A bachelor's degree for entering the nursing profession: A scoping review for supporting informed health care policies

Abstract

Background

Numerous studies have emphasized the relevance of work environment, staffing, and educational level in nursing as determinants of safe, timely, effective, equitable, and efficient patient-centered care. However, an overview of the evidence focusing on the nursing education level is still lacking.

Objective

To provide an overview of the existing evidence regarding bachelor's degree as an entry level for the nursing profession.

Design

This was a scoping review.

Methods

We conducted a systematic search of CINAHL, Medline via PubMed, Cochrane, and Web of Science Core Collection. Additionally, we conducted a free web search using Google and contacted international nursing associations via email. We summarized the evidence narratively. For reporting guidelines, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews.

Results

We included 10 studies, 12 response letters, 24 position papers, three books, and one webpage. The sources of evidence identified agreed that the inclusion of a higher number of nurses with a bachelor's degree would lead to a higher quality of care.

Conclusions

Using a bachelor's degree education as a minimum requirement to enter the nursing profession in the future is essential to generate a respected, competent, and satisfied nursing workforce that can impact the quality and safety of care; and positively influence outcome indicators for patients, nurses, healthcare organizations, and society.

Tweetable abstract

Policy makers and healthcare organizations should set bachelor's degrees as standards for registration and entry to nursing.

What is already known.

• •A higher number of nurses with higher education levels improves quality of care.
• •Patient outcomes are positively influenced by staffing practices that respect this standard.
• •An overview of the evidence, including the current recommendations, statements of nursing associations, and position papers, is lacking.

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What this paper adds.

• •The results related to failure-to-rescue, re-admission rates, and patient mortality were quite clear; the higher the proportion of nurses with a bachelor's degree working in a units or hospitals, the better were these outcomes.
• •The results of this review underscored the recommendations to set a bachelor's degree as the entry level requisite for nursing.

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1. Introduction

Numerous studies emphasize the relevance of the work environment, staffing, and educational level of nursing as determinants for safe, timely, effective, equitable, and efficient patient-centered care (Aiken and Salmon, 1994; McHugh et al., 2021; World Health Organization, 2020).

Moreover, economic studies have confirmed important returns on investments when investing in nursing (Amiri and Solankallio-Vahteri, 2020; Needleman, 2017). The strategic importance and benefits of investing in nursing are reported at all economic levels (World Health Organization, 2020).

Although important, subsidiaries’, effects regarding educational level include the impact of high-quality nursing leadership on the capacity to implement systematic evidence-based practice, and on the nature of interdisciplinary collaboration, promoting nurses’ “professional values, thus improving the quality of patient care (Cummings et al., 2018; Sibandze and Scafide, 2018). Furthermore, emerging trends in healthcare powered by innovation, technological development, and artificial intelligence require alignment with core nursing values and, therefore, rely on adequately trained nurses (Buchanan et al., 2020).

Therefore, associations, such as the Institute of Medicine, the American Association of Colleges of Nursing, and other renowned instances strongly recommend increasing the number of nurses with a bachelor's degree or setting a bachelor's degree as mandatory to enter the nursing profession (Aiken et al., 2017; American Nurses Association; Rosseter, 2014).

However, the past decades have shown that fears related to the financial impact of upscaling educational level in the nursing profession or setting a bachelor's degree as the minimum requirement to enter the nursing profession can prevent informed decision making. Nevertheless, several countries in Europe, such as Austria, Italy, Spain, and Ireland, introduced a bachelor's degree as an entry-level requirement for nursing. In this paper, a bachelor's degree is defined as an education based on at least 5400 h of training at a university or a university of applied sciences.

Today, there are overwhelming sources of evidence, such as studies, recommendations, and opinions, to suggest that an adequate number of nurses (quantity) with the appropriate educational level (quality) results in substantial overall improvement in the quality of care (Aiken et al., 2017; Rosseter, 2014; Butler et al., 2019). Griffiths et al. (2018) point out, that higher levels of registered nurses in hospitals reduced the risk of death for patients. However, an overview of the existing knowledge to support informed healthcare policies and recommendations on the required nursing education level to enter the profession is lacking. As Butler et al. (2019) state, the evidence about hospital nurse staffing remained still low. To improve the certainty of at least an aspect of nurse staffing in general this review was conducted. Hence, the following research questions guided the study: (1) What is known about the benefits of a bachelor's degree education on nursing and patient outcomes? (2) What is the state of the evidence to set a bachelor's degree as a minimum requirement to enter the nursing profession?

2. Methods

Nursing education is a concept, that differs between the geographic areas, as well as the health care systems. However, there are existing different reviews addressing patient or staff outcomes in the light of the nursing education level. Nursing education and nursing policy are complex systems, additional sources of evidence beside quantitative research is necessary to include in the discussion of this issue. Beside scientific literature, the context, professional knowledge, and patient experience (Rycroft-Malone et al., 2004). Peters et al. (2020) indicate, that scoping reviews are helpful to shed a light on complex research fields and might help decision makers to make a complex research of practice field more capable. According to Anderson et al. (2008) scoping reviews are useful to develop policy maps. The field of nursing education is a political issue. Watson et al. (2011) states that scoping reviews could be conducted to map research papers and policy documents. Scoping reviews allow to include further sources of evidence like reports, grey literature or other references. This permits the understanding of evidence according to Rycroft Malone et al. (2004) to be addressed more broadly in a review.

Owing to the broad research question, we decided therefore to conduct a scoping review (Arksey and O'Malley, 2005; Peters et al., 2020). This review method allowed us to include the synthesis of a systematic literature review as well as further sources of evidence. This approach allowed us to further develop the existing knowledge on the topic. There are several relevant reviews existing on the topic, which we did not want to reproduce, but to consider and to map in a broader body of knowledge.

We developed a research protocol for this literature review, which guided us through the evidence search. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews guideline (PRISMA-ScR) (Tricco et al., 2018).

2.1. Eligibility criteria

In this scoping review, we included systematic reviews and studies with a quantitative design. For this, we applied the following inclusion criteria: (1) focus on the impact of the nursing education level on bachelor's degree and (2) have a quantitative or systematic review design. We excluded studies which were already included in a systematic review to avoid redundancies in our results.

Additionally, we included position papers that met the following inclusion criteria: (1) published by a known and relevant association or institution and (2) addressing nursing education level. We also included statements from associations, opinion leaders, and policymakers that we contacted directly.

