As the president of the National Organization for Associate Degree Nursing and an associate degree (AD) nurse-educator for the past 11 years, I'm concerned and disturbed about the implications of Dr. Aiken's article, which has revived interest in the long-standing controversy over whether a baccalaureate should be required for entry into nursing practice. The fact that the authors are highly respected in their areas of expertise and that JAMA is considered to be a journal of excellence has added to the study's impact.
The authors concluded that “… in hospitals with higher proportions of nurses educated at the baccalaureate level or higher, surgical patients experienced lower mortality and failure-to-rescue rates.” But this statement isn't fully supported by the data.
Dr. Aiken and her colleagues based their analysis on hospital data, which showed that hospitals employing more nurses with ADNs were characterized by fewer technologic resources and higher workloads. One would expect hospitals with fewer resources to incur higher mortality rates, regardless of staffing characteristics. Yet, the authors cite nursing educational levels as the primary cause of higher mortality, a somewhat surprising inference.
The data also reveal that although a relationship exists between workforce characteristics and mortality, a strong relationship also exists between average patient age and mortality. In fact, average patient age accounts for 95.1% of the variation in hospital mortality rates.
Because the difference in average patient age is a significant factor, an examination of background mortality rates for the general population is strongly indicated. According to National Center for Health Statistics, mortality rates in the United States rise sharply between the ages of 57.3 and 61.3—the lowest and highest average ages of the hospital groups in the Aiken study.
When hospital mortality rates are age-adjusted for background mortality rates in the general population (that is, the ratio of Pennsylvania hospital mortality to U.S. mortality) a weak relationship emerges that counters the study's findings.
In the end, Dr. Aiken's data show an increase in mortality as ADN staffing levels—and patient age—increase. If the age data are adjusted for general mortality rates, however, the age-adjusted mortality rate actually goes down as average ages—and ADN staffing levels—go up. This totally contradicts the study's conclusions. More troubling are the policy suggestions for more public financing of baccalaureate nursing education and changing employer preference to baccalaureate-prepared RNs. The data simply don't support the policy suggestions.
The National Organization for Associate Degree Nursing adopted a model for nursing education and practice at its 2001 convention. This model reflects the belief that there is no value added when a graduate of an ADN program gets a BSN degree. It is true that the BSN usually requires several additional nonnursing courses, but if both the ADN and the BSN graduates take the same licensing examination and pass it at the same rates, it implies that these graduates have the nursing knowledge necessary to practice nursing at the RN level.
Since the article was published, several issues have arisen that may or may not be connected to the study and its conclusions. The Pennsylvania legislature was asked to look again at “entry into practice.” In New York, the state board for nursing is asking the state education department for regulatory change to require future graduates of AD and diploma nursing programs to receive a baccalaureate within 10 years of their graduation from the AD or diploma institution (See Clinical Rounds, page 35.) The graduates of the AD and diploma programs would receive a “provisional” license to practice nursing that would expire in 10 years unless they earn a BSN. If they don't earn a BSN, RNs with ADs will be demoted to LPNs.
As someone who has spent more than 15 years in baccalaureate and higher-degree nursing education, I believe that the difference in preparation and education provided by ADN and BSN programs isn't great enough to justify the additional study and cost. Graduates of ADN programs should look to continuing their education through the RN to MSN model, which many university nursing programs offer.
The BSN degree is expensive and redundant. It is time for nursing education to prepare the “entry- level RN” at the AD level and have the MSN become the specialty practice level for all nurses.