By Debra L Beck

Patients have a greater chance of surviving in-hospital cardiac arrest with good neurologic function at hospitals with a higher proportion of nurses with bachelor of science in nursing (BSN) degrees, suggests an analysis published in July.

For every 10-percentage-point increase in the number of nurses with a BSN degree, there was a significant 24% greater odds of survival with good cognitive function at the study's participating hospitals, after adjustment for patient, event, and hospital characteristics.

"Investing in human capital, including nursing resources, is part of organizational transformation to reduce harm and improve patient outcomes, particularly in emergency situations like cardiac arrest," said lead author Jordan M. Harrison, PhD, RN.

Having better-trained nurses in hospitals "may allow for more opportunity to recognize patient deterioration before cardiac arrest, along with effective response once an arrest has happened, minimizing the potential for neurological injury," said Harrison, a health services researcher from the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia.

About 200,000 in-hospital cardiac arrests occur in the United States each year, but this is the first study to address the correlation between nurse educational qualifications and cardiac arrest outcomes, she and her colleagues write.

Interestingly, the researchers found no significant association between nurse education level and survival to discharge when neurologic function was not considered.

Patient-to-Nurse Ratio

In another finding, for each additional patient per nurse, there was a 17% lower odds of survival to discharge with good neurologic function, and a 16% lower odds of surviving to discharge regardless of neurologic status (P < .05 for both).

The study population consisted of 11,123 patients at 36 hospitals in California, Florida, New Jersey, and Pennsylvania that participated in all of three surveys and registries: the American Heart Association's Get With the Guidelines–Resuscitation (GWTG-R) registry for 2013 to 2018; the RN4CAST-US hospital nurse survey covering 2015 and 2016; and the American Hospital Association's 2015 Annual Survey.

Across the datasets, the proportion of nurses in each hospital with a BSN ranged from 33% to 86%, with a mean of 61%. The patient-to-nurse ratios on general floors ranged from 2.8 to 6.6 patients per nurse, with a mean of 4.7.

Overall, 11.2% of patients survived cardiac arrest to discharge with good cerebral performance (cerebral performance category 1), 7.1% survived to discharge but with neurologic disability (CPC 2–4, indicating moderate or severe cerebral performance or coma or vegetative state), and 81.7% did not survive to discharge.

The majority of arrests were monitored (89%), were witnessed (87%), and occurred in the intensive care unit (70%).

"It's not easy to document what nurses bring to the table in many cases, and this study is wonderful in that it combined data from three datasets to gain a better understanding of an important clinical issue," said Eileen M. Handberg, PhD, ARNP-BC. Handberg directs the cardiovascular clinical trials program at the University of Florida College of Medicine in Gainesville.

Ramping Up to Recommended Levels

Based on research indicating that a more highly educated nursing staff is associated with better outcomes, the Institute of Medicine recommended in 2010 that at least 80% of nurses in the nurse workforce should have a BSN by 2020, the authors observe

Harrison estimated that currently about 55% of nurse in the United States have such degrees. "I don't think we'll get to 80% by 2020. This is partly a regional issue, in that in more rural areas, there is a lower supply of bachelor-prepared nurses. But there has been a large increase in the proportion of nurses who have a BSN because many hospitals are preferentially hiring bachelor-prepared nurses," said Harrison.

Added Handberg: "There really aren't enough BSN programs currently to accommodate everyone who wants to get one, so I think the call from this research is not just a call to the hospital system to increase the number of BSNs they hire, it's also a call to colleges and state legislatures that provide funding that we need seats available in colleges of nursing BSN programs."

It's also important to understand the differences between people who opt to get a 4-year degree and those who do an associate degree in nursing, Handberg said.

"When I went to nursing school, there were people who didn't have the grades to get into nursing school or didn't want to go for other reasons, and instead chose to do an associate program at the community college, and they are fabulous nurses."

The study was cross-sectional, so cause-and-effect can't be inferred, and there may be differences between hospitals that participated in the surveys and registries and those that didn't.

"What we don't know is what the impact of nursing education is in other settings, like outpatient and long-term care, where — especially in the case of long-term care — there is a nursing shortage and those jobs pay less. So it would be interesting to see how this might play out in other settings," Harrison said.