current and future national health care needs. Advances in medical science and technology, the changing practice boundaries between medicine and nursing, and the increase in the share of the population with multiple chronic health conditions create a level of complexity in health care that requires a more educated health care workforce. Nursing is the least well educated health profession by far but the one experiencing the greatest expansion in scope of practice and responsibilities. The National Advisory Council on Nurse Education and Practice (NACNEP) (1996), policy advisors to the Congress and the U.S. Secretary of Health and Human Services on nursing issues, urged almost 15 years ago that policy actions be taken to ensure that at least 66 percent of nurses would hold a baccalaureate or higher in nursing by 2010; the actual result is closer to 45 percent. As described in the sections below, growing evidence suggests that the shortage of nurses with BSN and higher education is adversely affecting a number of dimensions of health care delivery now and these problems will only become exaggerated in the future.

Quality of Hospital Care

A growing body of research documents that hospitals with a larger proportion of bedside care nurses with BSNs or higher qualifications is associated with lower risk of patient mortality. Aiken and colleagues (2003) in a paper published in the Journal of the American Medical Association (JAMA) showed that in 1999, each 10 percent increase in the proportion of a hospital’s bedside nurse workforce with BSN qualification was associated with a 5 percent decline in mortality following common surgical procedures. A similar finding was published by Friese and associates for cancer surgical outcomes (Friese et al., 2008). Aiken’s team has replicated this finding in a larger study of hospitals in 2006. Similar results have been published for medical as well as surgical patients in at least three large studies in Canada and Belgium (Estabrooks et al., 2005; Tourangeau et al., 2007; Van den Heede et al., 2009).

This research has motivated the American Association of Nurse Executives, the major professional organization representing hospital nurse chief executive officers who employ 56 percent of the nation’s nurses, to establish the BSN as the desired credential for nurses. Many hospitals, particularly teaching hospitals and children’s hospitals, are acting on the evidence base by requiring the BSN for employment. Nurse executives in teaching hospitals have a goal of 90 percent BSN nurses, and community hospital nurse executives aim for at least 50 percent BSN-prepared nurses (Goode et al., 2001). Since only 45 percent of bedside care nurses have a BSN, many executives cannot reach their goals.

Access and Costs

There is some research evidence that the cost effectiveness of nursing improves with a more educated workforce. In Aiken’s JAMA paper, evidence was



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