2.2. Information sources

The Cochrane Database of Systematic Reviews, MEDLINE via PubMed, Web of Science Core Collection, Cochrane, and CINAHL databases were systematically searched to identify systematic reviews of quantitative studies and additional single trials that evaluated the impact of nurses’ education on different outcome indicators. Forward and backward citation tracking using Scopus was conducted on the full identified texts. Furthermore, a free web search using Google was conducted to identify position papers. The International Council of Nurses, European Federation of Nurses, Secrétariat International des Infirmières et Infirmiers de la Francophonie, and all European national nurse associations were contacted directly via e-mail and asked to provide a position statement. The obtained information and documents included references that were also analyzed.

2.3. Search

The search strategy design was based on an exploratory search using PubMed on discussions in the research team, which included persons from direct nursing practice, nursing research, and education. The search strategy was developed by one author and controlled using the “Peer review of electronic search strategy”-Guidelines by a second author (McGowan et al., 2016). The search strategy adopted keywords related to nursing education, nursing, and outcomes. These were adapted according to different databases, and MeSH terms. Subject headings and Boolean rules were used to maximize the retrieval of relevant pieces of work. No limits were applied. Furthermore, we conducted forward and backward citation tracking using Scopus with the identified texts. An example of a search string is presented here (PubMed):

(“baccalaureate nursing education”[Title/Abstract] OR “Education, Nursing, Baccalaureate”[Mesh] OR “bachelor degree”[Title/Abstract] OR “associate degree”[Title/Abstract] OR “baccalaureate”[Title/Abstract]) AND nurse*[Title/Abstract] AND (“quality of care”[Title/Abstract] OR “safety”[Title/Abstract] OR “efficiency”[Title/Abstract] OR “person centered”[Title/Abstract] OR “person centered”[Title/Abstract] OR “person-centered”[Title/Abstract] OR “person-centered”[Title/Abstract] OR “nursing outcome”[Title/Abstract] OR “staff outcome”[Title/Abstract] OR “quality of health care”[Title/Abstract] OR “patient outcome”[Title/Abstract] OR “morbidity”[Title/Abstract] OR “mortality”[Title/Abstract] OR “readmission”[Title/Abstract] OR “cost”[Title/Abstract])

For the free web search, the following terms were used: “position paper,” “bachelor degree,” “nursing education,” and “outcome.”

In addition to the International Council of Nurses, European Federation of Nurses, and Secrétariat International des Infirmières et Infirmiers de la Francophonie, 27 European nurse associations were contacted. This request included information about our intention to present a position paper on the educational level of nurses when entering the profession, and how we intended to proceed. The European nurse associations received one reminder after two weeks. The associations were asked to provide the following information: (1) the current state or national position regarding the expected educational level in nursing when entering the profession in their country; (2) existing position papers, research, or reference material on this topic, or experts we should connect with; and (3) information about future or upcoming developments or recommendations on this topic.

Additionally, the current state of nursing education was identified by a web search in the contacted European countries where no position paper was available or no response letter was obtained. This web search led to additional publications of prominent organizations like the Institute of Medicine (IOM),and the American Association of colleges of Nursing (AACN).

2.4. Selection of sources of evidence

Three independent authors conducted title and abstract screening and full-text screening of the results of the systematic database search. Conflicts among the three were discussed within the group. The hits identified by the forward and backward searches were screened by two authors.

The first 100 hits in the free web search using Google were screened for each combination of search terms by one author. Specific known associations and institutions in nursing education, research, and practice were screened for position papers. Responses from the European nursing associations were collected and added to a table.

2.5. Data charting

A customized chart was developed for this study with the following sections: (1) citation, (2) year, (3) country, (4) research question or aim, (5) methods, (6) number of participants and references, (7) results, and (8) recommendations. Data charting was developed based on the Joanna Briggs Institute manual for systematic reviews (Aromataris and Munn, 2020). The extraction chart was tested by extracting the first reference and then discussing the extraction with the author's team. Data from the literature references were charted by one author and checked by a second author. The differences between the two authors were discussed and resolved.

The extraction chart for the free web search identified references, and the statements of the policy makers were developed by one author and discussed by the author team after the extraction of the first reference. Data extraction of the statements and additional references from the free web search was performed by one author and independently checked by two other authors. The extraction chart included the following sections: (1) association, (2) context and documents, and (3) main results. The final chart was discussed by all three authors.

2.6. Critical appraisal

Two authors independently conducted a critical appraisal using the checklists from the Joanna Briggs Institute (cross-sectional studies and systematic reviews) for the reference included in the systematic review. Discrepancies were discussed between the two authors, and persistent conflicts were resolved by including a third author in the discussion. There was no exclusion because of the critical appraisal of the included references, which was conducted to provide additional information on the interpretation of the identified data.

The references identified by the free web search and statements of the cited instances were critically discussed by the author team but did not undergo acritical appraisal.

2.7. Synthesis of the evidence

After charting the data, the main results of the different sources of evidence were reflected. Through a discursive process within the authors’ team, the main topics were identified and described within the body of data. Finally, in circular discussion meetings in the authors’ team, statements in line with the identified topics were used for recommendations.

3. Results

The initial systematic search of the databases resulted in 2703 hits; 2103 references remained after removing 600 duplicates. After removing 2065 references after title and abstract screening, 38 texts remained for full text screening, which yielded 11 potential references for inclusion after removing 27 references. Exclusion was based on different populations (e.g., students as target population) and publication types (e.g., reports or grey literature). We also excluded studies with quantitative designs that were already included in the identified reviews to avoid a double mention. Finally, six references were identified for inclusion. Four additional studies with quantitative designs were included during forward and backward citation tracking. Finally, we included three reviews (Audet et al., 2018; O'Brien et al. 2018; Harrison et al., 2019) and seven studies with quantitative designs. These reviews included a total of 59 studies that investigated the effects of nursing education on nursing outcomes. After removing duplicates within the reviews, a total of 39 studies with quantitative designs were included in the review papers. Finally, we included 46 studies with quantitative designs (7 studies we identified in our search, 39 were included in the identified reviews) that investigated the effect of educational level on nursing outcomes in our review. The search process is presented in the flowchart (Fig. 1).

Fig. 1.

Flowchart.

The free web search using Google and contact with nursing associations led to 24 position papers on the importance of nursing education level. Furthermore, we identified three relevant books and one webpage. In addition to the International Council of Nurses and Secrétariat International des Infirmières et Infirmiers de la Francophonie, 10 out of the 27 invited associations responded with a letter, resulting in 12 response letters. These associations shared additional information, and upcoming trends in addition to existing position papers. The majority responded via mail, with some using organized telephone discussions.

The essence of data extraction of the identified evidence is illustrated in Tables 1 and 2.

Table 1.

Included journal articles.

