Insights October 2009

Degrees of Separation: Do Higher Credentials Make Healthcare Better?

Steven Lewis

Somewhere around 2050, the last registered nurse without a university degree will ride off into the sunset. Manitoba had gamely held out as the last province to retain the diploma option, but it, too has thrown in the towel. Raising entry-to-practice credentials (ETPC) in health disciplines is the new pandemic. Among recent developments:

  • Nursing: decades-long evolution from hospital-based to college-based diplomas, and then baccalaureate degree ETPC
  • Medicine: lengthened the family medicine residency to 2 years from 1 in the early 1990s; major cause of subsequent doctor shortage
  • Physiotherapy: conversion to master's-level ETPC almost complete
  • Occupational therapy: ditto
  • Pharmacy: talk of moving to a PharmD ETPC; the University of Toronto has pitched it to the Government of Ontario, and Quebec has made similar noises
  • Various technologists and technicians: regular push for baccalaureate ETPC.

In a world that values education as an intrinsic good, these have to be admirable developments. Professions devoted to the public good and humbly aware of their limitations raise their ETPC as part of the journey to continuous improvement. Higher ETPC has to create better-prepared graduates, improved system quality, and a better patient experience. If a diploma is good, a degree is better; if a baccalaureate is adequate, a doctorate is superior.

Sounds sensible, right? Let's examine what we've learned about this phenomenon over the years[i]. First, no one can pin down where raising the ETPC starts. Many have looked, and more knowledgeable and savvy people than I cannot trace a change back to its origins. The best guess is that the movements begin in faculty lounges or around the board tables of professional associations. While we don't know how the credential upgrade begins, we know how it doesn't. Employers never demand increased ETPC; on occasion they explicitly oppose it. No one has ever produced evidence that those practicing with the about-to-be-abandoned credential were harming the public. Governments never instigate the changes.

Second, increasing the credential does not necessarily mean more training. Take the therapies. Until recently, you got to be a physiotherapist by taking a 4-year university degree in, sensibly, physiotherapy. Now you take a 2-year master's program following an undergraduate degree in anything. Same with OT - my brilliant and talented niece got her MSc on top of her architecture degree, consisting of about a year in the classroom and a year of practical experience. We are to take it on faith that we get a more capable entry-level therapist in half the time it used to take, armed with a degree that sounds more advanced.

Nursing has been even more artful. First, it bid adieu to an intensive, roughly 23-month diploma program in favour of the 4-year, but less jam-packed baccalaureate program. The degree students actually spend less time in practice settings during their training. The transition to a degree-only program predictably reduced the numbers of graduates. Employers and governments grew alarmed at forecasts of a 100,000+ shortage of RNs on the horizon.

No worries, responded the universities. We've got a solution. Presto - there are now 11 programs across the country that will give you a nursing degree on top of, say, a fine arts degree in 2 years! Follow the bouncing ball: two years wasn't sufficient to turn out a competent entry-level nurse fifteen years ago, but now it is again. Excellent. (Advice to students: demand a master's degree for your troubles, just like the physios and OTs. Of course, this would confuse regulators, irk nurses with 4-year baccalaureate degrees, and cause riots among nurses with real master's degrees. The physios and OTs had the good sense to eliminate the undergraduate option altogether.)

Third, at least in some jurisdictions, universities, wielding their academic freedom, have acted with remarkable vigour to satisfy professions' aspirations for increased ETPC. The University of Saskatchewan - my alma mater and annual recipient of my donations, in case this essay prompts it to withdraw my degrees - decided on its own not to enrol a new class of physiotherapy students a couple of years ago, as part of its campaign to adopt the MSc as the ETPC. It somehow forgot to notify the government or obtain its permission, although it invoked the Cool Hand Luke defence. One might think the Premier or Minister of Advanced Education might have called up the President to inform him that this ringing exercise of institutional autonomy suddenly made a few million dollars vanish from the university's budget. Nah; bygones.

Fourth, the ETPC movement has created subtle changes in the meaning of advanced degrees. I believe the technical term is "phoney baloney." These so-called professional master's degrees and doctorates require none of the rigour, research, or external scrutiny that used to be hallmarks of advanced education. While purveyors of these degrees acknowledge that they are different in important respects, they know full well that the public makes no such distinctions. The biggest assault on standards is where the advanced degree sits on top of an undergraduate degree in a different discipline. The master's-level PT and OT training has to be basic because no one has any grounding in the subject matter prior to entry into "graduate" studies.

