The Influence of NurseMidwife Education on Patient Outcomes

1
The Influence of Nurse/Midwife Education on
Patient Outcomes

• Sean Clarke, RN, PhD, CRNP, FAAN
• Associate Director, Center for Health Outcomes
  and Policy Research
• Class of 1965 Reunion Term Associate Professor of
  Nursing
• University of Pennsylvania
• Philadelphia, PA, USA

2
Outline

• History and background
• Research evidence related to the role of nursing
  education in outcomes
• Policy implications Why third-level nurse
  education is likely to be beneficial to patients
• Where next?
• Conclusion

3
Education

• Initial formal preparation to begin professional
  practice (prelicensure education)
• In the U.S. still divided, with about 60 below
  the bachelors degree
• Post-basic formal education leading to degrees
  and/or certificates
• Broader rubric of lifelong learning including
  individually-directed learning plans and
  shorter-term organized activities

4
Honors Nursing Graduates, U/Penn, 1927
5
1st Graduating Accelerated BSN Class Villanova
University, 2004
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3 Countries
8
General Patterns in Evolution of Nursing
Education Across Countries

• Formalized training in hospitals
• Debates about service vs. education as focus of
  nurse training programs
• Concerns about nurse training occurring outside
  of educational institutions
• Baccalaureate and higher education within and
  outside nursing for nurse leaders
• Beginning of lobbying to shift the entry
  credential to the baccalaureate level
• Development of masters and higher education for
  nurse leaders
• Shift to the baccalaureate as the entry credential

9
The U.S. Story

• 1872 First formal training program, New England
  Hospital for Women and Children
• 1903 Beginning of state regulation of nursing
  practice
• 1909 First bachelors degree program at
  University of Minnesota
• 1929 Goldmark Report recommends decreasing
  service and increasing educational component, and
  moving towards university education
• 1920s through 1960s Period of intense growth in
  certificate and degree programs for nurses and
  nurse leaders after initial hospital diploma
  education
• 1952 Creation of associate degree (AD) programs
  in nursing in community/junior colleges (lower
  tier of higher education hierarchy)
• 1960s through 1970s Cost factors lead many
  hospitals to close diploma programsAD programs
  take their place
• 1970s through 1990s Steady growth of doctoral
  programs in nursing, masters degrees
  increasingly required to teach nursing at any
  level
• 1990s Shift in focus of masters education to
  advanced practice, primarily for nurse
  practitioners

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Basic Nursing Education of the U.S. Registered
Nurse Population
Source National Sample Survey of Registered
Nurses, March 2004, HRSA
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NCLEX-RN (National Licensing Examination) Pass
Rates for Newly-Graduated Registered Nurse
Licensure Candidates by Program Type in 2004
(Source NCSBN)
Program Type Number of Graduates NCLEX-RN
Pass Rate Diploma 3,162 88.2 Associ
ate Degree 53,275 85.3 Baccalaureate
Degree 30,648 84.8
13
Initial Educational Preparation of Registered
Nurses, United States, 2004
Source National Sample Survey of Registered
Nurses, March 2004, HRSA
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Highest Educational Preparation of Registered
Nurses, United States, 2004
Source National Sample Survey of Registered
Nurses, March 2004, HRSA
15
The Canadian Story

• 1874 First formal training program, Mack
  Training School in St. Catharines, Ontario
• 1919 First bachelors degree program at
  University of British Columbia
• 1932 Weir Report recommends decreasing service
  and increasing educational component, and moving
  towards university education
• 1920s-1960s Period of intense growth in
  certificate and degree programs for nurses and
  nurse leaders after initial hospital diploma
  education
• 1959 First masters program at University of
  Western Ontario
• 1960s-1970s Many hospitals to close diploma
  programscommunity college programs awarding
  diplomas take their place
• 1989 All provincial nursing associations adopt
  motion in favour of baccalaureate entry to
  practice
• 1990s Birth, followed by steady growth of
  doctoral programs in nursing
• 2000 Movement is in place to consolidate basic
  nursing education in university-level programs in
  all provinces
• 2001 All prelicensure students in Ontario
  (largest province) enter bachelors programs,
  bachelors degree required of all new licensees
  in 2005 most other provinces close behind

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Highest Educational Preparation of Registered
Nurses in Canada, 1989 and 2004
2004
1989
Source Canadian Nurses Association
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The Irish Story