Study	Setting	Country	Design	Exposition	n	Outcomes	Recommendation
Backhaus et al. (2017)	Nursing Home	NL	Cross-sectional design (standardized data sampling)	number of hours of care delivered by BRNs	6145 residents 282 wards 95 facilities	Probability of experiencing fall (OR: 1.44; 95% CI: 1.06–1.96) was higher; probability of receiving antipsychotic drugs (OR: 2.15; 95% CI: 1.66–2.78) was higher; probability of having an indwelling urinary catheter was lower (OR: 0.70; 95% CI: 0.53–0.91); probability of experiencing a medication incident was lower (OR: 0.68; 95% CI: 0.49–0.95); suffering from nosocomial pressure ulcers did not significantly differ for residents.	No consistent evidence for a recommendation was found. Further research is necessary.
Harrison et al. (2019)	Hospital	USA	Cross-sectional (linked data from three sources); observational study	calculation of percentage of nurses with a bachelor's degree or higher degree in the hospital	36 hospitals.	Each 10% increase in hospital share of nurses with a bachelor's degree was associated with a 24% greater odds of surviving and be discharged with good cerebral performance among patients who experienced in-hospital cardiac arrest (OR: 1.24; CI: 1.08–1.42).	Findings suggest that patients in hospitals with higher proportions of nurses with a bachelor's degree and lower workloads have greater odds of surviving to be discharged with good cerebral performance following in-hospital cardiac arrest. Healthcare systems that continue to preferentially hire nurses with a bachelor's degree and invest in evidence based nursing staffing may see improvements in hospital performance benchmarking for cardiac outcomes.
Lasater et al. (2021)	Hospital	USA	Longitudinal study	the proportion of hospital bachelor's degree nurses	519 study hospitals	Reduced odds of risk-adjusted mortality (OR: 0.95; 95% CI: 0.92–0.98), reduced seven-day re-admission (OR: 0.96; CI: 0.92–0.98) and 30-day re-admission (OR: 0.98; CI: 0.95–1.00), and shorter lengths of stay (IRR: 0.98; CI: 0.97–0.99).	New evidence from panel data created a stronger case for the causal relationship between the proportion of bachelor's degree nurses in hospitals and lower odds of patient mortality, re-admission and shorter lengths of stay. This evidence supports the ongoing pursuit of achieving the Institute of Medicine recommendation of 80% bachelor's degree nurses, and should give confidence to hospital leaders to continue to increase employment of BACHELOR'S DEGREE s.
Choi et al. (2021)	Nursing Home	South Korea	Cross-sectional study	staffing level with bachelor's degree	62 nursing homes (of 107 all nursing homes with 100 or more beds), 224 nurses (216 returned the questionnaire)	decreased incidence rates of pressure ulcers (OR: 3.746, 95% CI: 1.680–8.353).	Education levels affect the quality of care provided by RNs in nursing homes, and this study showed that RNs with higher education levels were associated with lower incidences of pressure ulcers.
Coto et al. (2020)	Hospital	USA	Retrospective cross-sectional cohort analysis study using quarterly data from the NDNQI	percentage of nurses with a bachelor's degree	four magnet hospitals, 315 observations	A decrease of 0.03 falls per 1000 patient days may be expected with a 1-unit increase in the percentage of nurses with bachelor's degree s (95% CI: −0.04 − −0.02).	This study showed that improvements to patient outcomes may be optimized with increased percentages of bachelor's degrees and certifications for nurses
Haegdorens et al. (2019)	Hospital	Belgium	Retrospective observational study	proportion of staffing level with bachelor's degree	68 estimates, seven hospitals, 28 wards, 34,267 admissions, 1860 patients	The proportion of nurses with a bachelor's degree was negatively correlated with the composite mortality rate (B = −8.845, p = 0.023).	A higher proportion of nurses with bachelor's degrees is related to a reduction in patient mortality
Wieczorek-Wójcik et al. (2022)	Hospital	Poland	Retrospective longitudinal observational study	comparison between working hours of BScN/MScN nurses and nurses without higher education	14,369 patients from eight wards (four surgical and four non-surgical wards)	Decrease in re-admissions by 8.8 per 1000 patient days and by 24.7 per 1000 patient (−0.879; SD = 0.283) * and in surgical wards (−2.474; SD = 0.700) # (* p < 0.05, # p < 0.01). Decreased chances of an unplanned re-admission. Every zloty invested in increasing the number of BACHELOR'S DEGREE /MSc nursing hours yielded benefits worth USD 1.41. In surgical wards, the cost-benefit ratio indicated that each zloty saved by increasing the number of BACHELOR'S DEGREE /MSc nursing hours cost USD 0.02. Additionally, the benefit-cost ratio was USD 4.37, which means that every zloty invested in increasing the number of BACHELOR'S DEGREE /MSc nursing hours yielded benefits worth USD 4.37.	The study indicated that higher staffing levels in bachelor's degree /MScN nurses might help reduce re-admission and costs.
Bourgon et al. (2019)	Hospital	CA	Systematic review of English and French literature (44 articles included), 15 studies investigated nurses’ education level		included studies from United states, Europe, and Asia; Published between 2001 and 2018; data from 1989 to 2009; median number of patients = 232,432; 166 hospitals	Regarding the educational aspect in the staffing practice (higher proportion of BACHELOR'S DEGREE -nurses), this review found that a higher proportion of RNs with a baccalaureate degree were related to lower rates of both 30-day mortality and failure-to-rescue (six studies). One study found no significant association between these two and one found mixed results. One study found no significant association between education and in-hospital failure-to-rescue. Nine studies found a significant association between educational level and 30-day mortality rates; two had no significant results and one showed mixed results. These results were found regarding the association between education level and in-hospital mortality. Scant attention was given to other important staffing practices, such as skill mix, overtime hours, or temporary nurses	The high degree of methodological heterogeneity underscores the importance of standardizing methodological approaches in future studies. Furthermore, there is a strong need for longitudinal studies conducted at the patient level of analysis
O'Brien et al. 2018	Hospital	USA	Integrated review of literature (13 articles included).		no indications or synthetic table permitting to appreciate quantitative indications: high patient and nurse volumes	Ten research studies found decreased patient mortality rates when bachelor's degree nurses provided nursing care. Four articles reported that bachelor's degree s decreased failure-to-rescue rates. Three studies reported that bachelor's degrees contributed to a reduction in patient length of stay. The current state of the evidence showed significantly improved patient outcomes when nursing care was provided by bachelor's degree -educated nursing staff. A 10% increase in the proportion of bachelor's degree s providing bed-side care decreased the likelihood of patient mortality and failure-to-rescue rates. Other results included increase in patient satisfaction owing to bachelor's degree nurses, reduced pressure ulcer rates, and lower re-admission rates.	Additional positive patient outcomes were noted, but the breadth of findings is currently insufficient. Additional research is needed in cost-benefit analysis, patient satisfaction, correlation with decreased complications, and re-admission rates.
Audet et al. (2018)	Hospital	CDN	Reviewed 27 articles (20 of which investigated education)		27 Studies	11 studies (61.1%) found that higher proportions of RNs with baccalaureate degrees were significantly associated with lower mortality rates. Six studies (75%) reported that higher education was significantly associated with lower risks of failure-to-rescue. Interestingly, failure-to-rescue was more consistently related to RN education than mortality. Four studies examined the association between RN education and the rates of falls or falls with injury. Only one of these studies (25%) reported a significant association between these factors. Three studies examined the associations between RN education and the rates of medication errors; two of these studies (66.7%) reported no significant associations between the two, while one reported mixed findings. The third study suggested that increased RN experience was associated with lower rates of medication errors. Nosocomial infections, an AE indicator comprised of selected infections, were the focus of three studies examining their associations with RN education. Two of these studies (66.7%) reported no significant associations, whereas one (33.3%) found that higher RN education level was significantly associated with lower rates of nosocomial infections. No significant differences were found for pressure ulcers.	This systematic review provided further evidence in support of international efforts to increase an overall BACHELOR'S DEGREE -prepared workforce.

