Evidence-Based Project:

Increasing Percent of Bachelor-

Educated Nurses
By: Andrew Chittaphong, Rachel Colarullo, Molly Fung, Annet
Grijalva, Megan Malanowski, Michael Manns, Rachel Moses, Marco
Stevens Cota and Andrea Walsh
Nursing 470
University of Arizona
Introduction
● Should a Bachelor’s of Science in
Nursing be the minimum level of
education
● Evaluate and compare patient
outcomes resulting from BSN degree
holders versus ADN degrees
○ Never events
○ Length of stay
○ Mortalities

Image source:
https://newgradtonurse.wordpress.com/2012/07/16/my- 2
opinion-on-bsn-vs-adn-programs/
PICOT Question
(P) In the acute care setting, do nurses with a (I) Bachelor’s degree
have (O) better patient outcomes such as reduced mortality rates and
reduced length of hospital stays compared to those with (C) Associate
degrees (T) within the last ten years?

Image source:
http://educatebox.com/
associate-degree-vs-
bachelor-degree/ 3
Current Practice
● Local:
○ Banner UMC - BSN preferred
○ Veterans Affairs Hospital - BSN preferred
○ 79% of employers prefer BSN over ADN
○ ADN-BSN Pima Community College
● State: RN’s with BSNs increased from 46% in 2011 to 60% in 2015
○ The majority community college nursing programs offer concurrent
enrollment programs (CEP) with one or more BSN Program.
○ Nearly half of nursing students in Maricopa Nursing programs are enrolled
in the CEP

(American Nurses Association, 2019)

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Current Practice
● National: Institute of Medicine recommended that 80% of nurses hold BSN
degrees by 2020
○ Currently 55-60% of nurses hold BSN
○ Only increased 5-10% from when recommendation was made in 2010
● New York: The BSN in 10 is the newly adopted legislation in that requires nurses
who finish an Associate Degree Program to obtain BSN qualification in 10 years
time after their initial RN license
● Rhode Island and New Jersey put forth BSN in 10 bills but have not passed
● Magnet Status a big motivator for hospitals hiring BSN RN’s

(College for the People, 2018) 5

Literature Findings
● Each 10% increase in amount of BSN-RNs resulted in a decreased LOS by 4.2
days (Cho, Park, Choi, Lee, & Kim, 2017).
● Increase in the amount of BSN-RNs decreased mortality rates by 5%-30% for
patients (Aiken, Clarke, Cheung, Sloane, & Silber, 2011) (Aiken et al., 2014).
● BSN graduates are more comfortable in critical thinking than ADN graduates
(Leroy, Laplante, Patterson, & DeRuyter, 2014).
● BSN-RNs report being significantly more prepared in quality and safety than
nurses with associate degrees (Djukic, Witkoski Stimpfel, & Kovner, 2018).

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Literature Findings cont.
● Many different factors influence RNs to get a BSN (Matthias & Kim-Godwin,
2016).
○ Hospitals prefer BSN-RNs
○ Maintaining or obtaining employment
○ Advancing in their field
○ Moving away from the bedside role
● ADN graduates are strong bedside nurses who adequately manage the demands
of patient care, but are less ept to maintain cohesive and functional nursing units
(Kumm, Godfrey, Martin, Tucci, Muenks, & Spaeth, 2014).

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Article Strengths
● Large sample sizes

● Accredited nursing programs

● Author designed measuring tool

● Surveys completed by accredited nurses
● Self report bias minimized
Image source:
https://discoveryinaction.com.au/are-your-
team-members-using-their-strengths-every-
day/

● Split sample approach to reduce potential bias

8
Article Strengths cont.
● Authentic responses from sample population

● Face to face interviews

● Informed consent

● Same Investigator

● Environment of interviews

● Peer and audit review

9
 Image source:

Article Limitations
https://www.ipwatchdog.com/2017/08/28/beware-
conditional-limitations-when-drafting-patent-
claims/id=87242/

● Response bias

● Some articles had small, isolated samples

● Unmeasured confounding factors

● Cross sectional studies have restricted information about causality

● Nurse surveys were from different time periods on information available about
patients

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Article Limitations cont.
● Many studies only analyzed surgical patients

● Readmission to different facilities not included in studies

● Care of individual patients not linked to individual nurses

● Inaccurate measurements of experience such as age

● Varying countries have different definitions of baccalaureate education for

nursing

● Results can’t be generalized to other regions 11

EBN Recommendations
Here are several evidenced-based nursing recommendations regarding BSN and ADN
nursing outcomes:

● BSN degrees should be more accessible and obtainable by nursing students,

including bridge-programs that accredit ADN-to-BSN nurses.
○ (Knowlton and Angel, 2017)

● All BSN students must be educated on the 67 essentials that the AACN highlights
as nursing priorities.
○ (Gkanaras, I., Foreman, B., Thompson, D., Cannaby A. M., & Deshpande D. H., 2016)