• Nightingale era First formal training programs
• 1917 Beginning of state regulation of nursing
  practice
• 1940s Discussions regarding university courses
  for nurse leaders begin
• Nurses, particularly leaders, pursue
  post-diploma education in nursing and other
  fields, sometimes abroad
• 1980s and beyond Acceleration of discussions
  around preparation and creation of programs at
  undergraduate and postgraduate levels
• 2001 Government approval for a 4-year
  pre-registration degree as sole entry point to
  practice
• 2006 First class of university graduates emerges

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Back to North America

• Debate for past 40 years not so much about moving
  away from having prelicensure RN education
  programs in service institutions
• Social forces pushed nursing education out of
  hospitals in 1970s
• Debates more about which educational institutions
  should be entrusted with this (universities/4-year
  colleges vs. community colleges)
• criteria for admission, costs, accessibility
• what the content of the programs should be
• professional/leadership orientation
• VERSUS
• technical orientation

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The North American Fights Over Nursing Education
Much Heat Not Much Light

• Intensely political within nursing
• Clinicians, teachers, administrators, leaders
• Nursing education is big business in the U.S.
• Many disciplines (e.g. nutrition/dietetics,
  rehabilitation professions, pharmacy, etc.) all
  moved to postgraduate entry during 1980s and
  1990s in U.S.
• Physicians and health care administrators
  uninterested except when they believe RN supply
  threatened
• Data very thin on both sides (quite biased
  research) and never related to much to patient
  care until outcomes research methods started to
  be applied to the question

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Research Evidence
21
Key Papers Directly Tying Educational Composition
of Hospital Nursing Staff to Patient Outcomes in
Acute Care

• Aiken et al. (2003), Journal of the American
  Medical Association
• Estabrooks et al. (2005), Nursing Research
• Tourangeau et al. (2007), Journal of Advanced
  Nursing

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Hospital Nurse Staffing and Patient Mortality,
Nurse Burnout, and Job Satisfaction

• Linda H. Aiken, PhD, RN
• Sean P. Clarke, PhD, RN
• Douglas M. Sloane, PhD
• Julie Sochalski, PhD, RN
• Jeffrey H. Silber, MD, PhD

October 23/30, 2002. Journal of the
American Medical Association, 288,
1987-1993 Funding Source National Institute of
Nursing Research, National Institutes of Health
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Patient Selection Criteria

• between the ages of 20 and 85
• hospitalized between April 1, 1998 to November
  30, 1999
• underwent general surgical, orthopedic, or
  vascular procedures
• hospitalized in an institution that could be
  linked to survey and administrative datasets as
  an individual agency

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Surgical Proceduresin the 232,342 Patients
Vascular
Digestive Tract
Orthopedic
Hepatobiliary
Skin/Breast
Endocrine/Metabolic
25
Comorbidities in PA Surgical Patients (in s)

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Patient Characteristics PA Surgical Analyses

• 43.7 of the patients were male
• Mean age of the patients 59.3 ? 16.9 years
• 27.3 of these patients were admitted on an
  emergency basis

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Number of Beds 168 PA Hospitals
28
168 PA Hospitals Hospitals with Open Heart
and/or Major Organ Transplant Capacity
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168 PA Hospitals Teaching Status(Graduate
Medical Education)
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168 PA Hospitals Average Patient Load Carried By
Nurses on Last Shift Worked
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Outcomes in the 232,342Surgical Patients

• 4,535 (2.0) died within 30 days of admission
• 53,813 (23.2 ) were observed to experience a
  major complication
• the death rate among complicated patients
  (failure to rescue rate) was 8.4

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Effect of Nurse Staffingon Mortality

• For every one patient-per-nurse increase in
  nursing workload in Pennsylvania hospitals 14
  increase in risk of death within 30 days for an
  individual patient
• After controlling for 136 hospital and patient
  variables 7 increase in risk of death

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Education Levels of Hospital Nurses and Patient
Mortality

• Aiken, Clarke, Cheung, Sloane, Silber
  (September 24, 2003, Journal of the American
  Medical Association)
• The proportion of hospital staff RNs holding
  baccalaureate or higher degrees as their highest
  (not initial) credential ranged from 0 to 77
  across the hospitals.