Table 2.

Evidence from other source

Association/Country	Response Letter	Position Paper	Book	Web Search	Reference	Main Results
World Health Organization(Europe)		1	1		Rafferty et al. (2019)	This book explored the variations in structure and organization of the nursing workforce across different European countries. This diversity, and the reasons for it, are of more than just academic interest. The work of nurses has always had a critical impact on patient outcomes. As healthcare systems shift radically in response to rising demand, the role of nurses becomes even more important.
					World Health Organization, (2022)
International Council of Nurses (ICN)	1	2			Response letter David Stewart, (2022);	ICN works to ensure quality nursing care for all, sound global health policies, advancement of nursing knowledge, the worldwide presence of a respected nursing profession, and a competent and satisfied nursing workforce.
					World Health Organization, (2020)
						ICN emphasizes that nurses require appropriate initial and ongoing education and training as well as lifelong learning to practice competently within their scope of practice.
						The State of the World's Nursing 2020 report published by the WHO, ICN, and Nursing Now provided evidence and data to inform governments to scale up investment in expansion of nurses’ education. The report contained robust country data in nursing education and advocated for standardized education and training of nurses. It also supported the advocacy for a graduate-prepared global nursing workforce, and indicated studies that showed better patient outcomes for degree-prepared nurses in hospitals.
						It showed strong advocacy in support of graduate preparation for registered nurses, which we believe is crucial to ensure that nurses are prepared to promote patient safety, improve quality of care, and meet the health needs of the population and the demands of nursing practice.
						Vocational Training = ± two years vs. Graduate Training = four years bachelor training
Secrétariat international des infirmières et infirmiers de l'espace (sidiief)	1	3			Response letter	A bachelor's degree for nurses should be required at the entry level.
					SIDIIEF, (2011)	Increasing the proportion of nurses with a bachelor's degree was associated with reduced risk of patient morbidity and mortality.
					SIDIIEF, (2018)	A clear trend toward university training of nurses in all French-speaking countries.
					Rochefort, (2019)	It is important that this development is conducted in interdependence between countries to maintain quality standards equivalent to other disciplines.
						At the national level, it is a basic nursing practice level and access to an adequate level of education that determines the ability to implement and develop ANP.
Institute of Medicine (IOM)		1	2	1	Institute of Medicine of the National Academies, (2011)	The Future of Nursing: Leading Change, Advancing Health is a thorough examination of the nursing workforce. It stated that nurses should practice to the full extent of their education and training; nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression (80% bachelor's-degree-educated nurses by 2020); and nurses should be full partners, with physicians and other health professionals in redesigning healthcare in the United States. Effective workforce planning and policy making require better data collection and information infrastructure. A nation cannot fully thrive until everyone can live their healthiest possible life, and helping people live their healthiest life is and has always been the essential role of nurses. Nursing education coursework and experiential learning that prepare students to promote health equity, reduce health inequities, and improve the health and well-being of the population will build the capacity of the nursing workforce.
					Flaubert et al., (2021)
					Dzau et al., (2022)
					https://campaignforaction.org/
American Association of Colleges of Nursing (AACN)		4			Rosseter, 2019	There is a growing body of evidence that shows that bachelor's degree nurses bring unique skills to their work as nursing clinicians and play an important role in the delivery of safe patient care.
					Rosseter, 2019;
					American Association of Colleges of Nursing, no date;	Changing higher education, learners, faculty, healthcare systems, nursing workforce, regulation, etc. require competency based-education; the baccalaureate degree in nursing is adopted as the minimum preparation for registered nurse licensure and entry in the nursing profession.
					American Association of Colleges of Nursing, (2019)
The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN)		1			Association of Women's Health, Obestrics and Neonatal Nurses, (2021)	Supported the requirement of a baccalaureate degree in nursing as the minimum educational preparation for entry into professional nursing practice in the United States. Additionally, it encouraged registered nurses to pursue higher levels of academic education and continue nursing education to positively affect population health and professional growth.
						It states that all nurses should practice to the full extent of their academic education and training.
European Federation of Nurses (EFN)	1				Response letter	It states that the training of nurses responsible for general care shall comprise a total of at least three years of study which may be expressed with the equivalent ECTS credits (180 ECTS), and shall consist of at least 4,600 h of theoretical and clinical practice, with the theoretical training representing at least one third, and the clinical practice at least one half of the minimum duration of the training
Swiss Academy of Medical Sciences		2			SAMW, 2019;	A high level of competence required to respond effectively to the growing need for care, given the complexity of services and pathologies. Various studies link the level of training of nurses to patient safety.
					SAMW, 2011	A healthcare system that invests in nursing expertise is making an informed choice that will lead to a real transformation of care in the 21st century.
						A bachelor's degree in nursing as a prerequisite for entry into the nursing profession.
Austria	1	1			Response Letter	We recommend pushing the life-phase-oriented full- and part-time training programs to strengthen the existing training system, and thus, not create even more uncertainty in the care training landscape.
						Österreichischer Gesundheits- und Krankenpflegeverband, 2021
						Education and training in qualified nursing care is from 1.1.2024 only, provided in the context of a bachelor's degree at a university of applied sciences.
Belgium	1 1	2			Response Letter	Diploma and bachelor's degree are standard.
					Health Community VOKA, (2021)	A bachelor's degree for nurses at the entry level is recommended. One unique educational level for nursing (EQF6) could be a bachelor's degree for all future new nurses.
					Hogescholenraad, (2020)	“How should we explain to Europe the difference between a bachelor's degree and a vocational degree? How should we explain to Europe that both qualifications are equated with the EQF6 and that we require a two-year bridging course to go from a vocational to a bachelor's degree?”
						Approximately 52% of Europeans have a bachelor's degree education.
						There is a need to stop the all-RN model, for different educational levels, and for clinical ladders.
						The demand-supply index is a tool for comparing the predicted number of nurses with the number of expected deaths. With an index value of 100, there is an equilibrium (for 2011: 106; for 2021: 129; this implies a shortage of nurses).
England		2			Response Letter	There has been a move form diploma level (EFQ5) to degree level (EFQ6) after extensive consultation and research.
					Longley et al., (2007)	EC directive requires three years or 4,600 h.
					Tuning Calohee, 2018	EFN and ICN: require a minimum of bachelor level.
						Nursing education needs to be comparable to other health professionals and bachelor's degree level at point of registration.
						Arguments against degree preparation include a belief that nurses do not need degree level skills to provide quality care which may be at the detriment of more practical skills. There is also concern about a reduction in the diversity of applicants.
						The Tuning Project aims to harmonize nurses’ education in Europe to enhance the mobility of nurses across Europe.
						The new Directive 2013/55/EU (which recognizes ECTS) will enable a gradual move to better align development opportunities for nurses following their registration. However, we draw particular attention to the fact that the subject area of nursing operates within and between the ECVET (2005), ECTS, the European Qualification Frameworks and Dublin Descriptors. The two-credit-based systems operate in different ways, thus making it difficult for nurses trained in the ECVET system to gain recognition in the higher education system for their learning achievements.
