Recent Trends in Baccalaureate-Prepared Registered Nurses in U.S. Acute Care Hospital Units, 2004–2013: A Longitudinal Study

Recent Trends in Baccalaureate-Prepared Registered Nurses in U.S. Acute Care Hospital Units, 2004–2013: A Longitudinal Study
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First published: 9 October 2017Full publication history
DOI: 10.1111/jnu.12347 View/save citation
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Purpose

To examine the trends in baccalaureate (bachelor of science in nursing)–prepared registered nurses (BSN RNs) in U.S. acute care hospital units and to project the growth in the number of BSN RNs by 2020.
Design

This is a longitudinal study using the Registered Nurse Education Indicators data (2004–2013) from the National Database of Nursing Quality Indicators.
Methods

The level of BSN RNs in each unit was operationalized as the proportion of nurses holding a baccalaureate degree or higher among all the nurses in a unit. Our sample included 12,194 unit-years from 2,126 units of six cohorts in 377 U.S. acute care hospitals. A hierarchical linear regression model was used to examine the trends in BSN RNs and to project future growth in the number of BSN RNs when controlling for hospital and unit characteristics and considering repeated measures in units over time and clustering of units within hospitals.
Results

The proportion of BSN RNs in U.S. acute care hospital units increased from 44% in 2004 to 57% in 2013 (a 30% increase); when combining all cohorts, this rate increased from 44% in 2009 to 51% in 2013. On average, the proportion of BSN RNs in a unit increased by 1.3% annually before 2010 and by 1.9% each year from 2010 on. The percentage of units having at least 80% of their nurses with a baccalaureate degree or higher increased from 3% in 2009 to 7% in 2013. Based on the current trends, 64% of the nurses working in a hospital unit will have a baccalaureate degree by 2020, and 22% of the units will reach the 80% goal by 2020.
Conclusions

There was a significant increase in the proportion of BSN RNs in U.S. acute care hospital units over the past decade, particularly after 2010. However, given the current trends, it is unlikely that the goal of 80% nurses with a baccalaureate degree will be achieved by 2020.
Clinical Relevance

The U.S. nursing workforce is under educational transformation in order to meet the increasing healthcare needs. To help accelerate this transformation, further advocacy, commitment, and investment are needed from all healthcare stakeholders (e.g., policymakers, executives and managers of healthcare facilities, nursing schools, etc.).

Nurses compose the largest healthcare workforce in the United States. There were 2.75 million registered nurses (RNs) working in healthcare settings in 2014, of whom 61% (or over 1.6 million) worked in hospitals (Bureau of Labor Statistics, 2015). Given the dramatic changes within the U.S. healthcare system, such as the aging of the baby boomers and the expansion of health insurance coverage (Department of Health and Human Services, 2015; Garfield, Damico, Cox, Claxton, & Levitt, 2016), nurses will likely have an even greater role in improving quality of care and patient outcomes (National Academies of Sciences, Engineering, and Medicine, 2015). Consequently, it is critical to build a competent nursing workforce to meet the increasing and complex healthcare needs in the United States.

One strategy for preparing a competent nursing workforce is to advance nurse education, particularly by promoting the number of baccalaureate (bachelor of science in nursing)–prepared registered nurses (BSN RNs). Increasing evidence has demonstrated that higher nurse education is associated with better quality of care and patient outcomes (Aiken et al., 2014; McHugh & Ma, 2013). In a seminal study of 168 U.S. general acute care hospitals with 232,342 surgical patients, the researchers found that hospitals with higher proportions of nurses holding a baccalaureate degree (BSN) or higher had significantly lower surgical patient mortality and failure-to-rescue (Aiken, Clarke, Cheung, Sloane, & Silber, 2003). This study was replicated in the United States with more recent data of 665 hospitals and 1.3 million patients (Aiken et al., 2011) and internationally with similar results (Aiken et al.,2014; Ridley, 2008; Van den Heede et al., 2009). The linkage between higher proportion of BSN RNs and lower mortality rates has been further supported by findings from a panel study of 134 hospitals over time (1999–2006; Kutney-Lee, Sloane, & Aiken, 2013). Further complementing the results of large-scale studies, a detailed study of the dose response of care by BSN RNs in a single large U.S. hospital showed that better patient outcomes were associated with more hours of patient care by BSN RNs; and the hospital could financially benefit from hiring more BSN RNs (Yakusheva, Lindrooth, & Weiss, 2014).