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EBN Recommendations
● Healthcare facilities (e.g. long-term care, high-
acuity hospitals, and outpatient facilities)
should aim to employ 80% of all nurses with a
BSN degree or higher.
○ (Aiken, Clarke, Cheung, Sloane, and Silber, 2011;
American Nurses Association)

● Higher acuity areas such as Intensive Care

Units, Emergency Departments, and Critical Image source:
http://www.theamericannurse.
Care Units need to employ a high rate of BSN org/2012/08/06/have-bsn-will-
hire/
nurses.
○ (Knowlton and Angel, 2017)
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Application
● Increase the amount of BSN nurses to 80%
in the workforce by 2020, according to the
Healthy People 2020 Initiative
● RIBN program (North Carolina)
○ Regionally Increasing Baccalaureate Nurses
○ 4 year program that dually enrolls a student in community college and a university
○ Accepted into a nursing program from the start
○ After first three years, ADN; fourth year get BSN
○ Cheaper than 4 year tuition at university
○ Helps in rural areas and can live at home
● Call to more programs to get involved
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(Knowlton & Angel, 2017) https://nurse.org/resources/nursing-career-north-carolina/
Cost Analysis - Costs and Savings for Adverse Events
● Added cost of adverse events
○ Never events costs $19.9 million to $1 trillion (Slawomirski, Auraaen, & Klazinga,. 2017)
○ $600-$48,000 added per case (Bysshe, 2017)
● Deaths from never events
○ 5-150 deaths per 1,000 cases (Bysshe, 2017).
○ 2-15% of patients die from never events (Bysshe, 2017).
○ This costs $3 million up to $45 billion dollars
● Savings potential
○ An increase of BSN nurses decreases patient mortality by 5-30%
■ This could result in savings of $150,000 to $45 million
○ This could also save at least 87,000 patient lives (Bysshe, 2017).

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Cost Analysis - Patient Mortality
● 5.7 million ICU patients admitted annually (Society of Critical Care Medicine, 2016)
○ 20% will die (Khandelwal, 2016)
○ ~1.1 million patients die each year
● Mean cost for a terminal ICU stay: $39.3K-45.1K (Khandelwal, 2016)
○ Estimated costs of $49.5 billion
● Impact of more BSN-RNs:
○ Cost savings of $2.47 million to $14.8 billion
○ 55,000-330,000 patient lives saved

Image source:
https://www.colourbox.
com/image/dollar-
signs-around-3d-small-
16
person-image-4283997
Cost Analysis - Length of Stay
● Average cost for one day in the hospital: $1,700-$2,300 (Henry J. Kaiser Family
Foundation, 2018).
● 10% increase in BSN-RNs
○ Decrease in LOS by 4.2 days (Cho, 2017).
○ 4.2 days of stay costs $7,140-$9,660
● Never events increase LOS by 3-9 days (Slawomirski, Auraaen, & Klazinga,. 2017)
○ $5,100-$20,700
○ Increase in BSN-RNs will decrease never events and LOS

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Cost Analysis
● Salary of ADN-RN vs BSN-RN (Bureau of Labor Statistics, 2018)
○ ADN-RNs average salary: $67,490 per year
○ BSN-RNs average salary: $75,484 per year
○ Difference of ~$8,000
● Cost to increase BSN-RNs in the workforce
○ Cost to train BSN-RN vs. ADN-RN
○ Increasing the percentage of BSN-RNs by 10%
■ Hire at least 390,000 more BSN-RNs (Haddad & Toney-Butler, 2019)
■ $29.2 billion for total salary
■ $3.1 million more than hiring ADN-RNs
● Increasing the percent of BSN-RNs leads to savings as low as $7,000 and as high
as $45 billion
○ Theoretically, there would be a net cost savings over a year of $15.8 billion
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Risk and Benefit
Benefit to Patients (when cared for by BSN):

- Shorter hospitalizations (Aiken et al, 2011; Cho et al, 2017; Yakusheva, Lindrooth, & Weiss, 2014)
- Decreased mortality rates (Aiken et al, 2015; Cho et al, 2015; Gkanaras et al, 2016)
- Increased quality of care (Gkanaras et al, 2016, Djukic et al, 2018)

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Risk and Benefit
Benefit to Hospital (when hiring higher % of BSN vs ADN):

● Ability to manage large caseloads (Aiken et al, 2011, Aiken et al, 2014)
● Increased professional drive and confidence from staff (Leroy et al, 2014)
● Increased ability to retain staff for leadership advancement (Mattias et al, 2016)
● More competent in quality and safety implementation (Djukic et al, 2018)

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Risk vs Benefit
Risks to Hospitals (if hiring BSNs):

● Short staffed due to lack of BSN nurses

● ~$8,000 increase in salary paid to BSN vs ADN

Risks to Patients (if having BSN nurse):

● Less thorough stays (Yakusheva, Lindrooth, & Weiss, 2014)

Risk to Nurses (becoming RN-BSN):

● Increased cost of education to obtain BSN: $13,000-$105,000

● $25,000-$80,000 to go from ADN to BSN
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Evaluation
Institutions will increase the amount of BSN nurses to 80% in
the workforce, decrease mortality rates below 20%, and reduced
length of stay by 2020.