Fifth, no one seems to know or care about the practical consequences of raising ETPC. People will disagree about the wisdom of the nursing conversion, but shouldn't we at least be curious about the consequences? (I'm not picking on nursing here; it's just that nurses outnumber the other professions combined, so the implications are huge.) For example: 

  • How much did it cost? The transition reduced supply, which shifted bargaining power to nursing unions and led to bidding wars among the provinces. Every higher-than-normal contract settlement produced a domino effect across the country. I'm all for paying nurses well, but no one consciously decided that we ought to spend several billion dollars to make nursing more lucrative. Is it several billion? Well, if 200,000 nurses are getting 20% more than they would have had the diploma option remained in place, and the average nursing salary is $60,000, that would be $12,000 more per nurse x 200,000 nurses = $2.4 billion annually.
  • Is nursing care better? We have no clue. There is some (largely American) research that attributes hospital care outcomes to RN staffing levels, but the studies have deliberately avoided comparing diploma vs. baccalaureate degree nurses. Hint: you can read a tonne of quality improvement literature without coming across any references to ETPC as a key factor.
  • Are nurses happier? I hope not, because they remind us weekly of their collective misery and plummeting morale, so it would be terrible if this reported malaise is actually an improvement over their state of well-being prior to degreeing up.
  • Has the class structure of nursing education changed now that the profession is degree-only? Are fewer working class kids inclined to choose a career in nursing because it is much more expensive and time-consuming to acquire the credential? What about Aboriginal peoples, recent immigrants and other minorities?

You would think that public policy makers might be interested in some case studies of the consequences of these decisions. Uh-uh. A number of us have proposed a research agenda to get to the bottom of these monumental changes and produce real evidence to resolve the ongoing debates. It might cost a few million dollars to do the work comprehensively, but we're dealing with multi-billion-dollar issues. The failure to commission the research betrays not just a stunning lack of curiosity; it is wilful ignorance that will condemn decision-makers to the same sort of ad hoc, ill-informed choices that have created the current mess.

But, one might counter, even if the ETPC changes were in a sense unnecessary, there are worse sins than overeducating the healthcare workforce. Not so fast. One of the reasons professions raise ETPC is to increase their status and credibility in the academy. They do this in part by developing complex theory and creating specialized identities. Merging these identities into unified interprofessional teams is a challenge under any circumstances; even stronger and more fragmented identities forged in longer education programs will hardly make this easier. Furthermore, graduates with higher credentials will expect to work at a higher level and many will be disappointed and bored by the everyday but important work of patient care.

All that said, there is no definitive proof that increasing ETPC has been a colossal mistake. I'm saying merely that it might have been, but we know embarrassingly little about the consequences. And if we're going to require more education for healthcare newbies, we need to debate the form that education should take. Too many practitioners know nothing about the social determinants of health, health systems, policy, economics, and the arts of citizenship. Maybe they need to broaden their educational horizons rather than deepen their discipline-specific identities. That nurse with a BFA and a two-year nursing degree may indeed turn out to be admirably educated for the challenges of working in a variety of contexts. But let's not confuse that prospect with the ETPC essential to making healthcare better.

[i]Before I get into the analysis, full disclosure: as a public representative on the Canadian Nurses Association Board of Directors in the early 1990s, I cast the lone vote against what was then known as the BN 2000 resolution. For the past 6 years I have sat on the federal-provincial-territorial Coordinating Committee on Entry to Practice Credentials (we have a gift for catchy titles). So I have been around this topic for some time, and while it cannot compete with my obsession with baseball statistics, it ranks right up there among my day job preoccupations.


Robin Hesler wrote:

Posted 2012/08/14 at 11:36 AM EDT

As usual Steven Lewis is bang on! BAs Masters and doctorates do not necessarily make a an excellent or even an expert practitioner but only in their minds. My experience with nursing, as an example, reveals, in the case of the care of my aging parents that the diploma nurse side by side with a degree nurse provided more compassionate and competent care. The "doing patient care" is compromised by the reduction of hands on clinical bedside "get your hands dirty" care because of the academic focus vs the practical and the mind sets that go with it. Practical training and experience has given way to academic expertise and the balance has or is being lost. Many of my colleagues see that keeping up with the "Jones" often deviates the primary purpose of many provider groups and a way to bringing in money for the universities - right or wrong vs focusing on patient service. The issue really is, what competencies are really needed to deliver what type of quality and safe health care in an economic and sustainable way? There is an argument to be made that not all nurses or Medical Radiation Technologists etc need degrees to meet the patients needs and credential creep should be replaced by Provincial and National credential management.