Acting on the basis of growing evidence of a linkage between more BSN RNs and better patient outcomes, the Institute of Medicine (IOM) recommended in its milestone report, The Future of Nursing: Leading Change, Advancing Health, that 80% of U.S. RNs should have at least a baccalaureate degree in nursing by 2020 (80/20 goal; IOM, 2011). This recommendation was immediately supported, for the first time in history, by the Tri-Council, an alliance between the main nursing organizations in the United States, including the American Association of Colleges of Nursing, the American Nurses Association, the American Organization of Nurse Executives, and the National League for Nursing (Tri-Council of Nursing, n.d.). Since the report was released, a variety of initiatives (e.g., The Future of Nursing: Campaign for Action) have been carried out to achieve this 80/20 goal, and some changes have been noted. A 2014 survey of nursing schools by the American Association of Colleges of Nursing (AACN) indicated a 4.2% enrollment growth in entry-level baccalaureate programs and a 10.4% increase in “RN-to-BSN” programs for RNs with associate degrees or diplomas from 2013–2014 (AACN, 2015).

While there is mounting evidence demonstrating the significance of promoting baccalaureate education for nurses, empirical evidence illustrating the recent trends in BSN RNs in clinical settings over time is rare. Such evidence is critical for a better understanding of the ongoing educational transformation of the nursing workforce. To address the gap, the purpose of this study was twofold: (a) to illustrate the recent trends in BSN RNs using unit-level data (2004–2013) of U.S. acute care hospitals from a national database; and (b) to estimate whether the 80/20 goal is achievable based upon the current trend and, if not, how far away from it we remain.
Methods
Data and Sample

This was a longitudinal study using the Registered Nurse Education Indicators data (2004–2013) from the National Database of Nursing Quality Indicators (NDNQI). The NDNQI was founded in 1998 by the American Nursing Association with the mission of aiding nurses in efforts to improve care quality and patient safety and has been owned by Press Ganey, Inc. since 2014 (Montalvo, 2007). The NDNQI is a national nursing quality measurement data repository in the United States that enables researchers to compare the quality of hospital nursing and nursing-sensitive patient outcomes at the unit level. Over 2,000 hospitals nationwide were submitting nursing and patient outcomes data to the NDNQI by 2014.

One of the NDNQI's endeavors is to collect data on nurses’ education (RN education indicator) at the unit level from NDNQI member hospitals. RN education data in each eligible unit were collected by trained nursing staff in NDNQI member hospitals and reported quarterly to the NDNQI. Submitted information includes the number of eligible RNs on a unit and the number of RNs at each educational level (i.e., diploma, associate degree, bachelor's degree, master's degree, and doctorate degree). For nurses with multiple degrees, only the highest nursing degree is counted. RNs (full-time, part-time, and per-diem RNs) are eligible for this report if they were unit based, with direct patient care responsibilities for at least 50% of their time, and listed on the staffing roster during the reporting quarter. RNs who were on temporary vocational or medical leave were included, too. However, RNs were excluded if they were contract or agency nurses or not assigned to a specific unit.

In this study, the unit of analysis was the unit-year. We annualized the proportion of BSN RNs across quarters in each year from 2004 to 2013 for each unit. To be included in this study, units must have at least three quarters of RN education data in each year; units must also have at least 5 consecutive years of RN education data to ensure a sufficient amount of data for modeling time trends and projections. Units were categorized into different cohorts based on the first year a unit submitted data to the NDNQI. For example, cohort 2004 included units that submitted three or four quarters of data each year since 2004 and until 2013. In total, there were six unit cohorts (cohorts 04, 05, 06, 07, 08, and 09).

