Creating a More Highly Qualified Nursing Workforce

• According to the 2017 National Nursing Workforce Survey prepared by the National Council of State Boards of Nursing and the National Forum of State Nursing Workforce Centers, nursing is the nation's largest healthcare profession, with more than 3.8 million registered nurses (RNs) nationwide.
   
• In terms of highest level of nursing education, the latest workforce survey found that 64.2% of the nursing workforce is prepared at the baccalaureate and higher degree level.  This breaks down as follows: 45.2% with a Bachelor of Science in Nursing (BSN); 17.1% with a master’s; 1.2% with a Doctor of Nursing Practice (DNP) degree; 0.6% with a PhD; and 0.1% with another type of doctorate.
   
• According to a study published in the October 2017 Journal of Nursing Scholarship, the proportion of baccalaureate-prepared RNs in U.S. serving on acute care hospital units increased from 44% in 2004 to 57% in 2013 (a 30% increase). Based on the current trends, 64% of the nurses working on a hospital unit will have a baccalaureate degree by 2020. 
   
• In October 2010, the Institute of Medicine released its landmark report on The Future of Nursing, initiated by the Robert Wood Johnson Foundation, which called for increasing the number of baccalaureate-prepared nurses in the workforce to 80% and doubling the population of nurses with doctorates. The expert committee charged with preparing the evidence-based recommendations contained in this report state that to respond “to the demands of an evolving health care system and meet the changing needs of patients, nurses must achieve higher levels of education.”
   
• In March 2005, the American Organization of Nurse Executives (AONE) released a statement calling for all for registered nurses to be educated in baccalaureate programs in an effort to adequately prepare clinicians for their challenging and complex roles. AONE’s statement, titled Practice and Education Partnership for the Future, represents the view of nursing’s practice leaders and a desire to create a more highly educated nursing workforce in the interest of improving patient safety and providing enhanced nursing care.
   
• In December 2000, AACN issued a position statement titled The Baccalaureate Degree in Nursing as Minimal Preparation for Professional Practice, which updated a statement previously endorsed by AACN member schools in 1996. The statement identifies the BSN as the appropriate degree for entry-level registered nurses given the rapid expansion of clinical knowledge and mounting complexities in health care, which mandate that professional nurses possess educational preparation commensurate with contemporary practice expectations.

AACN and other authorities believe that education has a strong impact on a nurse’s ability to practice, and that patients deserve the best educated nursing workforce possible. A growing body of research reinforces this belief and shows a connection between baccalaureate education and lower mortality rates.

• In the July 2017 issue of BMJ Quality and Safety, Dr. Linda Aiken and colleagues reported findings from a study of hospitals in six European nations, which found that a greater proportion of professional nurses at the bedside is associated with better outcomes for patients and nurses. Reducing nursing skill mix by adding assistive personnel without professional nurse qualifications may contribute to preventable deaths, erode care quality, and contribute to nurse shortages. 
   
• In the October 2014 issue of Medical Care, researchers from the University of Michigan reported that a 10% increase in the proportion of baccalaureate-prepared nurses on hospital units was associated with lowering the odds of patient mortality by 10.9%. The authors also found that increasing the amount of care provided by BSNs to 80% would result in significantly lower readmission rates and shorter lengths of stay. These outcomes translate into cost savings that would more than off-set expenses for increasing the number of baccalaureate-prepared nurses in hospital settings.
   
• Posting online in August 2014 by the International Journal of Nursing Studies, a team of researchers from several nursing schools in South Korea and the University of Pennsylvania found that a 10% increase in baccalaureate-prepared nurses was associated with a 9% decrease in patient deaths in South Korean hospitals. The authors concluded that increasing the number of nurses with the BSN would significantly reduce the number of in-hospital deaths.
   
• Published in The Lancet in May 2014, new research from Dr. Linda Aiken shows that patients experiencing complications after surgery are more likely to live if treated in hospitals with adequate nurse staffing levels and higher numbers of BSN nurses. Following a review of more than 420,000 patient records in 300 hospitals spanning nine European countries, finding show that a 10% increase in the proportion of nurses holding a bachelor’s degree in an acute care setting is associated with a 7% decrease in the risk of death in discharged patients following common surgeries.
   