Estonia	1				Response Letter	This letter exclusively supported bachelor's degree.
						The current state or national position regarding the expected educational level in nursing when entering the profession is BA 210 ECTS.
						We are guided by the Directive 2013/55/EU in Estonia; the training of a nurse lasts three-and-a-half years and is conducted by two healthcare colleges.
France	1				Response Letter	This letter proposed 4,200 h (50% theoretical and 50% practice), which is below the EU requirement of 4,600 h (EU 2013/55).
Finland			X		Rafferty et al. (2019)	The three streams of education in this article included three-and-a-half years (210 ECTS credits) of study in basic education in nursing to fulfil the criteria set in the EU Directive 2013/55/EU.
						However, it is anticipated that increasing the number of new students in healthcare is not the only solution. There is also a need to fully utilize the existing workforce and immigrants.
						Finland educates nurses in Bachelor's degree exclusively.
Germany		1	X		Pachanov, 2020;	Nurse Professions Reform Act, the new nursing education program, was implemented in 2020.
					Rafferty et al. (2019)
Greece			X		Rafferty et al. (2019)	Diploma and bachelor's degree
						Training of nurses in Greece conforms to the EU standards for mutual recognition of qualifications according to European Community Directives-11 regulating the free movement of European healthcare professionals. For undergraduate studies, a student may pursue either a four-year undergraduate degree at a university or four-year undergraduate studies at a higher technological education institute. Both programs require 240 ECTS credits for graduation.
Iceland	1				Response Letter	Thank you for your inquiry and I do support your work. It is very important to increase all the nursing education to a BS level and higher. As research has shown us, this will provide better quality and safe nursing service.
						In Iceland, we go by Directive 2013/55 from the EU.
Ireland			X		Rafferty et al. (2019)	Supported bachelor's degree exclusively.
						Nursing degrees in Ireland are offered based on the National Qualification Framework (of Ireland) level 8 (240 ECTS credits) which equates to level 6 on the European Framework.
Lithuania			X		Rafferty et al. (2019)	Supported a higher professional bachelor's degree level education (full-time, three and-a-half years, 210 ECTS credits) and university education (full-time, four years, 240 ECTS credits), issuing professional qualification as a nurse for general practice and the degree of Bachelor's in Nursing.
						Diploma and bachelor's degree.
Luxembourg	1				Response Letter	Supported multilevel education with a strong ambition to set a bachelor's level as entry requirement for nursing.
Netherlands			X		Rafferty et al. (2019)	The intermediate level of nurses’ education takes four years and includes at least 6,400 h of theory and practice. Students may choose vocational training at school (Beroeps Opleidende Leerweg), including periods of practical learning, or an apprenticeship training (Beroeps Begeleidende Leerweg), which involves being employed for at least 24 h a week and following education for at least one day a week. The higher level of nursing education also takes four years and results in the Bachelor of Nursing degree. This includes 6,720 h (240 ECTS credits), with a minimum of 1,535 h of theoretical learning and a minimum of 2,300 h of on-the-job instruction.
Norway			X		Rafferty et al. (2019)	Supported a bachelor's degree exclusively.
						There are RNs and practical nurses in Norway. The two groups differ according to the duration of their education and their responsibilities. Registered nurses obtain licensure and a bachelor's degree at university colleges or universities. Practical nurses obtain a craft certificate upon completion of vocational training from upper secondary school.
Poland			X		Rafferty et al. (2019)	Supported a diploma and bachelor's degree.
						The education of nurses is conducted within the structure of bachelor's (first-cycle) and master's (second cycle) studies. The bachelor's degree program encompasses 4,720 h, of which 4,600 h constitute clinically oriented education and training. Half of this time is devoted to practical training. Bachelor's degree lasts three years and encompasses 180 ECTS credits.
Portugal	1				Response Letter	Access to nursing education is provided during the higher education system and graduate level (240 ECTS, four years of training).
						The access to specialty nursing education is possible with the professional title of nurse with two years of proven professional experience. The number of ECTS related to the master's degree is 90 ECTS (45 theoretical and 45 practical). The only exception is the Master's Degree in Maternal and Obstetric Health, which requires 120 ECTS (60 theoretical and 60 practical).
						Therefore, the Ordem dos Enfermeiros defends that the integration of nursing education in higher education will increase and consolidate the development of nursing skills, allowing for the integrated existence of training at the level of the three cycles (graduation, master, and PhD degrees), thus fostering an education that simultaneously promotes knowledge, is more focused on the knowledge that is being produced, and is able to support clinical practices. This would promote the development of nursing as a discipline and profession, and consequently, obtain health gains for the population.
Romania	1				Response Letter	We currently have many state and private schools. I personally wish you a lot of success in what you want to do, because this is not an easy thing. There are many obstacles, but you have to try. With so many leaders coming together, it is possible to have success.
Spain			X		Rafferty et al. (2019)	Supported a bachelor's degree exclusively.
						Since 2009, university studies have adapted to the European Higher Education Area. Therefore, nursing studies have become a four-year degree with the option to progress to a master's degree followed by a PhD in nursing.
						This requires 4,600 h of teaching, of which 50% was to be practical, as per the EU Directive which sets out the educational specification for nursing education. The nursing degree entails four years (210 ECTS credits) of study, which fulfils the criteria set in EU Directive 2013/55/EU.
Sweden			X		Rafferty et al. (2019)	Since 2007, as a part of the Bologna process, all registered nurses’ education in Sweden lead to a Bachelor of Science degree in nursing.
Switzerland		4			Swiss Nurse Leaders, (2019)	Compelling literature study (2019) supporting a bachelor's degree to enter the nursing profession.
					Musy et al., (2021)	It provided Swiss data and study supporting the evidence of a potential causal link between number of nurses and patient mortality.
					Eicher et al., (2022)	Lower staffing was associated with higher odds of mortality by 10% [OR: 1.10; 95% CI: 1.07–1.13].
					Baume-Schneider et al., (2018)	Higher levels of registered nurses positively impact outcome (i.e., lower odds of mortality) and lower levels negatively (for example, higher odds of mortality). Substitution of registered nurses by other professionals is not recommended. The results clearly showed that the need for skills in long-term care is increasing significantly, and that the necessary skills are not sufficiently present in practice at all levels of training and are not sufficiently taught at all levels of training. The resulting recommendations were general in nature, followed by specific recommendations for policy, education, and practice.
						General Recommendation 1: coordinated, education-specific definition of taxonomic levels of competence.
						General recommendation 2: estimation of the need for qualified personnel in the field of long-term care.
						General recommendation 3: targeted use of the education initiative of the nursing initiative.
						The impossibility of increasing the number of internship places without Limit and increasing the number of traineeships without limit, resulting in a predictable and paradoxical decrease in the annual number of graduates in the event of the opening of a higher education course.
						The absence of financial savings in the event of the opening of a vocational program (HF/ES).
						The adequacy of a bachelor's degree level competences in the face of the challenges of the 21st century healthcare system.
						The legitimate demands for increasingly high levels of competence in community and geriatric care settings.
						There would be confusion between university and professional titles. A title such as “professional bachelor” does not correspond to the very heterogeneous degrees in higher vocational education and training and only creates confusion, especially in Switzerland.
Total	12	24	3	1

