Advances in medical science and technology create new challenges for practicing nurses. The growing shortage of nurses leads to an organizational, administrative, and professional chaos in the nursing profession. Many young nurses find it particularly problematic to socialize in the complex healthcare environment and internalize the values needed to ensure the safety and efficiency of professional nursing care. In this context, the quality and level of education start to play one of the principal roles in the development of sustainable nursing workforce. Numerous incidents and the growing stakeholders’ concern about the future of healthcare have turned patient safety into the primary criterion of quality and professionalism in nursing. Education is believed to be one of the chief factors linking nurses’ professionalism and clinical judgments to patient outcomes. At the heart of this literature review is the question of whether it is important for nurses to achieve a bachelor’s level in practice. Based on the analysis of the recent theoretical and empirical findings, nurses with at least a bachelor’s degree have better skills, knowledge, and expertise to ensure patient safety and reduce patient mortality in the health care system. Simultaneously, with the growing importance of baccalaureate education in nursing, the existing curriculum, educational, and knowledge gaps need to be closed.
The search strategy was developed to locate peer-reviewed journal articles related to the topic. The databases used in the search strategy included: Google Scholar, EBSCOHost, ProQuest, and CINAHL. A total of 20 peer-reviewed journal articles were located, with the most peer-reviewed material coming from the EBSCOHost and CINAHL databases. Keywords used during the search included “bachelor”, “nursing”, “bachelor in nursing”, “nursing education”, “nursing education and patient safety”, “nursing education and patient outcomes”, “importance of nursing education”, etc.
Nursing education, bachelor’s degree, and patient outcomes
The relation of nursing education to patient outcomes is one of the leading themes in contemporary literature. In most cases, empirical and theoretical researchers seek to understand whether a bachelor’s degree in nursing (or higher) can help to reduce patient mortality in various health care units or at least enhance patient safety and the quality of nurse-patient relationships. According to Aiken et al. (2003), the importance of quality nursing education is justified by the fact that “nurses constitute the surveillance system for early detection of complications and problems in case, and they are in the best position to initiate actions that minimize negative outcomes for patients” (p.1617). Effective surveillance of patient problems and guidance in problematic situations is dependent on nurses’ clinical judgment and expertise (Aiken et al. 2003). The latter is impossible without attaining at least a bachelor’s degree in nursing.
It is interesting to note that nurses registered to work in the United States usually engage in one of the three basic types of educational programs to get their nursing degree: a 3-year diploma program administered in hospitals, an associate degree program administered in community colleges, or a baccalaureate nursing program developed by colleges and universities (Aiken et al. 2003). For many years, nurses’ professionalism was directly associated with their practical experiences (Aiken et al. 2003). The level of nurses’ education was considered as secondary to their successes in the workplace (Aiken et al. 2003). Most probably, that was the main reason why only one third of registered nurses in the U.S. ever obtained a bachelor’s degree in their profession (Aiken et al. 2003). Williams (2008) provides different statistics: only 16% of all registered nurses decide to continue their education and pursue a bachelor’s degree.
Despite those complexities, researchers are almost unanimous in that achieving a bachelor’s degree is necessary to help nurses reduce patient mortality, increase the level of patient safety, and enhance patient outcomes. Aiken et al. (2003) discovered that a 10% increase in the number of nurses holding a bachelor’s degree led to a 5% decrease in patient mortality. With more nurses holding a bachelor’s degree, the number of patients dying within the first 30 days of admission significantly decreases (Aiken et al. 2003). The level of nurses’ education is also inversely related to the odds of failure to rescue: the higher the level of education, the lower are the risks of failure to rescue patients in critical situations (Aiken et al. 2003). Later in 2008, Aiken et al. (2008) confirmed and expanded their empirical results by stating that nurses with at least a bachelor’s degree could create a better care environment in hospitals, lower the risks of patient death and failure to rescue. These results imply that hospitals and other health care institutions can optimize their care environments by considering and improving the level of nurses’ education. Particularly in surgical departments, the importance of nurses’ education can hardly be overstated: Aiken et al. (2011) claim that “better staffing, better work environments, and better-educated nurses all “work” to improve outcomes for general surgical patients” (p.1052).
Yet, surgical units are not the only place where a bachelor’s degree in nursing can play a role in saving patients from death. Intensive care units require a great deal of professionalism, clinical judgment, analytical thinking, and expertise to avoid or, at least, reduce the risks of adverse events. Kendall-Gallagher and Blegen (2009) write that adverse events in intensive care units are not uncommon. Nurses’ ability to prevent, mitigate, and create adverse events is directly related to their level of knowledge, clinical expertise, and, eventually, clinical certification (Kendall-Gallagher & Blegen 2009). Therefore, achieving a bachelor’s degree in nursing is essential to ensure high quality of care and safety in intensive care units. Kendall-Gallagher and Blegen (2009) have found that the proportion of certified and educated registered nurses is inversely related to the frequency of falls and medication administration errors. Kendall-Gallagher and Blegen (2009) suggest that the level of education, coupled with the number of years of experience, is inversely related to the risks of urinary tract infections in ICU patients. These findings can become the starting point in the analysis of adverse events taking place in intensive care units. At the same time, it is possible to conclude that achieving a bachelor’s degree in nursing is vital for patients’ safety and survival in hospitals and other medical institutions. However, given the small sample sizes in most empirical studies, future research is needed to explain the variations in nurses’ education across hospital units and their impacts on the quality of nursing care.