An advantage of the NDNQI database is that units are consistently and systematically classified into a certain type based on the patient population, type of care provided, and patient acuity level. This enables comparative analysis of units across hospitals. For this study, we included five adult unit types: critical care, step-down, medical, surgical, and medical-surgical combined. These units represent the vast majority of adult units reporting data to the NDNQI. They also are the most common units within acute care hospitals. The final analytic dataset consisted of 12,194 unit-years from 2,126 units in 377 acute care hospitals.
Variables

Unit BSN RNs. The level of BSN RNs in each unit was operationalized as the proportion of RNs holding a baccalaureate degree or higher among all the RNs in a unit. A time variable (named t) was generated to reflect the numbers of years from the baseline year, which varied by cohorts. A dummy variable named flag was also created to indicate whether a year was before or after 2010 (i.e., flag = 0 before 2010, flag = 1 from 2010 on). This variable was used to compare time trends before and after the release of The Future of Nursing report.
Covariates

Hospital- and unit-level characteristics at baseline were included as covariates. Hospital-level covariates were ownership, bed size, teaching status, Magnet status, and geographic location. Hospital ownership was categorized as nonprofit, profit, or government-owned. Hospital size was measured by the number of staffed beds and grouped into two categories (small, ≤299 beds; large, ≥300 beds). Teaching status was classified as teaching and nonteaching. Hospitals were also identified based on their Magnet status. Given the geographic locations, hospitals were classified as those located in the metropolitan area versus those out of metropolitan areas. A unit-level variable indicating unit type was included, too.
Analysis

Baseline characteristics (both hospital- and unit-level) were described first for each cohort. Levels of BSN RNs were then described for each cohort by unit type. BSN RN levels were plotted to show visually how the proportion of BSN RNs changed over time. Given the complex data structure that units clustered within hospitals and measures were repeated within units over time, a three-level hierarchical linear regression model was employed to examine whether there was a difference in the trends of growth in the number of BSN RNs before and after the release of the IOM's Future of Nursing report, when controlling for baseline hospital and unit characteristics. Random intercepts at both hospital and unit level were included to account for the cluster of units within hospitals and repeated measures within units. Our preliminary analysis suggested no significant differences in the overall trends by unit cohort. Therefore, regression models were conducted across all cohorts. Finally, based on the estimates of current trends in the growth in the number of BSN RNs from the above model, we projected the level of BSN RNs by 2020 and compared it with the recommended 80% goal.
Results

Table 1 describes the hospital- and unit-level characteristics at baseline. Of the 2,126 units, there were 547 (25.7%) critical care units, 299 (14.1%) step-down units, 426 (20.0%) medical units, 335 (15.8%) surgical units, and 519 (24.4%) medical-surgical combined units. These units were from 377 acute care hospitals, of which the majority were nonprofit (88.3%) and located in metropolitan areas (87.0%), 47.1% were teaching hospitals, 29.2% had at least 300 beds, and 7.7% were Magnet hospitals. There were some differences in hospital characteristics at baseline across cohort, such as hospital size, teaching status, and Magnet status.
Table 1. Hospital Characteristics and Unit Types at Baseline
Cohort
2004 2005 2006 2007 2008 2009 Overall

Note. A cohort was defined based on the first year that units submitted nurse education data to the National Database of Nursing Quality Indicators (NDNQI). For example, cohort 2004 includes units that submitted nurse education data to the NDNQI since 2004.