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Excess Surgical Deaths (Observed-Expected) per
1000 Cases Across PA Hospitals With Differing
Proportions of BSN/MSN-Educated Nurses
More deaths than expected
Fewer deaths than expected
Proportion of Nurses with BSNs/MSNs
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Odds Ratios for Patient Mortality (Fully-Adjusted
Model)

• Nurse education
• (10 increase in BSN)
• Nurse workload/staffing
• (1 pt per nurse increase)
• Nurse experience
• (per 1 year increase)
• Board-certified surgeon

• .95 (.91-.99) p.008
• 1.06 (1.01-1.10) p.02
• 1.00 (.98-1.02) p.86
• .85 (.73-.99) p.03

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Patient deaths after surgery were lowest in
hospitals where nurses cared for fewer patients
on average and had higher levels of education
Patient-to-nurse ratios
Estimated deaths per 1000 patients
Bachelors-prepared nurses
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Impact of Hospital Characteristics on 30-Day
Medical Mortality (N18,142), Alberta,
CanadaEstabrooks et al. (2005), Nursing
Research, Final Model
38
Tourangeau et al., J Adv Nurs 2007 57(1) 32-44.

• 46,993 patients with 4 medical conditions (AMI,
  CVA, pneumonia, sepsis) in 75 Ontario (Canada)
  hospitals in 2003
• Significant associations seen between risk
  adjusted 30-day mortality and
• Hours per patient day
• Registered Nurses
• baccalaureate-educated nurses
• Perceptions of staffing adequacy and support from
  managers

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The Bottom Line

• Early research suggests that patient mortality is
  lower in hospitals where higher proportions of
  front-line staff nurses hold undergraduate and
  higher degrees
• In studies where patient and hospital
  characteristics are measured and analyzed
• In studies where other organizational and
  physician-related factors are observed to have
  effects

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Caveats

• Correlational results at present
• Other factors may be involved in the association
• Proportion of BSN nurses may be partially a proxy
  for hospital/community characteristics
• Mortality is the best studied objective outcome
  of care to date (!)
• Currently lack empirical evidence that actual
  nurse practice differs at a clinically
  significant level across levels of education and
  across patient populations
• This is coming

41
What else is missingFuture avenues for research

• Outcomes for patients/clients in setting other
  than acute care
• Positive outcomes of acute care
• Outcomes that tend not to be observed when the
  educational composition is lower

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Caveats/Other Factors to Be Disentangled

• Role of jobs/academic preparation before
  professional nursing education
• Variable quality of students and of educational
  programs at all levels
• Role of non-nursing academic preparation
• Role of vision of practice established by nurse
  leaders and resources for enacting professional
  approach
• Role of (the right types of) clinical experience

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How Does Education Make a Difference? Thoughts
for Policymaking and Future Research
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How Does Academic Preparation Improve Quality of
Care Outcomes in General?

• Broader base of knowledge
• Courses and practice often can build on a more
  rigorous science and humanities preprofessional
  foundation
• Depth of coverage in courses possible when
  broader aims than technical proficiency targeted
• Benefits of being educated where knowledge is
  being created
• Learning to learn
• Greater flexibility in mastering new bodies of
  knowledge, new techniques
• Ability to see longer-term, bigger-picture
  aspects of care

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Attitudinal/Affective Benefits of a
Professionally Oriented Education

• A humanism in practice built on a deeper
  understanding of the profession, its history and
  its scientific basis
• Values
• Reflective practice
• Education (formal and informal)
• Community of care/working environments
• Importance of leadership
• Sense of self as a knowledge worker/self-confidenc
  e

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U.S. Institute of Medicine Report Crossing the
Quality Chasm

• Six aims in health care systems reform
• Safety avoid injuries
• Effectiveness evidence-based
• Patient-centeredness patient values guide
  decisions
• Timeliness reduce waiting and delay
• Efficiency avoid waste
• Equity care doesnt vary by gender, ethnicity,
  etc,

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Potential Impacts of Educationon Safety and
Quality

• Willingness to question other clinicians
  (colleagues, clinicians from other disciplines),
  managers
• Effective communication
• Effective leadership
• Longer-term, bigger-picture view that enables
  patients interests to be first priority
• Getting beyond task completion

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Potential Impacts of Educational Programs in
Other Aspects of Quality