• In an article published in the March 2013 issue of Health Affairs, nurse researcher Ann Kutney-Lee and colleagues found that a 10-point increase in the percentage of nurses holding a BSN within a hospital was associated with an average reduction of 2.12 deaths for every 1,000 patients—and for a subset of patients with complications, an average reduction of 7.47 deaths per 1,000 patients.
   
• In the February 2013 issue of the Journal of Nursing Administration, Mary Blegen and colleagues published findings from a cross-sectional study of 21 University Healthsystem Consortium hospitals which found that hospitals with a higher percentage of RNs with baccalaureate or higher degrees had lower congestive heart failure mortality, decubitus ulcers, failure to rescue, and postoperative deep vein thrombosis or pulmonary embolism and shorter length of stay.
   
• In the October 2012 issue of Medical Care, researchers from the University of Pennsylvania found that surgical patients in Magnet hospitals had 14% lower odds of inpatient death within 30 days and 12% lower odds of failure-to-rescue compared with patients cared for in non-Magnet hospitals. The study authors conclude that these better outcomes were attributed in large part to investments in highly qualified and educated nurses, including a higher proportion of baccalaureate prepared nurses.
   
• In an article published in Health Services Research in August 2008 that examined the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery, Dr. Christopher Friese and colleagues found that nursing education level was significantly associated with patient outcomes. Nurses prepared at the baccalaureate-level were linked with lower mortality and failure-to-rescue rates.
   
• In a study released in the May 2008 issue of the Journal of Nursing Administration, Dr. Linda Aiken and her colleagues confirmed the findings from their landmark 2003 study (see below) which show a strong link between RN education level and patient outcomes. The noted nurse researchers found that every 10% increase in the proportion of BSN nurses on the hospital staff was associated with a 4% decrease in the risk of death.
   
• In the January 2007 Journal of Advanced Nursing, a study of 46,993 patients conducted by researchers at the University Toronto found that hospitals with higher proportions of baccalaureate- prepared nurses tended to have lower 30-day mortality rates. The findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients.
   
• In the March/April 2005 issue of Nursing Research, Dr. Carole Estabrooks and her colleagues at the University of Alberta found that baccalaureate prepared nurses have a positive impact on mortality rates following an examination of more than 18,000 patient outcomes at 49 Canadian hospitals. 
   
• In a study published in the September 24, 2003 Journal of the American Medical Association, Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level. A 10% increase in the proportion of nurses holding BSN degrees decreased the risk of patient death and failure to rescue by 5%.

For more information on the link between nursing education and patient outcomes, see 
www.aacnnursing.org/News-Information/Fact-Sheets/Impact-of-Education.

AACN stands ready to work with the larger nursing community and representatives from associate degree and diploma programs to expand awareness of degree completion options, facilitate the establishment of articulation agreements, and enhance the educational preparation of the nursing workforce. 

• In March 2019, AACN’s members endorsed a new position statement titled Academic Progression in Nursing: Moving Together Toward a Highly Educated Nursing Workforce, which highlights the need for collaborative solutions that enable all nurses to take the next step in their educational development to better serve the health needs of the nation.
   
• In February 2015, a study published in Nursing Economics by Dr. Auerbach and colleagues found that the percentage of BSN-prepared nurses in acute care hospitals is increasing while the employment of associate degree nurses in these settings is decreasing.
   
• Employers are recognizing that education makes a difference and are moving to hire the best educated entry-level RNs possible. According to AACN’s latest survey on Employment of New Nurse Graduates and Employer Preferences for Baccalaureate-Prepared Nurses, more than 88% of employers are now requiring or expressing a strong preference for nurses with a baccalaureate degree. 
   
• In September 2012, the Joint Statement on Academic Progression for Nursing Students and Graduates was endorsed by the American Association of Colleges of Nursing, American Association of Community Colleges, Association of Community Colleges Trustees, National League for Nursing, and the National Organization for Associate Degree Nursing. This historic agreement represents the first time leaders from the major national organizations representing community college presidents, boards, and program administrators have joined with representatives from nursing education associations to promote academic progression in nursing. This statement represents the shared view that nursing students and practicing nurses should be supported in their efforts to pursue higher levels of education. 
   