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Conclusion
● Summary of introduction
● Issue: BSN vs. ADN and patient outcomes
● Supportive Studies
● Best practice: BSN education
● Application to facility
● Cost Analysis
● Risks vs. Benefits

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References
Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2011). Educational levels of hospital nurses and surgical

patient mortality. JAMA, 290(12), 1617-1623. doi: 10.1001/jama.290.12.1617

Aiken, L. H., Sloane, D. M., Bruyneel, L., Van Den Heede, K., Griffiths, P., Busse, R . . . Sermeus, W. (2014). Nurse staffing and

education and hospital mortality in nine European countries: A retrospective observational study. The Lancet, 383(9931), 1824-

1830. doi.org/10.1016/S0140-6736(13)62631-8

American Nurses Association. (2019). ANA Enterprise. Retrieved from https://www.nursingworld.org/

Bureau of Labor Statistics. (2018). Occupational employment and wages, May 2017: 29-1141 registered nurses. Bureau of Labor

Statistics. Retrieved from https://www.bls.gov/oes/2017/may/oes291141.htm#(3)

Bysshe, T., Gao, Y., Heany-Huls, K., Hockenberry, J., Hovey, L., Laffan, A. M., … & Watts, E. (2017). Estimating the additional

hospital inpatient cost and mortality associated with selected hospital-acquired conditions. Agency for Health Research and
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Quality. Retrieved from https://www.ahrq.gov/sites/default/files/publications2/files/hac-cost-report2017.pdf
References
Cho, E., Douglas, M. S., Kim, E., Kim, S., Choi, M., Yoo, I. Y., Lee, H. S., & Aiken, L. H. (2015). Effects of nurse staffing, work

environments, and education on patient mortality: An observational study. International Journal of Nursing Studies, 52(2), 535-

542. doi.org/10.1016/j.ijnurstu.2014.08.006

Cho, E., Park, J., Choi, M., Lee, H. S., & Kim, E. Y. (2017). Associations of nurse staffings and education with the length of stay of

surgical patients. Journal of Nursing Scholarship, 50(2), 210-218. doi.org/10.1111/jnu.12366

Djukic, M., Witkoski Stimpfel, A., Kovner, C., (2018). Bachelor's degree nurse graduates report better quality and safety educational

preparedness than associate degree graduates. The Joint Commission Journal on Quality and Patient Safety.

doi.org/10.1016/j.jcjq.2018.08.008

Gkanaras, I., Foreman, B., Thompson, D., Cannaby A. M., & Deshpande D. H. (2016). The effect of nurse graduateness on patient

mortality: a cross- sectional study. Journal of Advanced Nursing 72(12), 3034- 3044. doi: 10.111/jan.13059
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References
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Henry J. Kaiser Family Foundation. (2018). Hospital adjusted expenses per inpatient day by ownership. Henry J. Kaiser Family

Foundation. Retrieved from https://www.kff.org/health-costs/state-indicator/expenses-per-inpatient-day-by-ownership/#notes

Khandelwal, N., Benkeser, D., Coe, N. B., Engelberg, R. A., Teno, J. M., & Curtis, J. R. (2016). Patterns of Cost for Patients Dying in

the Intensive Care Unit and Implications for Cost Savings of Palliative Care Interventions. Journal of palliative medicine,

19(11), 1171-1178.

Knowlton, M. C. & Angel, L. (2017). Lessons learned: Answering the call to increase the bsn workforce. Journals of Professional

Nursing, 33(3), 184-193. doi.org/10.1016/j.profnurs.2016.08.015

Kumm, S., Godfrey, N., Martin, D., Tucci, M., Muenks, M., & Spaeth, T. (2014). Baccalaureate

outcomes met by associate degree nursing programs. Nurse Educator, 39(5), 216-220.
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References
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doi.org/10.1016/j.teln.2014.06.003

Matthias, A. D., & Kim-Godwin, Y. S. (2016). Rn-bsn students’ perceptions of the differences in practice of the adn- and bsn-prepared

rn. Nurse Educator, 41(4), 208-211. doi:10.1097/nne.0000000000000244

Slawomirski, L, Auraaen, A., & Klazinga, N. (2017). The economics of patient safety. Organization for Economic Cooperation and

Development. Retrieved from https://www.oecd.org/els/health-systems/The-economics-of-patient-safety-March-2017.pdf

Society of Critical Care Medicine. (2016). Critical care statistics. Retrieved from https://www.sccm.org/Communications/Critical-

Care-Statistics

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49 (6), 1747- 1786. doi: 10.1111/1475-6773.12236

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Questions?

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