A bachelor’s degree in nursing and nurses’ proficiency and skills
Needless to say, the fact that the level of nurses’ education impacts the quality and safety of nursing care also implies that educated nurses exercise better knowledge of the nursing profession and develop better professional abilities and skills. A vast body of literature was created to explore the impacts and implications of baccalaureate education on nurses. Generally, nurses with a bachelor’s degree and higher possess better information and computer literacy, ethical judgment, expertise and leadership capabilities, as well as motivation to continue formal education, compared to their colleagues without any formal degree. In a world characterized by the rapid advances in information technologies and science, nurses are expected to have skills and knowledge to deal with the growing amount and complexity of information (Barnard, Nash & O’Brien 2005). The level of nurses’ education is directly related to their information literacy, information processing, and decision making skills (Barnard et al. 2005). In many instances, achieving a bachelor’s degree in nursing is one of the best ways to structure nurses’ skills and knowledge around the principles of effective information use (Barnard et al. 2003). These skills, in turn, will create the basis for effective evidence-based practices by enabling nurses to successfully detect, appreciate, and apply relevant research findings in practice. Nurses without a bachelor’s degree have poorer decision making and critical thinking skills and can hardly use their knowledge to achieve better evidence-based patient outcomes (Insalacowarren & Ettamills 2009).
The level of practicing nurses’ education also plays a role in the way they handle computers and technologies in the workplace. Brumini et al. (2005) explored the link between nurses’ education and their attitudes towards computers. In a cross-sectional study conducted in several Croatian hospitals, Brumini et al. (2005) discovered that nurses with a bachelor’s degree generally displayed better attitudes towards computers and exercised better computer literacy skills, compared to their colleagues without any degree. Most probably, as the supply of brand-new software and hardware to hospitals will continue, achieving a bachelor’s degree will become the only way for nurses to develop advanced computer literacy and information management skills. Certainly, the fact that the study was limited to Croatian hospitals cannot be neglected, as the results of the study may not be applicable in other cultural environments. However, other researchers also confirm the relevance of baccalaureate education for nurses’ technical and computer skills. For instance, Pelletier (1995) suggests that diploma-prepared nurses experience greater comfort using professional technologies and equipment in the workplace, compared to nurses without a bachelor’s degree. Objectively, it is through baccalaureate education that nurses can prepare themselves to face the technical and information processing challenges that characterize today’s nursing profession.
The current state of research suggests that a bachelor’s degree for nurses is an important prerequisite for developing advanced ethical decision-making skills and professional expertise. Ethics education is one of the chief ingredients of baccalaureate education for nurses and other professions, and it greatly impacts the moral action of nurses in hospital environments (Grady et al. 2008). Grady et al. (2008) tried to trace the link between nursing education, its ethics components, and their implications for the quality of ethical and moral decision making in real-life healthcare environments. Not surprisingly, the researchers found that nurses with a bachelor’s or master’s degree and ethics education were much more confident in their moral reasoning skills and judgments than nurses without a degree and with no ethical education (Grady et al. 2008). Moreover, nurses with a bachelor’s or master’s degree and ethics education have better capabilities to locate available ethical resources and use these resources for timely moral action (Grady et al. 2008). Consequently, it would be fair to suggest that a bachelor’s degree for nurses is mandatory for their professional expertise. Given the importance of ethics in nursing care, only nurses with a bachelor’s degree can achieve and sustain a high level of ethical expertise and professionalism in their moral judgments and ethical relationships with patients and staff. This is, probably, why McHugh and Lake (2010) interpret the meaning of nurses’ clinical expertise through the prism of its two main components: nurse education and the hospital context in which nurses operate. After a detailed cross-sectional analysis of more than 8,000 registered nurses, McHugh and Lake (2010) concluded that nurses with at least a bachelor’s degree reported a more advanced expertise level. Unfortunately, the findings of the study are rather subjective and require further analysis and empirical validation. Yet, the fact that nurses cannot be experts in their profession without adequate education cannot be denied.
Nurses with at least a bachelor’s degree in their profession possess better leadership skills and greater motivation to continue formal education. In other words, baccalaureate education sets the stage for the development of truly professional nurse leaders with a strong motivation to pursue continuous education and learning throughout their professional career (Altmann 2012; Barnhill, McKillop & Aspinal 2012). As of today, one of the chief goals in the nursing profession is to develop a sustainable workforce with a minimum of 80 percent of baccalaureate-prepared registered nurses (Altmann 2012). This, in turn, will create an atmosphere that is favorable to continued formal education in nursing, because nurses’ attitudes towards formal education do not change with age but directly depend on the initial level of their professional education and their basic learning skills (Altmann 2012).