Hospital characteristics
Ownership
Nonprofit 59 (88.1%) 59 (91.9%) 67 (93.1%) 47 (97.9%) 45 (86.2%) 56 (88.3%) 333 (88.3%)
Profit 3 (4.5%) 0 3 (4.2%) 0 4 (7.6%) 5 (7.7%) 15 (4.0%)
Government-owned 5 (7.5%) 13 (18.1%) 2 (2.8%) 1 (2.1%) 4 (7.6%) 4 (6.2%) 29 (7.7%)
Bed size (≥ 300 beds) 27 (40.3%) 21 (29.2%) 21 (29.2%) 8 (16.8%) 14 (26.4%) 19 (29.2%) 110 (29.2%)
Teaching hospitals 34 (50.8%) 31 (43.1%) 35 (48.6%) 17 (35.4%) 22 (41.5%) 23 (35.4%) 162 (43.0%)
Location (metro area) 61 (91.1%) 63 (87.5%) 63 (87.5%) 42 (87.5%) 46 (86.8%) 53 (81.5%) 328 (87.0%)
Magnet hospitals 13 (19.4%) 3 (4.2%) 3 (4.2%) 2 (4.2%) 3 (5.7%) 5 (7.8%) 346 (91.8%)
Unit characteristics
Unit types
Critical care 113 (30.6%) 93 (25.4%) 115 (27.3%) 59 (22.5%) 63 (22.4%) 104 (24.4%) 547 (25.7%)
Step-down 52 (14.1%) 48 (13.1%) 54 (12.8%) 34 (13.0%) 40 (14.2%) 71 (16.7%) 299 (14.1%)
Medical 65 (17.6%) 79 (21.6%) 89 (21.1%) 57 (21.8%) 54 (19.22%) 82 (19.3%) 426 (20.0%)
Surgical 55 (14.9%) 58 (15.9%) 62 (14.7%) 42 (16.0%) 55 (19.6%) 63 (14.8%) 335 (15.8%)
Medical-surgical combined 84 (22.8%) 88 (24.0%) 102 (24.2%) 70 (26.7%) 69 (24.6%) 106 (24.9%) 519 (24.4%)

Table 2 presents the unit percentage of BSN RNs at the baseline year for each cohort by unit type. Overall, the percentage of BSN RNs at baseline slightly varied by cohort from 36% (cohort 2005) to 44% (cohort 2004). In each cohort, the percentage of BSN RNs varied by unit types, and critical care units had the highest levels of RNs holding bachelor's degrees or above at baseline. For example, in cohort 2004, the percentage of RNs holding a baccalaureate degree varied from 49% in critical care units to 36% in medical-surgical combined units.
Table 2. Unit Levels of BSN RNs (% of BSN RNs) at Baseline by Unit Types
Cohort, mean % (SD)
2004 2005 2006 2007 2008 2009

Note. BSN = bachelor of science in nursing; RN = registered nurse.

Overall (all units) 44.2 (19.4) 36.0 (17.9) 40.4 (17.5) 40.2 (19.5) 41.6 (19.8) 42.7 (18.1)
Critical care units 49.3 (19.3) 44.4 (16.5) 46.5 (17.4) 47.0 (18.5) 50.2 (18.5) 51.8 (17.2)
Step-down units 45.9 (21.0) 37.5 (20.7) 40.2 (17.4) 41.3 (17.5) 36.5 (18.5) 40.3 (18.0)
Medical units 46.5 (18.3) 35.8 (17.4) 37.6 (16.8) 35.5 (17.0) 39.5 (20.6) 40.9 (16.1)
Surgical units 42.9 (19.2) 33.5 17.6) 41.1 (17.3) 37.9 (21.1) 37.3 (18.9) 41.2 (16.5)
Medical-surgical combined units 35.5 (16.8) 28.3 (14.3) 35.8 (17.6) 39.2 (21.0) 41.8 (19.6) 37.8 (18.8)

Figure 1 (also shown in Table S1) illustrates the trends in BSN RNs at the unit level in each cohort from 2004 to 2013. The percentages of BSN RNs increased significantly over time in all cohorts. For example, for units in cohort 2004, the percentage of BSN RNs increased by approximately 30% from 44% in 2004 to 57% in 2013. Despite the differences in percentages of BSN RNs at the baseline years, our preliminary analyses (see Figure 1) indicated that there were no significant cohort differences in the trends in BSN RNs.
Figure 1.
Figure 1.

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Unit percentage of registered nurses (RNs) holding a bachelor's degree or above. BSN = bachelor of science in nursing.