• Timely, cost-effective
• Diagnosing problems in systems and acting as
  change agents
• Communication, leadership
• Effective
• Evidence-based practice (specifics and general
  methods)
• Culturally-sensitive, culturally-appropriate,
  patient-centered
• Humanism, philosophy of practice formal content

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Advantages of Addressing Prelicensure Education

• Where Irish nursing has succeeded and U.S.
  nursing has and will not

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The U.S. Story (Continued)

• Mobility has been a big attraction for entry to
  nursing historically
• BUT, upgrading to 4-year preparation after entry
  to practice is expensive for the student and
  society (particularly in a higher education in
  the US where public-private mix renders costs
  very high)
• Motivation for upgrading waxes and wanes
  depending on job market (wage incentives for
  upgrading now waning)
• Front-line clinicians in short supply (any RN
  qualifications more or less guarantee employment)
• Front-line management and education considered
  hard work for little benefit (both training and
  the work itself)
• Advanced practice clinical positions quite
  saturated

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Percentage of US RNs Who Upgrade Their Education,
by Age
Biviano et al., HRSA, 2004
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Declining Proportions of US Hospital Nurses in
Higher Education and Getting Employer Tuition
Assistance (NSSRN, 1984-2000)
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Problems Posed By Stagnant Growth in Numbers of
Nurses With Bachelors and Higher Preparation

• Many institutions, especially tertiary ones,
  would like 60 or more of their nurses to hold
  university degrees to deal with clinical and
  leadership challenges on the front lines
• Not possible with current mix
• Pipeline for leadership roles and for teaching in
  jeopardy
• Nursing education capacity limited by teacher
  shortage
• MSN required to teach in the US in any type of
  program

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Where the U.S. may be going

• BSN bachelors/university-level in 10
• All current license holders grandfathered
  (allowed to retain credential)no new
  requirements
• As of a certain date, allowing graduates of all
  types of programs to register initially but by
  year 10, must hold a university degree to renews
• Proposal working its way through in New York
  State and is under discussion in a number of
  other states
• Can colleges/universities keep up?

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Arguments of Increased Formal Education for
Nurses--Summary

• Implications for quality of care of a broader
  base, more depth in knowledge base, greater
  adaptability
• Environments for caresystems thinking, greater
  understanding of contexts of care and of quality
  of care
• Followership and stewardship
• Sowing the seeds for a new generation of clinical
  leaders, managers/executors, researchers,
  educators who will shape environments and steer
  practice

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Ongoing Challenges for Managers and Leaders
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• Managing work environments
• Work environments The common link between nurse
  retention and optimal quality of care
• Challenges of influx of individuals with academic
  instruction Reality shock and its remedies

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Work Environments and Well-Educated Staff Nurse
Chicken and Egg?
Higher quality of patient care, superior
environments
Better patient and staff outcomes
Better educated staff
Recruitment and retention
How do we lead highly-educated clinicians to
maximize their contributions to patient care over
a career?
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What Leads Some Institutions to Differentially
Attract and Retain Educated Nurses?

• Salary
• Differentials that recognize educational
  preparation
• Benefits
• Including tuition reimbursement
• Working conditions
• Stimulation
• Challenging patient care
• Like-minded colleagues
• Autonomy
• Opportunities for advancement

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Reality Shock Work Environments and the New
Clinician

• The Role of Nursing Leadership

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Kramer, M. (1974). Reality shock Why nurses
leave nursing. St. Louis Mosby.

• Reality shock stems from the realization that the
  way the graduate was taught to do things in
  school is not necessarily the way things are
  actually done on the job
• Originally developed to describe difficulties in
  socialization experienced by nurses in the US
  educated in the university model

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Where the conflict can arise Academia vs.
practice

• comprehensive vs. episodic/specialized health
  care
• quality vs. quantity of work
• unclear expectations/testing by coworkers
• bureaucratic/part-task orientation vs.
  professional orientation to nursing practice

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Bureaucratic Orientation

• Workers have specialized roles/tasks
• Extensive rules
• Overall orientation to rational, efficient
  implementation of goals
• Hierarchical authority structure
• Depersonalization of worker-client contacts

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Part-Task Orientation

• Relatively few skills needed, mostly learned on
  the job
• Evaluation through completion of tasks
• Hierarchical control and authority structure
• Rules and regulations serve as external standards
• Control and coordination removed from workers
• A layer of the organization to maintain the
  structure

