Hanlon's Razor: BSN in 10

Hanlon's Razor: "never attribute to malice that which can be adequately explained by stupidity."

This is horrifying. Some states are considering legislation that will mandate Registered Nurses obtain a 4-year BSN within 10 years or lose their jobs. Here's a quote from New Jersey's State Nurses Association:

Q: Why do we need to legislate that newly licensed RN’s in NJ need to obtain a BSN?  

A: The purpose of this legislation is to support the delivery of the best quality care to patients in an increasingly complex health care environment. Studies, comparing patient outcomes with the educational background of nurses, demonstrate that in facilities with a greater proportion of BSN or higher educated nurses patients have lowered mortality and adverse events.

 Ah, those wonderful "studies". I love those guys. You see, one of the great things about having a basic undergraduate education in elementary statistics is that you gain sensitivity to the limits of statistical inference. Consider one of the "studies" listed in support of the BSN-in-10 legislation.

Tourangeau, A.E, Doran, D.M., McGillis Hall, L., O'Brien Pallas, L., Pringle, D., Tu, J.V. & Cranley, L.A. (2007, January). Impact of hospital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing, 57(1), 32-41.

An ungated copy of the paper can be found here. I've read a few of the other ones, like the Estabrooks piece, and they're pretty much all the same thing (except they're all gated). Here, let the authors tell you in their own words:

Findings. Using backward regression, 45% of variance in risk-adjusted 30-day mortality rates was explained by eight predictors. Lower 30-day mortality rates were associated with hospitals that had a higher percentage of Registered Nurse staff, a higher percentage of baccalaureate-prepared nurses, a lower dose or amount of all categories of nursing staff per weighted patient case, higher nurse-reported adequacy of staffing and resources, higher use of care maps or protocols to guide patient care, higher nurse-reported care quality, lower nurse-reported adequacy of manager ability and support, and higher nurse burnout.

Holy post-treatment effects, Batman.

Look, people. It's great to find that extra education is linked to better patient outcomes. I can easily say that with all sincerity. This finding is a boon to folks looking to assign difficult cases to proficient hospitals. But taking this result and building a mandate on top of it violates some pretty basic reasoning.

Here is that reasoning.

Consider two hypotheses. Under hypothesis A, education creates excellent job performance. Under hypothesis B, education reveals excellent performers. Now consider how two cases look under each hypothesis.

Mike and Jeff are nurses. They're both good guys, competent and reliable.

• In scenario one, they're identical in every regard, from the creases in their little hats down to their diagnostic ability. Then, driven by the winds of fortune, Mike decides out of the blue to go ahead and get his Bachelor of Science in Nursing. As a direct result of the lessons learned there, he gains a new set of skills that improve his ability to coax patients from the jaws of death. Even with all else held equal, his hospital's mortality rates improve. 
• In scenario two, Mike is more than just a good guy, competent and reliable. He's a nursing powerhouse, and his innate nursing prowess drives him to not only provide the best possible care for his patients, but to obtain higher levels of education. As a direct result of his native talent and ability, he is both more able to coax patients from the jaws of death and more likely to obtain a BSN.

What the observational studies can do is to say that nurses with more education can be positively, affirmatively linked to better patient outcomes. What they cannot do is adjudge between these two hypotheses. Despite this painfully obvious observation on the limits of statistical inference, legislatures proceed as if hypothesis A is the only possible explanation. That you can take mediocre nurses, send them through expensive, time consuming education and out the other side, you'll have unicorns farting rainbow-colored clouds of strawberry compote. And if they can't hack it? Bye bye. You're out on your tuchus. 

This is scandalous. I have to assume that the people pushing for this are simply too stupid to know the difference between random selection and random assignment, because the alternative explanation would reveal them to be villains of the worst sort, holding patients hostage to secure higher barriers to entry, siphoning rents into the pockets of incumbents. I'm a cynical guy, but even I can't grasp cupidity that dire.

Nursing is not euvoluntary: the patient is always at the mercy of the caregiver. Making it less so under the thin cover of inappropriate "studies" is inconsistent with good reasoning, commonplace morality, and good sense. Proponents of this legislation should be ashamed, and voters should be appalled. 

h/t RKW