We also analyzed the proportion of units with ≥50% and ≥80% BSN RNs (Table S2). Overall, the percentage of units with ≥50% nurses with a BSN degree increased from 35% in 2009 to 52% in 2013 (a 47% increase); the percentage of units with ≥80% nurses with a BSN degree increased from 3% in 2009 to 7% in 2013 (a 73% increase). Although critical care units had the highest proportion of units with ≥50% nurses with a BSN degree in 2009, it had the lowest increase rate from 2009 to 2013. Medical-surgical combined units had the highest rate of increase (150%) in the proportion of units with ≥80% BSN RNs, from 2% in 2009 to 5% in 2013; and surgical units had the lowest rate of increase (55%) in the proportion of units with ≥80% BSN RNs, from 3.28% in 2009 to 5% in 2013.

Table 3 shows estimates of the differences in trends in BSN RNs before and after 2010 when controlling for hospital and unit characteristics at baseline. There was a significant difference in trends in BSN RNs before and after 2010 as indicated by the interaction term (coefficient = 0.63, p = .000). On average, the proportion of BSN RNs increased by 1.3% annually in the years before 2010; and it increased by 1.9% each year after 2010. In other words, the average increasing rate after 2010 was 1.5 times the rate in years before 2010.
Table 3. Trends in Growth in the Number of BSN RNs Before and After 2010
Coefficient p 95% confidence interval

Note. The interaction is between the numbers of years from baseline year (each cohort had different baseline years) and the variable indicating whether a year is before 2010 or not (variable = 0 if it is before 2010, and variable = 1 from 2010 on); therefore, the coefficient for the annual increase in the proportion of BSN RNs for years from 2010 on is 1.90 (1.27 + 0.63). BSN = bachelor of science in nursing; RN = registered nurse.

Years from baseline year (t) 1.27 .000 1.13 to 1.40
Years from 2010 when current year ≥2010 (interaction term) 0.63 .000 0.40 to 0.86
Cohort 2004 (reference group)
Cohort 2005 −1.23 .334 −3.72 to 1.26
Cohort 2006 0.40 .755 −2.10 to 2.89
Cohort 2007 1.00 .472 −1.73 to 3.73
Cohort 2008 2.98 .032 0.26 to 5.69
Cohort 2009 3.69 .008 0.97 to 6.40
Critical care (reference group)
Step-down −7.63 .000 −8.92 to −6.34
Medical −11.19 .000 −12.37 to −10.02
Surgical −12.17 .000 −13.43 to −10.92
Medical-surgical combined −10.98 .000 −12.13 to −9.82
Non-Magnet (reference group)
Magnet 1.63 .236 −1.07 to 4.32
Nonprofit
Profit −3.59 .334 −10.88 to 3.70
Government-owned −1.59 .561 −6.96 to 3.78
Small hospital (≤299 beds)
Large hospital (>300 beds) 1.80 .227 −1.12 to 4.72
Nonteaching hospital
Teaching hospital 7.40 .000 4.40 to 10.39
Nonmetro area
Metro area 10.61 .000 6.06 to 15.15

Table 4 presents the estimates of proportion of BSN RNs in the future based upon the current trends, both overall (all units) and by unit types. By 2020 there will be a projected 64% RNs that provide direct patient care holding at least a BSN degree; critical care units would have the highest proportion of BSN RNs (72%), whereas medical-surgical combined would have the lowest (60%). The 80% goal will not be reached until at least 2029 (81%); critical care units will likely be the first to reach the 80% goal by 2025, and by 2031 units of all types will achieve the 80% goal. In general, 22% of the units in this study will reach the 80% goal by 2020 and 57% of the units will reach the goal by 2023 (Table S3). Table S3 also displays the predicted proportion of units with ≥50% and ≥80% nurses with a BSN degree by 2020, 2025, and 2030.
Table 4. Projections of Proportion of BSN RNs
% of BSN RNs
By 2020 By 2025 By 2026 By 2027 By 2028 By 2029 By 2030

Note. BSN = bachelor of science in nursing; RN = registered nurse.

