Jersey, and Rhode Island. Barriers
to increasing the overall education levels for RNs
include the weakness of the evidence supporting the
benefits to patient care of nurses with higher educa-
tion and difficulties in financing this additional edu-
cation. More resources will be needed to provide
access to baccalaureate education, and health systems
and policy leaders need strong evidence that invest-
ments will improve the quality of care.
Over the last 40 years, researchers have studied
the association between nursing education levels and
the quality of care provided.
baccalaureate nursing education is growing; however,
it is still equivocal.
Beginning in 2002, studies linked
the percentage of RNs in a hospital with baccalaure-
ate degrees to decreased patient mortality (in-hospital
and 30-day mortality, failure to rescue).
other studies have not found significant relationships
between mortality and nursing education.
few studies that examined the impact of baccalaureate
education on other patient outcomes, particularly those
that are considered sensitive to nursing care, did not
find beneficial effects.
JONA Vol. 43, No. 2 February 2013 89
Author Affiliations: Professor Emerita (Dr Blegen); Professor
(Dr Spetz), School of Nursing, University of California, San
Francisco; Professor (Dr Goode), College of Nursing, University
of Colorado at Denver; Research Associate (Dr Park), School of
Nursing, University of Kansas Medical Center; Associate Professor
(Dr Vaughn), College of Public Health, University of Iowa.
Funding: Supported by an Interdisciplinary Nursing Quality
Research Initiative grant from theRobertWoodJohnson Foundation
and with assistance from the University HealthSystem Consortium.
The authors declare no conflicts of interest.
Correspondence: Dr Blegen, 1778 So Tucson St, Aurora, CO
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Despite the lack of consistent evidence, many nurs-
ing administrators want nurses prepared at the bacca-
laureate (BS) level. Chief nursing officers (CNOs) in
academic health centers preferred hiring more RNs
with BS degrees; they had an average of 51% BS-
prepared nurses and desired 71%.
in New York also preferred hiring more BS-prepared
RNs, whereas fewer than 50% of their current RNs
had BS degrees.
RNs are desired, there are few incentives for nurses
to complete a BS in terms of salary differential or pres-
tige in nursing.
There is a need for further studies of RN edu-
cation examining nursing-sensitive patient outcomes
while controlling for other factors known to affect
outcomes, such as nurse staffing and hospital and
This project examined the
relationships of RN education with nurse-sensitive
outcomes while simultaneously considering other
hospital characteristics and nurse staffing levels. The
hypothesis was that controlling for hospital character-
istics (eg, Medicare case mix index, technology, safety-
net status, patient risk factors, and nurse staffing),
hospitals with higher proportions of RNs with bac-
calaureate degrees (BS) will have better patient out-
comes. The hypothesis was tested once with nurse
staffing on general adult units and once with staffing
on adult intensive care units (ICUs).
Design and Data
This cross-sectional study used data sets created by
the University HealthSystem Consortium (UHC), a
subset of the data used for a study reported else-
The clinical data set contained patient diag-
nosis and procedure codes, actual and expected length
of stay (LOS). The operational data set contained di-
rect caregiver hours for each unit. Values for staffing
and outcomes were calculated for each of the 4 cal-
endar quarters for 2005. Data from the UHC did not
contain information about nurse education; there-
fore, a mailed survey to CNOs obtained that infor-
mation. The final sample included 21 UHC-member
teaching hospitals that had contributed data to both
clinical and operational data sets and from whom we
had complete responses to the education survey. Data
for 84 quarters were available (4 quarters from each of
21 hospitals). The study was approved by the University
of California, San Francisco institutional review board.
Patient outcomes included 1 measure provided by
UHC, the proportion of nonobstetric adult patients
with a LOS longer than the diagnosis-related group
(DRG)Yprescribed LOS for their diagnosis, as well
as adverse outcomes computed from patient discharge
data. Adverse event rates were calculated using the
patient safety indicator and inpatient quality indica-
tor software developed by the Agency for Healthcare
Research and Quality (AHRQ).
The outcome in-
dicators were adjusted for patient risk by using the
AHRQ procedures to create a ratio of observed rates
of adverse events to expected rates. If the hospital’s
performance was as expected for their mix of patients,
the value is 1.0. If a higher than expected rate of ad-
verse outcomes exists, the value is greater 1.0, and if
fewer adverse occurrences, the expected the value is
less than 1.0. Indicators were calculated if there were
30 or more patients meeting the inclusion criteria in
the quarter; if there were fewer cases, the value was
considered unreliable and set to missing.