Nurses with a bachelor’s degree are more likely to become professional leaders, because baccalaureate education obligatory includes numerous learning activities, which support leadership training within and beyond the nursing profession (Heller et al. 2004). Based on everything stated above, baccalaureate education for nurses can be rightly considered as the source of major advantages for the entire nursing profession, patients, and the health care system. In light of the growing shortage of professional nurses and increased nursing workloads, achieving a bachelor’s degree can become the only way to reduce possible and real losses to the nursing profession (Bircumshaw & Chapman 1988).
Getting a bachelor’s degree in nursing: The dark side of the issue
The benefits of baccalaureate education for nurses have been abundantly documented. The results of this literature analysis suggest that nurses with at least a bachelor’s degree can reduce patient mortality, eliminate the risks of adverse events in intensive care units, enhance patient safety in hospital environments, and exercise better computer literacy and ethical decision-making skills. Baccalaureate-prepared nurses also possess better leadership skills and professional expertise, as well as higher motivation to continue formal education compared with their less educated colleagues. Unfortunately, little attention has been paid to the problems and gaps in nursing education. Only a few researchers discussed the main issues inherent in today’s nursing curriculums and the problems, which baccalaureate-prepared nurses encounter in their striving to make a fast and productive career.
It appears that baccalaureate education causes little changes in nurses’ values and attitudes towards their profession (Martin, Yarbrough & Alfred 2003). These results contradict to everything ever said by professional researchers about the benefits of baccalaureate education for nurses. However, the small sample size used by Martin et al. (2003) implies that the results of their study require further analysis. Moreover, and possibly, it is due to the existing gaps in curriculum organization and education quality that the researchers have failed to detect any difference in educated and non-educated nurses’ values. These problems were also discussed by Maxine Duke. Duke (2001) is particularly concerned about the lack of flexibility in the subjects offered to nurses who seek baccalaureate education. Some students are convinced that contemporary nursing curriculums do not let them utilize their previous knowledge (Duke 2001). Furthermore, there is “a statistically significant difference in the perceptions of nurses in acute health care agencies and faculty in BSN programs about the importance of entry-level competencies needed by BSN graduates” (King, Smith & Glenn 2003, p.179). Additionally, nurses with a bachelor’s degree are more likely to experience stress and burnout in the workplace, mainly because they are more sensitive to the situations that are nonbeneficial or futile to their patients (Meltzer & Huckabay 2004). Nevertheless, nurses without a formal degree are more likely to fail the basic professional standards than more educated nurses (Yigit et al. 2004). Thus, the main question to consider should be not whether it is worth obtaining a bachelor’s degree among nurses, but how to improve baccalaureate education in the nursing profession and make sure that the whole community benefits from it.
The importance of baccalaureate education in nursing remains one of the most popular topics in professional literature. Nevertheless, despite the growing amount of empirical literature, the relation between nurses’ education and the quality of nursing care remains poorly understood. The current state of research suggests that achieving a bachelor’s degree in nursing is one of the best ways to ensure the health, safety, and security of patients in hospital environments. A number of researchers confirmed that the growing proportion of baccalaureate-prepared nurses in hospitals leads to decreased patient mortality and reduces the risks of adverse events, especially, in surgical and intensive care units.
No less important is the contribution made by baccalaureate education to the development of nurses’ professional and decision making skills. The fact that nurses with a bachelor’s degree possess better information processing skills is well-known to the public. Furthermore, baccalaureate-prepared nurses hold more favorable attitudes towards the use of computer technologies and professional equipment in the workplace. Bearing in mind that ethics is a primary element of baccalaureate education in nursing, nurses with a bachelor’s degree and higher exercise a better ethical/moral decision making capacity than their colleagues without a formal degree. Other benefits of achieving a bachelor’s degree in nursing include better leadership skills, better professional expertise, as well as greater motivation to pursue formal education and continuous learning during the entire career.
Unfortunately, contemporary nursing science lacks theories that could explain the relationship between nurses’ education and the quality of their professional performance and patient outcomes. The findings of the empirical literature overemphasize the benefits of having a bachelor’s degree in nursing against the problems and barriers encountered by educated nurses in their profession. The latter include disappointment, stresses, and burnouts, as educated nurses become more sensitive to problems and situations that may lead to undesirable patient outcomes. Thus, the chief problem is not in whether achieving a bachelor’s degree is necessary for registered nurses but how to improve baccalaureate education in nursing and ensure that it benefits the society. Greater attention needs to be paid to the gaps and issues that are characteristic of nursing education today. Future researchers should focus on the analysis of nursing curriculums and provide recommendations to create a sustainable baccalaureate-prepared nursing workforce of the future. Larger samples, cross-cultural research methods, and the use of objective measurement criteria and scales will help create a better picture of baccalaureate education and its usefulness for the professionalism of nurses and the quality of nursing care.