Degree level education in nursing – time to move the discussion on.

Dr David Barrett, Director of Pre-Registration Nurse Education, Faculty of Health and Social Care, University of Hull

There is now an established body of evidence that in any given clinical setting, the greater the proportion of Registered Nurses (RNs) with graduate-level education, the better the patient outcomes. In one of the most far-reaching, comprehensive and robust studies in this area, Aiken et al (2014) found that a 10% increase in Bachelor’s Degree-educated nurses in the RN skill mix was associated with a 7% reduction in 30-day inpatient mortality. A recent systematic review and meta-analysis supported this finding, establishing that a 10% increase in the proportion of nurses with Bachelor degrees was associated with a 6% reduction in overall mortality (Liao et al, 2016). There is also evidence to suggest that increasing the proportion of graduate nurses is linked with shorter length of stay and reduced incidence of complications such as venous thromboembolism (Blegen et al, 2013).

Though findings such as this tend to focus on Western healthcare and relate largely to the care of surgical patients (Liao et al, 2016), the conclusion reached is clear: more nurses with degree-level education leads to better patient outcomes. However, there has been little consideration of the crucial follow-up question: why does a greater proportion of degree-level nurses improve patient outcomes?


Whenever any intervention in healthcare has an impact on patient outcomes, it is not enough to simply accept that fact; identifying the mechanism of action is equally important. By doing so, it is possible to establish the effective characteristics of the intervention and use them to replicate benefits. For some interventions linked to the nursing workforce, the mechanisms are clear: we know that decreasing the ratio of patients to RNs in a clinical area improves patient outcomes (Aiken et al, 2014). The mechanism of action there is straightforward – the fewer patients a nurse has to care for, the more time they can devote to each.

The impact of degree-level education on patient outcomes is more difficult to explain. RNs without degrees are no less caring, compassionate, competent or committed than graduates. The mechanism of benefit must therefore be either organisational and/or educational. It is possible that organisations or clinical settings that seek to employ degree-educated nurses do so as a reflection of a broader ethos that values education. These organisations might recognise that celebrating and supporting educational achievement in all their staff is a method of motivating and retaining high-quality employees – this ethos may underpin better performance and better outcomes.

Equally, the improved outcomes linked with degree-level nurses may stem from their educational preparation. If there is an area where degree-level nurses are better prepared educationally, it is unlikely to be in clinical skills or the fundamentals of nursing care. Instead, we need to look at the how degree-level education may instil in students a better understanding of the nature of knowledge and the ways in which it can enhance care.

There is evidence that newly graduated nurses, after a ‘settling-in’ period, show a trend towards accessing and using research to support and enhance their care (Crenshaw & Champion, 2013). Maybe this provides a real clue to why degree-level nurses appear to improve patient outcomes: it is not their inherent nursing ability, or the range of clinical skills they possess. Instead, it is their ability to access, to critique and to apply the latest evidence that may support the delivery of care that improves patient outcomes.

These possibilities – the better application of research evidence or an organisational understanding of the importance of education – are just two potential explanations for the findings related to degree-level nurses and improved patient outcomes. To test these ideas and explore other mechanisms, we need to target future research not on whether degree-level education for nurses enhances patient care, but on the question of how it does so.


Aiken LH et al (2014) Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet 383(9931): 1824–1830

Blegen MA et al (2013) Baccalaureate Education in Nursing and Patient Outcomes. Journal of Nursing Administration 43(2): 89–94

Crenshaw JT, Champion JD (2013) Newly graduated Swedish nurses show a trend for increasing research use in the 5 years following qualification, with the trend starting after the second year. Evidence Based Nursing 16: 27-28 Available from:

Liao LM et al (2016) The association of nurse educational preparation and patient outcomes: Systematic review and meta-analysis. Nurse Education Today 42: 9–16


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