3.1. Characteristics of the included evidence

The characteristics of the included evidence are reported in two sections: (1) the characteristics of the included studies, and (2) the characteristics of the included statements and reports.

3.1.1. Characteristics of the studies

We identified 10 references based on a systematic search of the databases published between 2017 and 2022. Three of these references were reviews, and seven reported empirical studies: five cross-sectional (two retrospective studies) and two longitudinal studies. One study was conducted in Asia (South Korea), one in Canada, three in Europe (Belgium, the Netherlands, and Poland), and five in the United States. Two studies included home settings, whereas the other eight focused on the hospital settings. The empirical studies aimed to investigate the impact of the staffing level of nurses with a bachelor's degree on patient-related outcomes (mortality, falls, pressure ulcers, re-admissions, length of stay, survival with good cerebral performance after cardiac arrest, the use of antipsychotic drugs, urinary catheter use, and medication incidents) and financial outcomes (cost-effectiveness).

This review aimed to investigate the body of evidence regarding the impact of nursing care provided by nurses with a bachelor's degree on patient outcomes (mortality, falls, pressure ulcers, re-admission, failure-to-rescue, length of stay, medication errors, and nosocomial infections).

The results of critical appraisal are presented in Table 3 and Table 4. Two of the included reviews had good reporting quality and one review did not report crucial aspects. The critical appraisal strategy in two references were not transparent. The dangers of publication bias and how to address it were not mentioned in the reviews.

Table 3.

Critical appraisal cross sectional studies.

Table 4.

Critical appraisal reviews.

The cross-sectional and longitudinal studies achieved different results in the critical appraisal. Mainly, the attention to confounders, which in the present question is a significant issue, was not addressed or reported appropriately.

3.1.2. Characteristics of the responses, position papers or statements

We identified 44 sources composed of response letters, mail, books, research, and position papers. The International Council of Nurses, European Federation of Nurses, and Secrétariat International des Infirmières et Infirmiers de la Francophonie responses, as well as the obtained Institute of Medicine, the World Health Organization, the American Association of Colleges of Nursing, and the Association of Women's Health, Obstetric, and Neonatal Nurses publications included an extensive bibliography and references of recent research. References and publications were mainly from North America and Europe. The responses, position papers, or statements addressed the systemic impact of a bachelor's degree in nursing as a prerequisite for entering the profession. A common marker was that all international instances and European nurse associations who responded directly underscored the importance of elaborating and disseminating a national position paper on the expected educational level of nurses.

3.2. Main results of the included evidence

The results of the studies were reported in two sections: (1) results of the included studies and (2) results of the included statements and reports.

3.2.1. Main results of the studies

The included studies suggested that a higher proportion of nurses with bachelor's degrees positively impacted the research outcomes. However, the degree of registered nurses was mentioned to be one factor that influences patient outcomes in addition to other factors, such as working hours or nurse-to-patient ratio (Bourgon Labelle et al., 2019a).

No significant effects were reported on medication errors and the use of antipsychotic drugs (Audet et al., 2018b; Backhaus et al., 2017). The results regarding disease complications and length of stay were heterogeneous (Audet et al., 2018b; Backhaus et al., 2017; Choi et al., 2021; Lasater et al., 2021; O'Brien et al., 2017). Wieczorek-Wójcik et al. (2022) and O'Brien et al. (2017) provided new insights regarding cost-effectiveness due to the increased number of staff with bachelor's or master's degrees. Both studies showed a significant cost reduction due to a higher proportion of nurses with a bachelor's degree working in the investigated wards. The results regarding failure-to-rescue, re-admission rates, and patient mortality were quite clear: the higher the rate of bachelor's-degree-level-educated nurses working in wards or hospitals, the better were these outcomes(Audet et al., 2018a; Bourgon Labelle et al., 2019b; Haegdorens et al., 2019; Lasater et al., 2021; O'Brien et al., 2018; Wieczorek-Wójcik et al., 2022).

The three identified reviews emphasized the need for further research to strengthen the body of evidence on the positive effect of a higher proportion of nurses with a bachelor's degree (Audet et al., 2018b; Bourgon Labelle et al., 2019a; O'Brien et al., 2017). Specifically, Bourgon et al. (2019) mentioned the need for longitudinal studies to support the existing evidence. Provides an overview of the results of the studies (Table 5).