A short list of patient outcome indicators was
selected using 2 criteria: 1st, indicators that were sen-
sitive to nursing care in past research or recommended
by the National Quality Forum
; 2nd, if the indi-
cator appeared to be stable in the data set. Patient
outcomes included were mortality for congestive heart
failure patients (CHF mortality), hospital-acquired pres-
sure ulcers (HAPUs), failure to rescue (death in surgical
patients who developed complications), infection due
to medical care, postoperative deep vein thrombosis
or pulmonary emboli (DVT/PE), and proportion of
patients with LOS greater than expected for their
DRG (LOS 9expected).
The measure of nurse education was the propor-
tion of RNs employed at each hospital during 2005
who had a BS or higher degree. Data from the sur-
vey questionnaires were matched to the hospital by
UHC. The data were merged and the hospital iden-
tities were omitted before transmitting the data set
to the investigators.
Given recent study findings about poorer outcomes
in safety-net hospitals,
the analysis controlled
for hospital characteristics such as safety-net status
as well as patient acuity (Medicare case mix index)
and higher technology services provided. Medicare
case mix index for 2005 was in the UHC data and
the index for high-technology services was calcu-
lated using 2005 American Hospital Association
Safety-net status was reported in the UHC
data set according to the Centers for Medicare and
Medicaid Services definitionVhospitals receiving
adjustment payments to provide care to a dispropor-
tionate share of low-income patients (http://www.hhs
90 JONA Vol. 43, No. 2 February 2013
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The UHC operational dataset used the most informa-
tive method of measuring the amount of nursing care
provided on inpatient care units: the hours of direct
caregivers (RNs, licensed practical nurses [LPNs], and
nursing assistants [NAs]) per patient day in each in-
patient unit. Precision was further increased by cap-
turing the worked hours exclusive of management
and clinical specialist hours, counting patients on the
units for observation or short stay in addition to
those counted in the midnight (MN) patient census,
and separating the nurse staffing according to pa-
tient’s needs for ICU or general (non-ICU) care.
Two nurse staffing variables were used in this
study. First, the total hours of nursing care per patient
day (Tot HPPD) for each unit was calculated by di-
viding the total hours of direct patient care from RNs,
LPNs, and NAs in each quarter by the total number
of adjusted patient days in the quarter on the unit.
The adjusted patient days are calculated by adding,
to the MN census counts, 1 day for each 24 hours of
observation and short-stay patient time on the unit
(ie, patients not officially admitted and staying less
than 24 hours). The RN skill mix (RN mix) was cal-
culated for each unit by dividing the RN hours by the
total hours. Because the intensity of nurse staffing is
much greater on ICUs, and combining both types of
units would obscure the effects of the specific staffing
patterns, staffing for general adult units were kept
separate from those on adult ICUs. Nurse staffing
data were aggregated to the hospital level to link with
the rate of adverse outcomes and RN education, both
of which were available only at the hospital level.
Staffing levels on adult general units (including step-
down units and excluding obstetric, psychiatric, reha-
bilitation, and skilled care) and on adult ICUs were
aggregated separately in each hospital.
Data analyses were performed using STATA,
version 9. Because of the nesting of quarterly data in
hospitals, robust regression with clustering by hospi-
tals was used. Given the small sample (84 quarters of
data from 21 hospitals), there was a high likelihood
of type 2 error, and we discuss findings with sta-
tistical significance levels PG.10 as well as those at
The average size of these hospitals was 557 beds, all
were teaching hospitals, and 14 were safety-net hos-
pitals. On average, 62% of RNs working in these hos-
pitals held a BS or higher degree, ranging from 44%
to 84% (Table 1). Safety-net hospitals had lower pro-
portions of BS nurses (57%) than nonYsafety-net hos-
pitals (71%) did. Tot HPPD varied from 11.63 hours
(SD, 1.55 hours) in general care units to 21.56 hours
(SD, 2.80 hours) in the ICU. The RN mix on general
units was 62.6% (SD, 5.54%) and on ICUs was
76.7% (SD, 6.00%).
The average of the ratios of observed to expected
patient outcome was below 1 (better than expected)
for CHF mortality and failure to rescue and was above
Table 1. RN Education, RN Staffing, and Patient Outcomes in 21 Academic Health
Variable Mean (SD) Minimum-Maximum
Baccalaureate or higher education 61.55 (13.01) 43.8-83.9
Tot HPPD, general units 11.63 (1.55) 8.31-15.05
RN mix, general units 62.61 (5.54) 51.70-79.49
Tot HPPD, ICUs 21.56 (2.80) 15.43-30.72
RN mix, ICUs 76.65 (6.00) 65.09-93.00
Bed size 557 (146) 328-900
Case mix index 1.82 (0.147) 1.44-2.08
Technology 29.54 (3.62) 19.7-34.6
Patient outcomes (ratio of observed to expected)
CHF mortality 0.77 (0.44) 0.00-2.38
Pressure ulcers 1.30 (0.60) 0.39-3.16
Failure to rescue 0.88 (0.16) 0.43-1.26
Hospital-acquired infection 1.85 (0.74) 0.66-3.60
Postoperative DVT/PE 1.65 (0.49) 0.80-3.48
LOS 9expected 0.008 (0.004) 0.0025-0.0164
Data expressed in mean unless otherwise indicated.
