A recent study has delivered new ammunition in the fights for mandatory minimum nursing education requirements and improvement in nurses' workplace satisfaction. The authors found that mechanically ventilated ICU patients-a group with one of the highest mortality rates-may be less likely to die within 30 days of their hospitalization if the nurses caring for them either have (at least) a bachelor of science in nursing (BSN) or report a better work environment.

In a cross-sectional analysis, researchers examined data related to 55,159 inpatients needing ventilation at 303 hospitals in California, Florida, Pennsylvania, and New Jersey. They focused on critical care nurse staffing (the average number of patients per shift), work environment (31 self-reported quality features, including staffing and resource adequacy, nurse-physician collegiality, and support of nurses), education (BSN or higher), and experience (average number of years worked in direct patient care). The researchers used patient demographics and hospital characteristics to control for mitigating factors such as patient age, hospital volume, and the presence of an intensivist-or critical care specialist-on staff.

There was little variation among hospitals with respect to ICU nurse-to-patient ratios-most had a ratio of one nurse to two patients-but the data revealed significant variability in the proportions of ICU nurses with BSNs (from zero to 100%) among hospitals. Each 10-point increase in a hospital's percentage of ICU nurses with BSNs brought about a 2% decrease in patient deaths. This suggests that hospitals with 75% of ICU nurses holding BSNs would have a 10% lower patient mortality rate than hospitals that had 25% of nurses holding BSNs. Work environments rated as "better" (24% of respondents) were associated with an 11% decrease in mortality, compared with those rated as "mixed" (49% of respondents).

The authors argue that comparatively minimal investments by hospitals to advance nurses' education and improve workplace satisfaction make clinical and economic sense. And the lack of significant associations between mortality and ICU nurse-to-patient ratio or nurses' years of experience is consistent with "prior evidence that experience may not be a substitute for education."-Sibyl Shalo Wilmont, BSN, RN

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