Table 5.

Overview of the results of the studies.

Outcome	Significant Results	Non-Significant Results	Mixed Results		Total Studies Investigating the Outcome (After removing duplicates)	Significant Results	Non-Significant Results	Mixed Results
Fall	Coto et al. (2020)		Backhaus et al. (2017)	n	2	1		1
				%	100	50	0	50
Fall with injury	Audet et al. (2018) (1/4)	Audet et al. (2018) (3/4)		n	4	1	3
				%	100	25	75	0
Receiving antipsychotic drugs			Backhaus et al. (2017)	n	1			1
				%	100	0	0	100
In-dwelling urinary catheter	Backhaus et al. (2017)			n	1	1
				%	100	100	0	0
Medication errors		Audet et al. (2018) (2/3)	Backhaus et al. (2017),Audet et al. (2018) (1/3)	n	4		2	2
				%	100	0	50	50
Disease complications (e.g., pressure ulcer, vein thrombosis, pulmonary embolism, and nosocomial infections)	Audet et al. (2018) (1/3) Choi et al. (2021)	Backhaus et al. (2017),O'Brien et al. (2017) (1/1) Audet et al. (2018) (2/3)		n	4	2	2
				%	100	50	50	0
Discharge with good cerebral performance	Harrison et al. (2019)			n	1	1
				%	100	100	0	0
Mortality	Lasater et al. (2021)			n	1	1
				%	100	100	0	0
Seven-day re-admission	Lasater et al. (2021)			n	1	1
				%	100	100	0	0
Length of stay	Lasater et al. (2021),Audet et al. (2018) (1/4)		O'Brien et al. (2017) (3/3) Audet et al. (2018) (3/4)	n	6	2		4
				%	100	33.3	0.0	66.7
Failure-to-rescue	Bourgon et al. (2019) (6/8) O'Brien et al. (2017) (4/4) Audet et al. (2018) (6/8)	Bourgon et al. (2019) (1/8) Audet et al. (2018) (2/8)	Bourgon et al. (2019) (1/8)	n	10	8	1	1
				%	100	80	10	10
Patient mortality	Bourgon et al. (2019) (9/12) O'Brien et al. (2017 (10/10) Audet et al. (2018) (11/18) Haegdorens et al. (2019)	Bourgon et al. (2019) (2/12) Audet et al. (2018) (6/18)	Bourgon et al. (2019) (1/12) Audet et al. (2018) (1/18)	n	23	14	8	1
				%	100	60.9	34.8	4.3
Patient satisfaction	O'Brien et al. (2017) (1/1)			n	1	1
				%	100	100.0	0.0	0.0
Re-admission rate	Lasater et al. (2021),O'Brien et al. (2017) (2/2) Wieczorek-Wòjcik et al. (2022)		Audet et al. (2018) (1/1)	n	5	4		1
				%	100	80.0	0.0	20.0
Financial benefits	O'Brien et al. (2017) (1/1) Wieczorek-Wòjcik et al. (2022)			n	2	2
				%	100	100.0	0.0	0.0

3.2.2. Main results from the included responses, position papers or statements

The identified sources provided clear evidence to scale up the investment in nursing education and unambiguously advocate for a bachelor-educated nursing workforce. Hence, there was an overwhelming trend in setting the educational level of nurses at the bachelor's degree level. The main observations and findings are as follows:

• (1)Nurses are pivotal to safe, timely, efficient, effective, equitable, and person-centered healthcare systems.

This essential role will increase and strengthen in the near future. Nurses provide care and care coordination that helps ensure safe and seamless care, they serve as advocates for patients and communities, and assist in increasing individuals’ trust in and engagement with the healthcare system (The future of nursing 2030 – Buchan et al., 2022; Flaubert et al., 2021). Healthcare systems have shifted rapidly and radically in response to rising demands, technical innovations, and patient expectations. The role of nurses has become increasingly important in guaranteeing access to deliver and manage care across healthcare and social sector boundaries (The State of the World's Nursing 2020 report - WHO, 2020a; Buchan et al., 2022; Flaubert et al., 2021). Nursing education requires compatibility with the complexity of integrated care, evolving socio-demographic phenomena, accelerated care paths, higher levels of decision-making, clinical judgement, systematic integration of evidence-based practice, and team leadership.

• (2)Policymakers are key to promoting informed healthcare policies and targeted investments in nursing.

Coordinated, multilevel, and systemic interventions are required to prepare nurses adequately for challenges in healthcare, design conditions that allow nurses to work to the full extent of their competencies, engage in lifelong learning, and increase their ability to remain fully effective in nursing (Buchan et al., 2022; Secrétariat International des infimières et infirmiers SIDIIEF, 2012; Institute of Medicine of the National Academies, 2010, Flaubert et al., 2021; American Association of Colleges of Nursing, 2019, 2021). Effective workforce planning and policymaking with improved data collection and information infrastructure are required. Healthcare policies need to integrate the existing knowledge and evidence base, allow the free market to operate, and facilitate access to bachelor's degrees by removing limiting factors (such as quotas, inappropriate funding, etc.) (Buchan et al., 2022; Institute of Medicine of the National Academies, 2010; Flaubert et al., 2021; Vlaams Netwerk van Ondernemigen [VOKA] 2021).

• (3)Healthcare organizations have business cases when investing in nurses with bachelor's degrees.

Educational level determines the quality and safety of care, professional growth, level of inter-professional collaboration, patient safety and quality initiatives, development of the nursing discipline (e.g., Advanved Practice Nurses), population health, and the economic and reputational benefits (Buchan et al., 2022; Secrétariat International des infimières et infirmiers SIDIIEF, 2012; Ordem dos Enfermeiros, 2022). Nurses must be systematically involved in political decision-making processes at all levels. Educational level influences the quality of leadership, and there is a need to strengthen nurse leadership, both current and future leaders, to ensure that nurses have an influential role in healthcare policy formulation and decision-making and can contribute to the effectiveness of health and social care systems (Swiss Nurse Leaders [SNL], 2019; Schweizerische Akademie der Medizinischen Wissenschaften, 2011). Different levels of education or insufficiently differentiated care-giving profiles cohabiting complicated work organizations increase risks and generate significant hidden costs for organizations. Nurses with bachelor's degrees are a cost-effective intervention (American Association of Colleges of Nursing, 2021).

4. Discussion

The results of the studies, statements, and reports included in this review indicated that workforce with a bachelor's degree in nursing will lead to positive effects, demonstrating clear evidence of setting a bachelor's degree as a minimum requisite for entering the nursing profession.