Tot HPPD is the total hours of care per patient day from all nursing care providers (RN, LPN, NA). RN mix is the proportion of total hours
provided by RNs. BSN or higher is proportion of nurses in the hospital with a baccalaureate degree or higher.
JONA Vol. 43, No. 2 February 2013 91
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1 for HAPUs, infections, and DVT/PE (Table 1). The
average LOS was 5.94 days and the proportion of
patients who had LOS 9expected was 0.8%.
To describe the relationships between RN edu-
cation and patient outcomes, we 1st examined the
unadjusted correlations of RN education with nurse
staffing and outcomes (Table 2). Hospitals with
more BS-prepared nurses also had more Tot HPPD
for general units (r= 0.202, PG.10) and for ICUs
(r= 0.358, PG.05). The RN mix in ICUs was lower
when the BS proportion in the hospital was higher
(r=j0.262, PG.05). The relationships between
hospitals’ RN education level and their staffing
patterns underscores the need to control for staffing
when assessing the effect of education. As RN edu-
cation increased, patient adverse events and LOS
decreased. These decreases in adverse outcomes were
statistically significant (PG.05) for CHF mortality
(Pearson r=j0.240), HAPUs (r=j0.500), failure
to rescue (r=j0.399), DVT/PE (r=j0.289), and
LOS 9expected (r=j0.333). Although still in the
expected direction (negative), the correlation be-
tween RN education and infection due to medical
care was not statistically significant.
Multivariate models, with clustering of quar-
terly data at the hospital level and robust standard
errors, were estimated twice for each outcome, once
including nurse staffing in ICUs and once including
nurse staffing in general units (Table 3). All 12 mod-
els were statistically significant at the PG.10 level,
and 7 of those at PG.01. Most of the negative cor-
relations between the proportion of RNs with BS
degrees and patient outcomes remained statistically
significant in the multivariate analyses when adjusted
for staffing and hospital characteristics (case mix in-
dex, safety-net status, and technology).
Our hypotheses were supported. Specifically,
hospitals that have higher proportions of BS-educated
RNs had lower rates of CHF mortality, HAPUs,
failure to rescue, DVT/PE, and LOS 9expected.
These effects are present when nurse staffing and the
other hospital characteristics were included in the
analyses. The variance explained (R
) ranged from
0.103 to 0.525. The least well-explained outcomes
were infections due to medical care (R
= 0.103 and
0.168 for models including nurse staffing on general
units and on ICUs, respectively) and CHF mortality
= 0.118 and 0.114); whereas the best explained
outcomes were DVT/PE (R
= 0.525 and 0.437);
LOS 9expected (R
= 0.302 and 0.357); and HAPUs
= 0.321 and 0.324).
Total nurse staffing on ICUs was associated
with reduced CHF mortality (PG.05), failure to res-
cue (PG.10), and hospital-acquired infections (PG
.10). The RN mix on ICUs reduced the infections
further (PG.01), but the RN mix on ICUs was as-
sociated with higher DVT/PE (PG.01). Nurse staffing
on general units was not related in these analyses to
patient outcomes, except for higher DVT/PE. Hos-
pital characteristics were related to some of the out-
comes as well. Hospitals with higher Medicare case
mix index had lower rates of DVT/PE and LOS 9
expected (PG.05) and higher CHF mortality (PG.05).
Availability of higher technology services was as-
sociated with higher rates of DVT/PE. Safety-net hos-
pitals had higher rates of most adverse outcomes, but
the relationships were not statistically significant in
these adjusted models.
This study is the 1st to find a beneficial effect for
nursing education on patient outcomes other than
mortality rates. Hospitals in this study with higher
proportions of BS-educated RNs had lower rates of
HAPUs, postoperative DVT/PE, and LOS as well as
failure to rescue and CHF mortality. Furthermore,
these findings held when nurse staffing and hospital
characteristics were controlled. The hypotheses were
supported for most of the nurse-sensitive outcomes
studied, and thus, the recommendation in the Future
of Nursing report
to increase the education level of
practicing nurses was supported by these results.
