Economic Evaluation of the 80% Baccalaureate Nurse Workforce Recommendation: A Patient-level Analysis

Document Type




Format of Original

6 p.

Publication Date



Lippincott Williams & Wilkins, Inc.

Source Publication

Medical Care

Source ISSN


Original Item ID

doi: 10.1097/MLR.0000000000000189


Background: Higher proportions of BSN-educated nurses were associated with improved outcomes in hospital-level studies. A recent Institute of Medicine report calls for increasing the proportion of BSN-educated nurses to 80% by 2020. Patient-level evidence of cost and quality implications of the 80% BSN threshold is needed for a business case to support these efforts.

Objectives: To conduct the economic analysis of meeting the 80% BSN threshold on patient outcomes and costs, using linked patient-nurse data.

Research Design: Retrospective observational patient-level analysis of electronic data. Linear and logistic regression modeling with patient controls and diagnosis and unit fixed effects.

Subjects: A total of 8526 adult medical-surgical patients matched with 1477 direct care nurses from an Eastern US academic medical center, during June 1, 2011–December 31, 2011.

Measures: Outcomes include hospital mortality, all-cause same-facility 30-day readmission, length-of-stay, and total hospitalization cost. BSN proportion is a continuous measure for the proportion of nurse assessment inputs into the patient’s electronic medical record made by BSN-educated nurses; a dichotomous indicator for BSN proportion is 0.8–1.0.

Results: Continuous BSN proportion was associated with lower mortality (OR=0.891, PP=0.04) and 1.9% shorter length-of-stay (P=0.03). Economic simulations support a strong business case for increasing the proportion of BSN-educated nurses to 80%.

Conclusions: A combined approach of increasing the hospital-level BSN proportion to 80% and assuring a high BSN dose through individual patient-level staffing assignments is needed to achieve projected quality and costs benefits.


Medical Care, Vol. 52, No. 10 (October 2014): 864-869. DOI.