However, the studies primarily focused on patient outcomes. The results related to failure-to-rescue, re-admission rates, and patient mortality were quite clear: the higher the proportion of nurses with a bachelor's degree working units or hospitals, the better the outcomes (Audet et al., 2018a; Bourgon Labelle et al., 2019b; Haegdorens et al., 2019; Lasater et al., 2021; O'Brien et al., 2018; Wieczorek-Wójcik et al., 2022). These results aligned with a seminal study by Aiken et al. (2014), in which the authors concluded that hospitals that employed a greater number of nurses with bachelor's degrees had lower patient mortality rates. Aiken et al. (2014) reported that a 10% increase in the proportion of nurses with bachelor's degree was associated with a 7% decrease in patient mortality, confirming the significance between nurses’ education qualification and patient outcomes. Results regarding disease complications and length of stay were heterogeneous; however, both length of stay and re-admission rates were reduced because of a higher staff level with a bachelor's degree (Audet et al., 2018b; Backhaus et al., 2017; Choi et al., 2021; Lasater et al., 2021; O'Brien et al., 2017, Wieczorek-Wójcik et al., 2022).

The results of medication administration errors were inconclusive. Evidence to support that a bachelor's degree could reduce medication administration errors was weak, although this was not significant (Audet et al., 2018). Numerous studies have examined the factors that promote medication errors, and educational attainment was identified as one of the most important and common factors associated with such medication (Kerari and Innab, 2021).

Only two studies examined financial outcomes. Wieczorek-Wójcik et al. (2022) and O'Brien et al. (2017) provided new evidence on cost-effectiveness owing to increased staffing of nurses with bachelor's and master's degrees and contributed to shortening patients’ length of stay. Therefore, it is relevant to conduct studies on the cost-effectiveness of bachelor's degree education in the future.

Additionally, the analyzed documents of the mentioned leading organizations and the different nurse associations involved in the study stressed the importance of setting the bachelor's degree level as a standard to enter the profession. A strong tendency occurs to recognize the social and strategic value of an appropriate educated nurse workforce for the future of healthcare systems. Literature also shows the central role of nurses – and the impact of the educational level- on patient safety and care satisfaction. Lowering requirements or educational level of nurses to tackle nurse shortage are regularly advocated by political decision-makers. This is a shortsighted and misguided strategy that is proven to be harmful for access, quality and safety of care (Secrétariat international des infirmières et infirmiers de l'espace francophone, 2023).

Nurse associations play a central role in strengthening cohesion, playing out the collective political force of nurses, and defining specific taxonomic levels of competence and initiatives facilitating access to a bachelor's level education. Nurses and nursing associations also play an essential role in promoting the social value of nursing (Swiss federal office of public health, 2022). A bachelor's degree in nursing not only helps nurses adapt to the demands of the jobs, but also contributes to the emancipation of a predominantly female professional group and allows the median salary of bachelor's degree holders in the country to be claimed univocally (SNL, 2019; University of applied sciences of the western part of Switzerland, 2019). Countries that set the minimum requirement for nursing education at the bachelor's degree level find this strategy very efficient in tackling nursing shortages. Concerns about shrinking recruitment basins are tackled by the perceived professional perspectives at the bachelor's degree level. Nurse associations need to take up an active role in political influence and lobbying to advocate this strategy. They should work together to have an effective impact on political choices and promote a minimal level of nurses’ education.

Due to the heterogeneity of healthcare systems and the multitude of factors to be taken into consideration, it is very complicated to determine the efficiency or cost-benefit ratio of different nursing training programs. The current demographic and epidemiological challenges in healthcare require strong competencies and the ability to deal with complex and unpredictable environments. The inflow is an important aspect and several entry routes may co-exist. However, the bachelor's level seems best suited to the demands of today's nursing work. In this respect, policies could evolve and define standards, requirements for new entrees in the profession and adjust existing systems to facilitate transition, validation of prior learning and access to a bachelor's degree.

In the future, it is important to find innovative ideas for higher education policies, practices, and funding to promote the growth and employment of nurses with bachelor's degree (in terms of education initiative, working conditions, and social and legal recognition). COVID-19 brought to the light the essential workforce and its working conditions. The world health organization, the international council of nurses and other have issued publications and recommendations to improve working conditions and retention of nurses (Buchan et al., 2022; World Health Organization 2021). The policy priority is to set education programs competency-based, through effective learning design, to meet quality standards, and is aligned with the health needs of the population (Table 5).

In our review, we identified two longitudinal studies that clearly demonstrated the positive impact of having nurses with a bachelor's on patient outcomes (Wieczorek-Wójcik et al., 2022; Lasater et al., 2021).

Further research is needed to strengthen the evidence for this positive impact of a higher proportion of nurses with bachelor's degrees, as noted in three longitudinal studies (Audet et al., 2018b; Bourgon Labelle et al., 2019; O'Brien et al., 2017).

The large number of studies that have shown such results allows for a strong recommendation for increasing the proportion of bachelor-educated nurses.

4.1. Limitations

This review included different sources of evidence; however, the statements of the associations must be viewed in light of their political forces. A critical and careful interpretation of these references is necessary. We also conducted a free web search to identify position papers; however, we cannot rule out other sources on the subject that we may not have considered. The different types of information sources were heterogeneous, and the conclusions we made from a variety of documents must be considered carefully. We did not include qualitative research papers. Qualitative research papers might have given further information on the body of evidence.

The results of the included studies strongly underline the benefits of a bachelor's degree education in nursing, but we did include the reviews and excluded the included trials, which means we mainly included a secondary data source. However, the second research question “What is the state of the evidence to set a bachelor's degree as a minimum requirement to enter the nursing profession?” was mainly addressed by the information from the position papers and letters. Although, these recommendations in the light of the results of the studies allow the conclusion that a bachelor's degree as minimum to enter the nursing profession might improve the nursing care in general and strengthen the profession, it must be considered carefully.

4.2. Conclusions

An extensive and growing body of evidence shows that a bachelor's degree as an entry level requirement for nursing affects the quality and safety of care and positively influences outcomes for patients, nurses, healthcare organizations, and society at large. Nursing experience seems inconsistently related to the occurrence of adverse events. Therefore, setting a bachelor's degree as the minimum requirement for entering the nursing profession is essential to achieve a respected, competent, and satisfied nursing workforce. However, further research, especially longitudinal studies, are required to identify the long-term effects on the dedication of nurses with bachelor's degrees on a broader range of outcomes.

Funding sources

No external funding.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

• Data is available on request.