Overall 64.40 73.88 75.78 77.67 79.57 81.47 83.36
Critical care units 71.64 81.12 83.02 84.91 86.81 88.71 90.60
Step-down units 63.63 73.11 75.01 76.91 78.80 80.70 82.60
Medical units 63.78 73.26 75.16 77.05 78.95 80.85 82.74
Surgical units 61.00 70.48 72.38 74.27 76.17 78.07 79.96
Medical-surgical combined units 59.93 69.41 71.31 73.21 75.10 77.00 78.90
Discussion

In this study, we examined the recent trends in BSN RNs in U.S. acute care hospital units between 2004 and 2013 using data from a national nursing quality database. Our findings provide empirical evidence illustrating the ongoing educational transformation of the nursing workforce, particularly in hospital care settings.

Our study shows that there is a consistent increase in the proportion of BSN RNs in acute care hospital units, and this increase appears to have begun several years before the 2010 IOM report of The Future of Nursing was released. In our study, for example, we found that in cohort 2004 approximately 44% of the nurses providing direct patient care on a unit had BSN degrees in 2004, and this number reached 57% in 2013; across cohorts, 51% of RNs held a baccalaureate degree or higher in 2013. Our finding is similar to that of the National Sample Survey of Registered Nurses (NSSRN). The NSSRN is a national survey conducted by the Health Resources and Services Administration (HRSA) between 1977 and 2008 and aimed at examining the characteristics of U.S. registered nurses. Data from the NSSRN indicated that approximately 45% and 50% of the RNs held a bachelor's degree or higher in 2004 and 2008, respectively (HRSA, n.d.). Data from the National Nursing Workforce Survey showed that there were about 61% RNs holding a baccalaureate or higher degree (Budden, Zhong, Moulton, & Cimiotti, 2013). Using data from the Integrated Post-Secondary Education System, Buerhaus, Auerbach, and Staiger (2016) estimated that the proportion of nursing graduates with baccalaureate degrees increased from 45% in 2002 to 53% in 2012; in 2011, there were more BSN graduates than associate degree in nursing (ADN) graduates for the first time. Despite slight differences in the estimates of proportion of BSN RNs, which are mainly due to the different sampling strategies employed in each study, a common theme of a consistent and significant increase in the proportion of BSN RNs is conclusive across studies.

Our findings also suggest that the increase in the proportion of BSN RNs in acute care hospital units accelerated from 2010 on. In our sample, we found that on average the proportion of BSN RNs on a unit increased by 1.3% annually before 2010 and 1.9% annually in 2010 and after. In 2010, the IOM published the milestone report of The Future of Nursing. Although we cannot claim a causal relation between the publication of this report and the accelerated increase in the number of BSN RNs, our finding does suggest that the publication of The Future of Nursing report may have contributed to this change. This report has drawn extensive media coverage that raised national attention to improving nurse education nationwide and resulted in various initiatives nationwide for promoting nurse education. For example, shortly after the report was published, the American Association of Retired Persons and the Robert Wood Johnson Foundation jointly initiated the Future of Nursing: Campaign for Action. One of its aims is to promote more efficient articulation between associate degree and baccalaureate nursing programs and help state action coalitions develop local and regional strategies to increase the number of nurses with BSNs (Campaign for Action, n.d.). Another example is the Magnet Designation Program, which recognizes healthcare organizations for high-quality patient care, excellent nursing practice, and innovations in professional nursing practices. It now requires hospital applicants to provide evidence documenting progress or effort toward achieving a nursing workforce of 80% BSNs. In addition, hospitals also show increasing and strong preference in hiring BSN RNs (AACN, 2016; Bates, Chu, & Spetz, 2016), and nursing schools have demonstrated their commitment by implementing new models to educate more BSN RNs (Close & Orlowski 2015; Gaines & Spencer 2013). These changes well demonstrate the influence of national initiatives on nursing workforce development.