The reduced mortality of patients with CHF and
in surgical patients after a complication (failure to
rescue) found in this study is consistent with previous
Table 2. Correlation of RN Education
With Staffing and Patient Outcomes
(N = 21 Hospitals)
Tot HPPD general 0.202
RN mix general 0.015
Tot HPPD ICU 0.358
RN mix ICU j0.262
Mortality: CHF j0.240
Pressure ulcer j0.500
Failure to rescue j0.399
Infection due to medical care j0.088
LOS 9expected j0.333
Tot HPPD is the total hours of care per patient day from all
nursing care providers (RN, LPN, NA). RN mix is the
proportion of total hours provided by RNs. BSN or higher is the
proportion of nurses in hospital with a baccalaureate degree
92 JONA Vol. 43, No. 2 February 2013
studies. Hospitals with a higher proportion of RNs
with BS degrees have been shown to have lower in-
patient and 30-day mortality, lower failure to rescue,
and lower cardiac deaths.
The finding that hospitals with a higher propor-
tion of BS-prepared RNs had lower rates of HAPUs
is unique to this study. Although this finding was
statistically significant only at the PG.10 significance
level in the adjusted analyses in this small sample, the
effect of education was stronger than the effect of nurse
staffing. Other larger studies have also been challenged
to find an effect of nurse staffing on HAPUs.
Education of RNs did not affect hospital-acquired
infections once other characteristics were controlled,
whereas nurse staffing levels did. Postoperative DVT/
PE was less frequent in hospitals with more BS-prepared
RNs when adjusting for nurse staffing on general units.
This finding is particularly interesting, although dif-
ficult to explain, because higher RN mix was associated
with more cases of DVT/PE. Few previous studies used
this patient outcome and more research is needed to
understand this association.
Patient LOS has not previously been linked with
nurse education, although nurse staffing levels have
been shown to decrease LOS.
This study found
that hospitals with more BS-educated RNs had fewer
patients staying longer than expected for their diagnosis.
The strengths of this study included specific, di-
rect data on the education level of the nurses in the
hospitals, precise measures of unit-level nurse staffing,
the use of the well-developed AHRQ outcome mea-
sures, and the inclusion of hospital characteristics in the
analyses. The depth and precision of the data were pos-
sible because of the availability of unique and credible
information from a small sample of academic health
center hospitals. Adjusting for nurse staffing, controlling
for patient risk in 2 ways (observed-to-expected ratios
for each outcome and overall patient severity at the hos-
pital), and adjusting for technology and safety net status
increased the robustness of the study.
These large teaching hospitals represent high-
complexity hospitals with higher nurse staffing levels
and they likely had sicker patients and
more advanced technology than other hospitals in the
United States. Two-thirds were designated as safety-net
hospitals. Furthermore, these academic hospitals had a
higher level of RN education (62% with BS) than
average in the United States.
analyses found an effect for nurse education even when
the average and even the range for the overall sample
was high adds confidence to the findings.
Limitations of this study include a small sample
that was underpowered for the number of predic-
tors used. To balance this risk of a type 2 error, we
Table 3. Robust Regression Results for Nurse Education and Patient Outcomes Adjusting
for Nurse Staffing, Medicare CMI, Hospital Technology and Safety Net Status
(N = 84 Hospital/Quarters)
Adjusted for nurse staffing on general units
RNs with BS j0.012
Tot HPPD 0.065 j0.085 j0.002 j0.153 0.060 j0.022
RN mix 0.012 j0.007 j0.002 j0.037
Medicare CMI 0.247 j0.085 j0.009 0.403 j0.885
Technology j0.000 j0.024 j0.002 j0.032 0.046
Safety net j0.001 0.307 0.064 0.312 0.105 j0.093
Adjusted for nurse staffing on ICUs
RNs with BS j0.006
j0.000 j0.002 j0.014
Tot HPPD j0.027
RN mix 0.005 j0.018 j0.002 j0.050
Medicare CMI 0.649
j0.383 0.081 0.304 j0.867
j0.016 j0.005 j0.029 0.035
Safety net 0.083 0.199 0.077 0.193 0.131 j0.176
Analysis done with robust regression, clustering by hospital. Outcomes O/E were adjusted for patient risk, ratio of observed to expected.
Coefficients for LOS 9expected multiplied by 100.
Abbreviation: CMI, case mix index.
PG.001 (nonstandardized regression coefficients).
PG.05 (nonstandardized regression coefficients).
PG.10 (nonstandardized regression coefficients).
JONA Vol. 43, No. 2 February 2013 93
mention findings with a PG.10. The sample of large
academic teaching hospitals in the United States limits
the generalizability to all hospitals. The data for this
study were from 2005 and may not fully reflect current
patient outcome levels. There are also concerns about
the reliability and validity of indicators developed by
AHRQ; however, these quality indicators continue
to be widely used because there are few alternatives.
Further work is needed to improve quality and safety
measures and to link them with hospitals and nursing
This study adds to the growing body of research
supporting a move toward BS education for RNs.
The findings are consistent with previous work exam-
ining mortality rates and add new findings with out-
comes other than mortality rates. Therefore, policy
makers, educators, and administrators have a stronger
evidence base on which to make their decisions regard-
ing the encouragement and funding for nurses’ higher
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