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Professional (Whole-Task) Orientation

• Specialized competence with an intellectual
  foundation (total knowledge and skills) for
  global approach to work
• Extensive authority, influence, responsibility in
  exercising special competence
• Commitment
• Peer control/authority

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Reality Shock Conceptualized
Professional values
Bureaucratic values
ROLE CONFLICT ROLE DEPRIVATION
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Reality ShockFour Phases

• Honeymoon Phase
• Shock (Rejection) Phase
• Recovery Phase
• Resolution Phase

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Kramers Four Typologies of Nurses Dealing with
the Conflict
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Counteracting Reality Shock

• Sociological immunization anticipatory
  guidance and other types of educational
  interventions
• Careful and thoughtful orientation of new
  graduates
• Improve the odds that students will become
  bicultural
• Training in change theory
• Reform nursing education
• Nursing leadership on the front lines through the
  executive level that visibly promotes the
  professional model

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Challenges in Practice

• Respecting experience and length of
  serviceturbulence and uncertainty produced by
  change
• Particularly when a lot of other change is going
  on
• Generational considerations (not just educational
  difference)
• Fostering mutual respect among staff with
  different backgrounds

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What issues/questions are arising in your
institutions and settings?
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What Aspects of Education Need To Be Modified to
Ensure/Protect/Advance Quality of Care?

• Basic clinical preparation
• Postgraduate/advanced clinical education
• Preparation of managers and leaders
• Lifelong learning for all
• Areas for research
• Modes of delivery
• Use of technologies
• Evaluation of outcomes for nurses and their
  clients(!)

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Next Steps in Research and Evaluation

• Currently, no tools/datasets for examining
  individual nurses practice and outcomes in
  relation to education/experience that permit
  direct comparisons/evaluations of educational
  models
• Major challenge to be addressed

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The Challenges of Nursingin the Academy

• Challenges of educating clinicians
• for meeting healthcare needs of very complex
  societies in changing healthcare systems
• equipping them for lifelong learning
• Adding more is decreasingly an
  optionfundamental reworking is necessary (at
  least in North America)
• Scholarly imperativefiguring out personnel mix
  in Schools of Nursing and designing manageable
  jobs to allow top-flight student experiences and
  permit nurse academics to meet the institutional
  expectations

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ConclusionPutting It Together and Making It
About Patients
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Scenario

• September, 2000 17-year-old patient with
  neurological complications of sickle-cell
  disease, undergoes gallbladder surgery at
  internationally-renowned pediatric hospital with
  10-week-old preop bloodwork
• returns to general surgical floor from recovery
  room, initially under the care of an RN trained
  in a well-regarded BSN program with one year of
  experience (who has been assigned 5 patients)
• preponderance of nurses working on floor had less
  than three years experience, and there was an
  exodus of experienced nurses from the ward
  since October, 1999

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Scenario (Contd)

• 2 hour delay in transfer from recovery room.
  320 p.m. 45 minutes after admission to floor,
  HR and RR elevated, BP 80/40
• Testimony of RN at coroners inquest "I did not
  realize how serious her blood pressure was. I did
  realize her blood pressure was low and it was not
  normal."
• RN continues to record worsening VS (not BP) at
  prescribed intervals, patient develops cold hands
  and feet

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Scenario (Contd)

• 6 p.m.--Electronic monitor begins sounding
  nurses disregard it, believing readings to be in
  error
• Around 6 p.m.--Surgeon visits patient, standing
  in doorway, chatting with patients mother, and
  then leaving without physically examining the
  teen, reading a vital-signs chart close by, or
  reviewing the read-outs on her heart and breath
  monitors
• 750 p.m.--Nurses respond to respiratory rate
  alarm
• 800 p.m.--Patient goes into cardiac arrest and
  dies
• Cause of death six hours after admission
  Postoperative hemorrhage

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Unhelpful (and erroneous) explanations

• A focus on individual practitioners, their
  qualifications, and what they did or didnt do at
  specific moments
• Shame and blame
• The second victim
• Treating symptoms
• A focus on specific procedures and regulations
  heeded or not heeded alone

