ORIGINAL CONTRIBUTION Educational Levels of Hospital Nurses and Surgical Patient Mortality

NURSE UNDERSTAFFING IS ranked by the public and physicians as one of the greatest threats to patient safety in US hospitals. Last year we reported the results of a study of 168 Pennsylvania hospitals showing that each additional patient added to the average workload of staff registered nurses (RNs) increased the risk of death following common surgical procedures by 7%, and that the risk of death was more than 30% higher in hospitals where nurses’ mean workloads were 8 patients or more each shift than in hospitals where nurses cared for 4 or fewer patients. These findings are daunting given the widespread shortage of nurses, increasing concern about recruiting an adequate supply of new nurses to replace those expected to retire over the next 15 years, and constrained hospital budgets. These findings also raise questions about whether characteristics of the hospital RN workforce other than ratios of nurses to patients are important in achieving excellent patient outcomes. Nurses constitute the surveillance system for early detection of complications and problems in care, and they are in the best position to initiate actions that minimize negative outcomes for patients. That the exercise of clinical judgment by nurses, as well as staffing adequacy, is key to effective surveillance may explain the link between higher nursing skill mix (ie, a higher proportion of RNs among the nursing personnel of a hospital) and better patient outcomes. Registered nurses in the United States generally receive their basic education in 1 of 3 types of programs: 3-year diploma programs in hospitals, associate degree nursing programs in community colleges, and baccalaureate nursing programs in colleges and universities. In 1950, 92% of new RNs graduated from hospital diploma programs, whereas by 2001, only 3% graduated from hospital diploma programs, 61% came from associate degree programs, and 36% were baccalaureate program graduates. Surprisingly little is known about the benefits, if any, of the substantial growth in the numbers of nurses with bachelor’s degrees. Indeed the conventional wisdom is that nurses’ experience is more important than their educational levels.