Deborah Lee wrote:

Posted 2012/08/14 at 03:46 PM EDT

In terms of nursing, there is VAST evidence in terms of ETPC. This is from the American Association of Colleges of Nursing. Yes, it is from the U.S., but highly relevant to Canada.
There is a growing body of evidence that shows that BSN graduates bring unique skills to their work as nursing clinicians and play an important role in the delivery of safe patient care.
In a January 2011 article published in the Journal of Nursing Scholarship, Drs. Deborah Kendall-Gallagher, Linda Aiken, and colleagues released the findings of an extensive study of the impact nurse specialty certification has on lowering patient mortality and failure to rescue rates in hospital settings. The researchers found that certification was associated with better patient outcomes, but only when care was provided by nurses with baccalaureate level education. The authors concluded that “no effect of specialization was seen in the absence of baccalaureate education.”
In an article published in Health Services Research in August 2008 that examined the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery, Dr. Christopher Friese and colleagues found that nursing education level was significantly associated with patient outcomes. Nurses prepared at the baccalaureate-level were linked with lower mortality and failure-to-rescue rates. The authors conclude that “moving to a nurse workforce in which a higher proportion of staff nurses have at least a baccalaureate-level education would result in substantially fewer adverse outcomes for patients.”
In a study released in the May 2008 issue of the Journal of Nursing Administration, Dr. Linda Aiken and her colleagues confirmed the findings from her landmark 2003 study (see below) which show a strong link between RN education level and patient outcomes. Titled “Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes,” these leading nurse researchers found that every 10% increase in the proportion of BSN nurses on the hospital staff was associated with a 4% decrease in the risk of death.
In the January 2007 Journal of Advanced Nursing, a study on the “Impact of Hospital Nursing Care on 30-day Mortality for Acute Medical Patients” found that BSN-prepared nurses have a positive impact on lowering mortality rates. Led by Dr. Ann E. Tourangeau, researchers from the University of Toronto and the Institute for Clinical Evaluative Sciences in Ontario studied 46,993 patients admitted to the hospital with heart attacks, strokes, pneumonia and blood poisoning. The authors found that: "Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."
In a study published in the March/April 2005 issue of Nursing Research, Dr. Carole Estabrooks and her colleagues at the University of Alberta found that baccalaureate prepared nurses have a positive impact on mortality rates following an examination of more than 18,000 patient outcomes at 49 Canadian hospitals. This study, titled The Impact of Hospital Nursing Characteristics on 30-Day Mortality, confirms the findings from Dr. Linda Aiken’s landmark study in September 2003.
In a study published in the September 24, 2003 issue of the Journal of the American Medical Association (JAMA), Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level. In hospitals, a 10 percent increase in the proportion of nurses holding BSN degrees decreased the risk of patient death and failure to rescue by 5 percent. The study authors further recommend that public financing of nursing education should aim at shaping a workforce best prepared to meet the needs of the population. They also call for renewed support and incentives from nurse employers to encourage registered nurses to pursue education at the baccalaureate and higher degree levels.
Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 – one by the state of New York and one by the state of Texas – clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level. These findings are consistent with findings published in the July/August 2002 issue of Nurse Educator magazine that references studies conducted in Arizona, Colorado, Louisiana, Ohio and Tennessee that also found that nurses prepared at the associate degree and diploma levels make the majority of practice-related violations.
Chief nurse officers (CNO) in university hospitals prefer to hire nurses who have baccalaureate degrees, and nurse administrators recognize distinct differences in competencies based on education. In a 2001 survey published in the Journal of Nursing Administration, 72% of these directors identified differences in practice between BSN-prepared nurses and those who have an associate degree or hospital diploma, citing stronger critical thinking and leadership skills.
Studies have also found that nurses prepared at the baccalaureate level have stronger communication and problem solving skills (Johnson, 1988) and a higher proficiency in their ability to make nursing diagnoses and evaluate nursing interventions (Giger & Davidhizar, 1990).
Research shows that RNs prepared at the associate degree and diploma levels develop stronger professional-level skills after completing a BSN program. In a study of RN-to-BSN graduates from 1995 to 1998 (Phillips, et al., 2002), these students demonstrated higher competency in nursing practice, communication, leadership, professional integration, and research/evaluation.
Data show that health care facilities with higher percentages of BSN nurses enjoy better patient outcomes and significantly lower mortality rates. Magnet hospitals are model patient care facilities that typically employ a higher proportion of baccalaureate prepared nurses, 59% BSN as compared to 34% BSN at other hospitals. In several research studies, Marlene Kramer, Linda Aiken and others have found a strong relationship between organizational characteristics and patient outcomes.
The fact that passing rates for the NCLEX-RN©, the national licensing exam for RNs, are essentially the same for all three types of graduates is not proof that there are no differences among graduates. The NCLEX-RN© is a multiple-choice test that measures the minimum technical competency for safe entry into basic nursing practice. Passing rates should be high across all programs preparing new nurses. This exam does not test for differences between graduates of different entry-level programs. The NCLEX-RN© is only one indicator of competency, and it does not measure performance over time or test for all of the knowledge and skills developed through a BSN program.


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