Despite the consistent and significant increase in the proportion of BSN RNs, our findings suggest that the goal of 80% BSN RNs by 2020 is unlikely to be achieved in acute care hospitals. Based on the current trend, our estimates indicate that it will be 2029 that 80% of hospital RNs will be BSN prepared, and that nurses on critical care units will reach this 80% goal first (by 2025), compared to other unit types. There are many reasons that challenge the achievement of this 80/20 national goal. One of them is the shortage of faculty and other resource constraints of nursing schools to enroll more BSN students. According to the AACN, there was a nurse faculty vacancy rate of 8.3% nationwide in 2013; 79,659 qualified applicants were turned away from nursing baccalaureate and graduate programs in 2012; on average, doctoral-prepared and master's degree–prepared nurse faculty holding title of “professor” were 61 and 57 years old, respectively (AACN, n.d.). The small difference in wage premium of BSN RNs and ADN or Diploma RNs also discourage AND or Diploma RNs from pursuing a baccalaureate degree (Spetz & Bates, 2013). In addition, some hospital executives and administrators are reluctant to invest more money and resources to hire BSN RNs. However, researchers have estimated that, in addition to better quality of care and patient outcomes, increasing BSN RNs can be cost saving by improving patient outcomes such as reducing readmissions (Yakusheva et al., 2014).

Findings from our study have several implications for accelerating the progress of achieving the goal of 80% of RNs holding a baccalaureate degree. First, further efforts are needed to promote national recognition of the importance of advancing nursing education in health care, as well as policy and financial support from federal, state, and local government. Both findings from our study and previous research have suggested that such support can have a significant impact on the transformation of the nursing workforce (Aiken, Cheung, & Olds, 2009). Second, administrators in hospitals and other healthcare facilities should commit to more investment in hiring BSN RNs or support employed AND or Diploma RNs to obtain a baccalaureate degree. Researchers have shown that RN-to-BSN is the fastest growth pathway for RNs to obtain a baccalaureate degree (e.g., a 10% increase from 2013 to 2014) (AACN, 2015). It was also found that in hospitals that provided tuition and other benefits (e.g., more flexibility in scheduling) or value and respect higher nursing education, RNs were more likely to enroll in RN-to-BSN programs (Spetz & Bates, 2013). Last but not least, researchers need to provide more evidence demonstrating the business case of having more BSN RNs providing care to patients.

Our study has some limitations. Although the NDNQI collects data from a large sample of hospitals nationwide, participation of hospitals in NDNQI data submission is voluntary. Therefore, hospitals with certain characteristics may be overrepresented or underrepresented. Specifically, there are a higher proportion of large (>300 beds) and not-for-profit hospitals in our sample, when compared to 2011 American Hospital Association data (Choi, Boyle, & Dunton, 2014). In addition, only data from NDNQI-affiliated hospitals were used; thus, one should be cautious when generalizing the results from this study to other hospitals or other healthcare settings (e.g., nursing homes, rehabilitation centers, and home care agencies). Our projections of the proportion of BSN RNs in acute care hospital units were based on the current trends; thus, it is conservative.
Conclusions

To our knowledge, this is the first longitudinal study using unit-level data from hospitals nationwide to examine the trends in BSN RNs over a decade (2004–2013). Our findings provide unique insights into the current ongoing educational transformation of the nursing workforce. Despite the significant increase in BSN RNs, results from our study suggest that further efforts and commitment from healthcare stakeholders (e.g., policymakers, executives and managers of healthcare facilities, nursing schools, etc.) are needed to advance nursing education and promote the use of BSN RNs, which in turn will result in superior quality of care and better patient outcomes as researchers have suggested.
Acknowledgments

We would like to thank Dr. Nancy Dunton and Dr. Emily Cramer for their support to this project, and Press Ganey, Inc. for providing access to NDNQI data.

This research reflects the views of the authors and should not be construed to represent the views or policies of the U.S. Food and Drug Administration. Dr. Lili Garrard completed this work as a statistical analyst at the National Database of Nursing Quality Indicators.
Clinical Resources

American Association of Colleges of Nursing. Advancing healthcare transformation: A new era for academic nursing. http://www.aacn.nche.edu/AACN-Manatt-Report.pdf
Campaign for Action. The future of nursing: Campaign for action. http://campaignforaction.org/
Institute of Medicine. The future of nursing: Leading change, advancing health. http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

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Volume 50, Issue 1
January 2018
Pages 83–91
PROFESSION AND SOCIETY