Do BSN Nurses Provide Better Care? | Guest Blog

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

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 1,000 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 a third of them were staff nurses in general hospitals. The information from those nurses (presumably about 8,333 of them) 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 — a discrepancy of over 2,000.

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 more than 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 many graduating surgical residents are not ready to practice independently.

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

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 900 page views per day, and he has over 5,800 followers on Twitter.

  • MauraMc says:

    Home nurses lack competence at a MUCH higher rate than those in hospital service. We only hire RNs for our home & find rare nurses with any skill, knowledge or experience with tracheostomies. In the home setting, training falls on the shoulders of the sleep-deprived parents whom the nurse is supposed to be supporting & training. Too often doctors assume that a family is receiving competent nursing support at the frequency the doctor orders. This is sadly never the case. I, myself, am the person qualified & experienced enough to assess whether my children can maintain at home or need to be inpatient, or save their lives when there is an urgent need an hour from a medical center. It is a skill set I am comfortable with needing but really wish there was more pre-service training so nurses could be SOME support.

    • Skeptical Scalpel says:

      Maura, I agree with you. The home care nursing and visiting nurse situations are often scary. Some lack experience, and some just don’t seem to be able to tell who is sick and who isn’t.

  • Jay says:

    Very interesting article. Thanks for highlighting the issue!

  • Karen RN says:

    Skeptical Scalpel: I trained in a 3 yr Diploma program. Don’t even know if there are any left. We were worked like dogs, were in class or on rotation more weeks than a 4 yr BSN program. Yes, there were still some marginally competent nurses who graduated, but it wasn’t for lack of exposure. I started my first job alongside several BSN grads in an ICU. They got their jobs because they were BSNs. I got mine because, thankfully, someone in California was familiar with the program I graduated from in Illinois. Despite being scared half to death that I might make a mistake and harm someone – confidence was not my strong suit, but I soon found it – I was stunned at what the BSNs didn’t know. Apparently that has not changed – maybe worsened? I wonder if the big picture has gone out of fashion? Our obligation is to the guy in the bed.

    • SkepticalScalpel says:

      Karen, thank you for the comment supporting my post. I’m not sure there are any diploma programs left either. It’s too bad. Some great nurses came from those programs.

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  • Jennie says:

    We all need to develop critical thinking skills, and participate in hospital training at respected institutions in preceptorship. If that doesn’t happen, our patients suffer. I did post graduate surgical training. I cannot imagine working as a surgical PA without it.

    • Skeptical Scalpel says:

      Jennie, thanks for commenting. Perhaps some need postgraduate training to be a surgical PA, but I have worked with many surgical PAs who joined our staff right out of PA school. They did very well.

      Similarly at one time, nurse graduates did not need “residencies” and were perfectly good nurses.

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  • Laura RN says:

    Perhaps, for less clinically emphasized areas such as Home Health, and Nursing Home Nursing, there should be yearly training for clinical skills required. Things such as skills labs and clinical assessment lab requirements in their jobs. That way in the cases when they DO need those clinical skills, they will have a foundation to pull from.

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