The Institute of Medicine (IOM) has called for 80% of the nursing workforce to hold at least a bachelor of science in nursing (BSN) by the year 2020, but a 2008 national survey of RNs showed that only 45% of U.S. nurses held a nursing baccalaureate. Recognizing that policymakers needed stronger evidence to support such a dramatic increase in education requirements, researchers analyzed 1999 and 2006 nurse-survey and patient-discharge data from Pennsylvania acute care hospitals. What they found was unequivocal: a 10% greater proportion of nurses who have BSNs was associated with an average reduction of 2.12 deaths per 1,000 surgical patients and an average reduction of 7.47 instances of failure to rescue per 1,000 patients.

The authors estimated that if all of the hospitals in the study had increased their BSN proportion by 10%, some 500 deaths might have been prevented among general, orthopedic, and vascular surgery patients. Assuming a linear decrease in deaths as the proportion of BSNs climbed, the authors estimated that had BSN levels been at the recommended 80% at all of the hospitals, some 2,100 (60%) of the deaths that occurred in 2006 could have been prevented.

According to Linda H. Aiken, a coauthor of the study and the Claire M. Fagin Leadership Professor in Nursing at the University of Pennsylvania in Philadelphia, these findings could have a big impact on hospitals that are feeling the pressure to get good value for their investments. "They can do it through preferential hiring, so it's low cost but has huge benefits," she says. And nurses seem to be on board with the change. The proportion of nurses with baccalaureates is increasing faster than in past decades.

Length really does matter. A second study (also coauthored by Aiken), which examined shift length and scheduling among more than 22,000 RNs, found that nurses working extended shifts (10 hours or longer) had significantly greater odds of reporting poor quality and safety on their units than nurses working eight or nine hours. The odds were more than two times greater among those working the longest shifts (over 13 hours).

Despite the IOM's recommendation in 2003 that nurses not work longer than 12 hours per day, in fewer than half of hospitals did all nurses report having worked less than 13 hours on their most recent shift. Interestingly, even the nurses working the longest shifts reported being satisfied with their schedules-despite their own reports of poorer care quality and safety.

"The shift issue is a paradox," says Aiken. "Long shifts are popular with nurses, but outcomes aren't very good and there is significantly higher burnout."

Although the momentum is clearly moving toward BSN hiring, building the same momentum toward shorter shifts will take some cultural change.

"This is a longer conversation that nurses are going to have to have," says Aiken. "External forces might step in and regulate hours if nurses don't limit their hours themselves."-Laura Wallis

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