• In March 2012, the Robert Wood Johnson Foundation funded the Academic Progression in Nursing (APIN) program to advance state and regional strategies to create a more highly educated nursing workforce. A total of $4.3 million in funding was awarded to the Tri-Council for Nursing to steer this initiative. Tri-Council members include the American Association of Colleges of Nursing, National League for Nursing, American Nurses Association and the American Organization of Nurse Executives. 
   
• The nation’s Magnet hospitals, which are recognized for nursing excellence and superior patient outcomes, have moved to require all nurse managers and nurse leaders to hold a baccalaureate or graduate degree in nursing by 2013. Settings applying for Magnet designation must also show what plans are in place to achieve the IOM recommendation of having an 80% baccalaureate prepared RN workforce by 2020. www.nursecredentialing.org
   
• In its October 2010 report on The Future of Nursing, the Institute of Medicine states “an increase in the percentage of nurses with a BSN is imperative as the scope of what the public needs from nurses grows, expectations surrounding quality heighten, and the settings where nurses are needed proliferate and become more complex.” 
   
• In May 2010, the Tri-Council for Nursing, a coalition of four steering organizations for the nursing profession (AACN, ANA, AONE, and NLN), issued a consensus statement calling for all RNs to advance their education in the interest of enhancing quality and safety across healthcare settings. In the statement titled Education Advancement of Registered Nurses, the Tri-Council organizations present a united view that a more highly educated nursing workforce is critical to meeting the nation’s nursing needs and delivering safe, effective patient care. In the policy statement, the Tri-Council finds that “without a more educated nursing workforce, the nation's health will be further at risk.” 
   
• In December 2009, Dr. Patricia Benner and her team at the Carnegie Foundation for the Advancement of Teaching released a new study titled Educating Nurses: A Call for Radical Transformation, which recommended preparing all entry-level registered nurses at the baccalaureate level and requiring all RNs to earn a master’s degree within 10 years of initial licensure. The authors found that many of today’s new nurses are “undereducated” to meet practice demands across settings. Their strong support for high quality baccalaureate degree programs as the appropriate pathway for RNs entering the profession is consistent with the views of many leading nursing organizations, including AACN. 
   
• In the July/August 2009 issue of Health Affairs, Dr. Linda Aiken and colleagues call for adapting federal funding mechanisms (i.e. Title VIII and Medicare) to focus on preparing more nurses at the baccalaureate and higher degree levels. This policy emphasis is needed to adequately address the growing need for faculty and nurses to serve in primary care and other advanced practice roles. The researchers reported that new nurses prepared in BSN programs are significantly more likely to complete the graduate level education needed to fill nursing positions where job growth is expected to be the greatest.  
   
• Currently, 777 RN-to-Baccalaureate programs are available nationwide, including more than 600 programs that are offered at least partially online. These programs build on the education provided in diploma and associate degree programs and prepare graduates for a broader scope of practice. In addition, 219 RN-to-Master’s degree programs are available which cover the baccalaureate content missing in the other entry-level programs as well as graduate level course work.
   
• Articulation agreements support education mobility and facilitate the seamless transfer of academic credit between associate degree and baccalaureate nursing programs. In addition to hundreds of individual agreements between community colleges and four-year schools, statewide articulation agreements exist in many areas including Florida, Connecticut, Arkansas, Texas, Iowa, Maryland, South Carolina, Idaho, Alabama, and Nevada to facilitate educational advancement.

Aiken, L. H., Sloan, D., Griffiths, P. et al. (2017). Nursing skill mix in European hospitals: association with mortality, patient ratings, and quality of care. BMJ Quality & Safety, 26(7), 559-568. doi:10.1136/bmjqs-2016-005567.

Aiken, L. (2014, October). Baccalaureate nurses and hospital outcomes: More evidence. Medical Care, 52(10), 861-863.

Aiken, L., Sloane, D.M., et al. (2014, May 24). Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet, 383(9931), 1824-1830.

Aiken, L., Sloane, D.M., et al. (2014, May 24). Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet, 383(9931), 1824-1830.

Aiken, L.H., Clarke, S.P., Sloane, D.M., Lake, E.T. & Cheney, T. (2008, May). Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration, 38(5), 223-229.

Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., & Silber, J.H. (2003, September 24). Educational levels of hospital nurses and surgical patient mortality, Journal of the American Medical Association, 290, 1617-1623.