82
What elements might explain what
happened?Possible Root Causes 1

• Staffing levels relative to patient needs
• Staff mix (levels of experience)implications for
  recruitment and retention
• Opportunities for senior clinical staff to assist
  less experienced nurses
• Staff development issues
• NURSE HUMAN RESOURCES IN A BROAD SENSE (not
  staffing numbers alone)

83
What other elements might explain what
happened?Possible Root Causes 2

• Maintaining high level of suspicion for rare, but
  potentially fatal complications in a busy,
  intense environment
• Team functioning--overlapping functions,
  cross-checking, building in redundancies to build
  in safety
• Climate, culture and resources to remain
  patient-focused in context of heavy demands
• SAFETY CLIMATE, INTER- AND INTRAPROFESSIONAL
  COMMUNICATION

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Another Case, This OneFrom the U.K. in 1998

• 54-year-old woman undergoes hysterectomy
• Registered nurse patient ratio on postsurgical
  floor 301
• Patient experiences severe internal bleeding when
  arterial ligature slips and detection is delayed
  heart attack and brain death
• 2 d postoperatively, life support discontinued
• See Nursing Standard, September 6 2006, p. 16

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Successful Rescues When Complications Arise

• Surveillance
• Interpreting cues
• Taking appropriate immediate actions
• Bringing the right personnel to the bedside
• Instituting appropriate definitive corrective
  treatment in time

Clarke Aiken, 2003
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Surveillance in Practice
Intervention
Yes
Assessment Patient condition and potential
for complications (frequency and risk)
Plan Assessment parameters and frequency
of assessments
Implementation Surveillance and interpretation of
cues
Abnormalities Correction needed?
No
Regular review With passage of time Change of
settings Handover, etc.
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Abnormal assessment findings needing correction
Establish immediate priorities
No
Immediate actions
Reestablish surveillance with new data
Inform other clinicians
Problem resolved?
Yes
Collaborative actions
Intervention Phase
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Package of Work Environment Issues Associated
With Rescue

• Basic staff competencies
• Experience issuesopportunities for oversight of
  less experienced nurses care
• Culture of clinical practice style
• Staffing levels
• Unit physical layout
• Policies/procedures for adjusting staffing
• Culture of interprofessional interactions
• Resources for rescue (equipment/personnel)
• Dealing with the rare/unusual or off-service
  care

89
Recent Patient Safety Events in North
America--Importance of Systems Thinking

• Labor and delivery unitMadison, Wisconsin
• A 16-year-old dies in labor when a bag with
  epidural anesthetic is connected to her IV line
  instead of the prescribed antibiotic experienced
  nursefatigue implicated in the event
• Neonatal ICUIndianapolis
• 3 infants die from heparin overdoses
• Adult dose vials of heparin mistakenly delivered
  to the unit by a pharmacy technician
• Emergency DepartmentWaukegan, Illinois
• 47 year old woman with 10/10 Chest pain, nausea
  made to wait 15 minutes to be triaged and 2 hours
  in the waiting room before being seen died an
  hour later
• Quebec, Canada
• Report on 12 deaths from respiratory depression
  following the use of narcotic analgesics in
  otherwise healthy adults under 50 over a 10-year
  period coroner directly attributed 8 to failure
  of nurses to adequately monitor patientsHigh
  profile news stories

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Another Case, This OneFrom the U.K. in 1998

• 54-year-old woman undergoes hysterectomy
• Registered nurse patient ratio on postsurgical
  floor 301
• Patient experiences severe internal bleeding when
  arterial ligature slips and detection is delayed
  heart attack and brain death
• 2 d postoperatively, life support discontinued
• See Nursing Standard, September 6 2006, p. 16

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In the end

• Education is a critical piece of the puzzle
• as are adequate staffing levels
• as is a positive work environment
• Front-line workers cover non-nursing tasks
• Clinical resource nurses/specialists
• Collegial relations with physicians and other
  workers and professionals
• Support of front-line nurses by
  managers/administrators
• Profile of nursing in the institution/facility
• Orientation, lifelong learning
• Quality measurement and improvement
• All are needed to get optimal patient outcomes
  and to retain staff

92

• Without good and careful nursing many must
  suffer greatly, and probably perish, that might
  have been restored to health and comfort, and
  become useful to themselves, their families, and
  the public, for many years after.
  Benjamin Franklin (1751)

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sclarke_at_nursing.upenn.eduhttp//www.nursing.upen
n.edu/chopr