24 FOCUS ON EDUCATION | 2018 | www.advanceweb.com individual states and state boards of nursing attempted to legislate baccalaureate educa- tion as the minimum entry level to practice. Oregon, Montana, Maine, and North Dakota took on the issue and moved the concept to action. The Oregon State Board of Nursing moved to make a BSN the minimum to enter practice. The Oregon Community College Association (OCCA) lobbied successfully to remove the Oregon State Board of Nursing’s authority to set this practice standard. The OCCA argued that financial costs would be a deterrent to the student and the health care industry. This argument would become a reoccurring theme in future attempts to establish the BSN entry point. Finally, in April of 1985, legislation halted the progress of the Oregon State Board of Nursing initiative, and the forward momen- tum to implement failed. Similar sets of circumstances faced and per- plexed the states of Maine and Montana. In each of these events, effective lobbying efforts from various entities convinced each state’s legislative bodies that the boards of nursing did not have the power to change educational standards. Components of influence were very much the same as the state of Oregon’s attempt at the BSN as entry level to practice. Strong opposition statements came in the way of concerns of higher educational costs for students, lack of educational facilities to meet the mandate, and a reduction in the supply of licensed nurses. To this point, the state of North Dakota came the closest to requiring a BSN as an entry level to practice. In November of 1985, the North Dakota Board of Nursing was provided approval and implemented a BSN as the entry level of practice standard. It was not until 1987, after two years of lawsuits, that the legislative action was put into place. Still determined to oppose the new ruling, lobbing groups from various North Dakota health care agencies kept up their efforts to rescind the BSN as the minimum entry to practice. Then in 2003, the legislative work that had been completed to set the standard was revised, and North Dakota returned to its previous system of education and licensing of nurses. The literature suggests that lobbying efforts through special interest groups—combined with nursing staff shortages and higher predicted education costs—were the bar- riers to successful and sustained implemen- tation. In short, the decision-making power to increase the educational standards was taken away from the nurses and the boards of nursing. Decision power was given to each state’s higher education agencies as a result of the influence of the special interest lobbying groups that made the choice for the nursing field (Smith, 2009). NURSING EDUCATION AND RESEARCH TAKES THE LEAD As the political debates between interested parties continued, nursing researchers began to study the issue. Two notable and signifi- cant works came from Dr. Linda Aiken and colleagues (2003; 2011) from the University of Pennsylvania School of Nursing, Centers for Health Outcomes and Policy Research. The studies reviewed educational levels of hos- pital nurses and surgical mortality through the effects of nursing staffing. Specifically, the studies looked at nurse educational levels and mortality rates in various work environ- ments, applying research methodology and statistical analysis. The studies elaborated on many details of clinical practice and focused on patients undergoing surgical procedures. Aiken’s 2003 study reviewed 168 hospital facilities; 36% were academic medical centers. The sample of hospitals demonstrated a wide distribution of employed baccalaureate-pre- pared nursing staff ranging from none to 70% of the staffing complement. The tendency for higher percentages of BSN or higher educated nurses was seen in academic or high-technol- ogy-based medical centers. The largest categories of surgical patients in the sample hospitals were observed within two medical groups. These were patients receiv- ing orthopedic surgical procedures, such as total joint replacement or bone fracture sta- bilization, and patients undergoing abdomi- nal surgical procedures, such as surgery of the digestive or biliary tract. Aiken and her team controlled for comorbidities that included hypertension and diabetes mellitus (Aiken, Clarke, Cheung, Sloane, & Silber, 2003). The study findings presented measured results that indicated improved patient out- comes in the groups cared for by nurses with a baccalaureate-preparation or higher level of education. To the extent possible and con- trolling for the characteristics of the hospital settings, with each 10% increase in the propor- tion of nurses with higher educational prepa- ration, there was a decreased risk of mortality by a factor of 5 (Aiken et al., 2003). A second cross-sectional study by Blegen and colleagues (2013) reviewed data sets com- pleted by the health care entity University Hospital Systems Consortium (UHC). The data review noted that commonly seen com- plications were experienced with inpatients in all hospital settings. These included the following: • Heart failure (HF) mortality. • Hospital-acquired pressure ulcers (HAPU). • Deep vein thrombosis/pulmonary emboli (DVT/PE). • Extended length of stay/hospitalization. The results of the data analysis demon- strated a significant statistical difference based on the nursing education level of the care provider. Specifically for the four measured variables: • CHF mortality (Pearson’s r = -0.240). 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