American Association of Colleges of Nursing (2019). Academic Progression in Nursing: Moving Together Toward a Highly Educated Nursing Workforce. Position Statement. Washington, DC: Author.

American Association of Colleges of Nursing (2019). 2018-2019 Enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, DC: Author.

American Association of Colleges of Nursing (2018). Employment of New Nurse Graduates and Employer Preferences for Baccalaureate-Prepared Nurses. Research Brief. Washington, DC: Author.

American Association of Colleges of Nursing (2000). The Baccalaureate Degree in Nursing as Minimal Preparation for Professional Practice. Position Statement. Washington, DC: Author.

American Organization of Nurse Executives. (2005). Practice and education partnership for the future. Washington, DC: American Organization of Nurse Executives.

Auerbach, D.I., Buerhaus, P.I., & Staiger, D.O. (2015, January-February). Do associate degree registered nurses fare differently in the nurse labor market compared to baccalaureate-prepared RNs? Nursing, Economics, 33(1), 8-12, 35.

Benner, P., Sutphen, M., Leonard, V. & Day, L. (2009). Educating Nurses: A Call for Radical Transformation. Carnegie Foundation for the Advancement of Teach.  San Francisco: Jossey-Bass.

Blegen, M.A., Goode, C.J., Park, S.H., Vaughn, T. & Spetz, J. (2013, February). Baccalaureate education in nursing and patient outcomes. Journal of Nursing Administration, 43(2), 89-94.

Cho, E., Sloane, D.M., Kim, E., Kim, S., Choi, M., Yoo, I.Y, Lee, H.S. & Aiken, L. (2014, August). Effects of nurse staffing, work environments, and education on patient mortality: An observational study. International Journal of Nursing Studies. In Press. DOI: http://dx.doi.org/10.1016/j.ijnurstu.2014.08.006

Estabrooks, C.A., Midodzi, W.K., Cummings, G.C., Ricker, K.L. & Giovanetti, P. (2005, March/April). The impact of hospital nursing characteristics on 30-day mortality. Nursing Research, 54(2), 72-84.

Friese, C.R, Lake, E.T., Aiken, L.H., Silber, J.H. & Sochalski, J. (2008, August). Hospital nurse practice environments and outcomes for surgical oncology patients. Health Services Research, 43(4), 1145-1163.

Institute of Medicine. (2010). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press.

Kutney-Lee, A., Sloane, D.M. & Aiken, L. (2003, March). An increase in the number of nurses with baccalaureate degrees is lnked to lower rates of postsurgery mortality. Health Affairs, 32(3), 579-586.

Ma, C., Garrard, L. & He, J. (2017, October). Recent Trends in Baccalaureate‐Prepared Registered Nurses in U.S. Acute Care Hospital Units, 2004–2013: A Longitudinal Study. Journal of Nursing Scholarship. https://doi.org/10.1111/jnu.12347

McHugh, M.D., Kelly, L.A., Smith, H.L., Wu, E.S., Vanak, J.M. & Aiken, L.H. (2012, October). Lower Mortality in Magnet Hospitals. Medical Care, Publication forthcoming (published ahead of print).

Smiley, R.A., Lauer, P., Bienemy, C., Berg, J.G., Shireman, E., Reneau, K.A., & Alexander, M. (2018, October). The 2017 National Nursing Workforce Survey. Journal of Nursing Regulation, 9(3), supplement (S1-S54).

Tourangeau, A.E, Doran, D.M., McGillis Hall, L., O'Brien Pallas, L., Pringle, D., Tu, J.V. & Cranley, L.A. (2007, January). Impact of hospital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing, 57(1), 32-41.

Tri-Council for Nursing. (2010, May). Educational advancement of registered nurses: A consensus position.

Van den Heede, K., Lesaffre, E., Diya, L., Vleugels, A., Clarke, S.P., Aiken, L.H. & Sermeus, W. (2009). The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: Analysis of administrative data. International Journal of Nursing Studies, 46(6), 796-803.

Yakusheva, O., Lindrooth, R. & Weiss, M. (2014, October). Economic evaluation of the 80% baccalaureate nurse workforce recommendation: A patient-level analysis. Medical Care, 52(10), 864-869.