Historically, the nursing profession has been plagued with cyclic nursing shortages. Healthcare experts predict the latest shortage to be the most significant of its kind based on several compounding factors. The first factor is the aging nursing workforce. A 1996 National Sample Survey of Registered Nurses revealed that the average age of employed Registered Nurses (RN) was 42.3 years. In June 2000 the Journal of the American Medical Association reported on a retrospective cohort analysis of employment trends of recent RNs over their lifetimes. The study found that the number of full-time equivalent RNs observed in recent cohorts has been approximately 35% lower than that observed at similar ages for cohorts that entered the labor market 20 years earlier (Buerhaus, Staiger, & Auerbach, 2000). The second factor involves the declining enrollment into Baccalaureate Nursing Programs, a fact that compounds the nursing shortage. The American Association of Colleges of Nursing reported that entry-level enrollees in Baccalaureate Nursing Programs steadily decreased 6.73% from 1995 to 1998.
Due to the every increasing concern of the pending nursing shortage, healthcare organizations are developing proactive measures to position themselves to combat the shortage. One such measure is obtaining “magnet hospital” status. The term magnet hospital was coined originally to describe hospitals that had no difficulty attracting nurses. It stemmed from studies conducted in the 1980s that attempted to identify leadership characteristics and professional practice attributes of nurses within these organizations (Scott, Sochalski, & Aiken, 1999).
The American Nurses Credentialing Center (ANCC), the nation’s largest and foremost nursing accrediting and credentialing organization, administers the Magnet Recognition Program. Magnet Status is awarded to health care organizations that demonstrate sustained excellence in nursing care. This program was developed by the American Nurses Credentialing Center in 1994 to recognize health care organizations that provide the very best in nursing care and upholds the tradition within nursing that supports professional nursing practice. The Magnet Recognition Program is based on quality indicators and standards of nursing practice as outlined in the American Nurses Association's Scope and Standards for Nurse Administrators. It measures both qualitative and quantitative factors of nursing services (ANCC, 2003).
The magnet Recognition Program provides a framework to recognize excellence in four ways: the management philosophy and practices of nursing services; adherence to standards for improving the quality of patient care; leadership of the chief nurse executive in supporting professional practice and continued competence of nursing personnel; and attention to the cultural and ethnic diversity of patients and their significant others, as well as the care providers in the system (ANCC, 2003).
The ANCC has four objectives for establishing the Magnet Recognition Program (ANCC, 2003):
Additional information about the Magnet Recognition Program is available on line at www.nursingworld.org/ancc/ (ANCC, 2003).
The American Academy of Nurses (AAN) published the initial study of 41 magnet hospitals in 1983. This initial study continues as the most extensive study of hospital organizations and it is the basis for comparison for all subsequent studies.
As the concepts of magnet status became solidified, the research methodology moved from qualitative to quantitative in its application. The purpose of the initial AAN research was to identify the organizational characteristics of magnet hospitals that enabled them to recruit and retain nursing staff. Descriptive studies performed from 1983 to 1991 focused on characteristics of nursing service organizations within magnet hospitals. Comparisons were made with non-magnet hospitals.
Prior to 1994, no connection had been made between magnet hospitals and patient outcomes. In 1994, the gap between the two bodies of knowledge was bridged. This was accomplished by making the connection between magnet hospitals and decreased Medicare mortality (Aiken et al., 1994). At the same time, the study methods had evolved into more rigorous designs moving from descriptive (Kramer & Schmalenberg, 1988, 1991; Kramer, 1990) to more quasi-experimental designs (Aiken, Smith & Lake, 1994).
The variables of the research have progressed from an overall organizational descriptive overview of hospitals (AAN, 1983) to the nursing service organization (NSO) level (Kramer, 1990). At the NSO level the staff mix, structure, and governance was examined. Recent research focused on patient outcomes and satisfaction level (Aiken et al., 1994; Aiken et al., 1997, & Aiken et al., 1999).
This same progression was noted in the area of selecting study subjects. The subjects in the initial AAN research report were at the organizational level in which the subjects were deemed to be the hospitals themselves. The subjects in research conducted by Kramer et al. progressed to the NSO level and were viewed as nurses within a system. Finally, the subjects from the Aiken et al. research progressed to the most basic level, that of the patient.
The data analysis began as descriptive analysis (AAN, 1983; Kramer & Schmalenberg, 1988, 1991; Kramer, 1990). It has progressed to more quantifiable techniques (Aiken et al., 1994, 1997, & 1999). One particularly useful technique is that of logistic regression (Aiken et al., 1997; 1999). It is especially useful in the measurement of outcomes. It calculates the odds of one outcome occurring rather than other possible outcomes. Because of the current clinical interest in predicting outcomes of nursing practice, this procedure is expected to become increasingly important to nursing research (Burns & Grove, 1997).
The conclusions published in these research reports begin with the identification of organizational characteristics identified in 41 hospitals known for recruitment and retention of nurses (AAN, 1983). Those characteristics included a strong and visible leader, good collaboration, flexible work schedules, and good nurse-physician relationship. Follow-up studies in 1988 (Kramer & Schmalenber, 1988) and 1990 (Kramer, 1990) revealed little change in core practices or performances of magnet hospitals.
In 1994, research about patient mortality identified a direct correlation between nursing autonomy and control to patient mortality (Aiken et al., 1994). This research found excessive mortality of 5% in the control group versus that of magnet hospitals. The latest research report published in 1999 discovered a decreased mortality by a factor of 0.40 (Aiken et al., 1999). The research also noted an increase in patient satisfaction within magnet hospitals as compared to conventional hospitals. Dr. Linda Aiken's research shows that Magnet Designated facilities consistently out-perform their peers in recruiting and retaining nurses (ANCC, 2003).
A 1997 research report about nurse injury revealed that nurses in magnet hospitals are less likely to sustain an injury (i.e. needlestick, exposure to blood) by a factor of 0.37 in the prospective study and 0.18 in the retrospective study (Aiken et al., 1997).
The initial research report titled Magnet Hospitals: Attraction and Retention of Professional Nurses, began in 1982 and was performed by Margaret L. McClure, Muriel A. Poulin, Margaret D. Sovie, and Mabel A. Wandelt. It was subsequently published in 1983 by the American Academy of Nursing. Its purpose was to identify hospitals that seemed to attract and retain nurses. It also intended to identify and describe the organizational practices that promoted nursing satisfaction. A descriptive study was performed using 41 identified magnet hospitals. The variables included type of hospital ownership, hospital size, nursing leaders education level, and techniques used in recruitment and retention of nurses. The sources used to collect the data included a Hospital Index Form for demographic data, organizational charts to evaluate organizational structure, and an interview form for the staff nurse that included nine specific questions.
The validity of the study was decreased due to self-reporting of key data as well as the fact that each hospital’s Director of Nursing (DON) selected the staff nurse to be interviewed. This automatically introduced a bias on the part of the DON. Reliability was decreased due to the use of several separate interviewers. The inclusion criteria for this study consisted of three factors: 1) the hospital was considered a good place to work, 2) must have had a record of increased ability to recruit and retain nursing staff, and 3) the hospital must have been in direct competition with other facilities. The exclusion criteria for the study involved the staff nurse interview. The staff nurse to be interviewed could not have any type of charge responsibilities.
Through the descriptive analysis process the researchers found that the magnet hospitals had certain characteristics that included a strong, visible leader, good collaboration, flexible work schedules, and a good nurse-physician relationship.
A follow-up study to the original magnet study was published in 1988 by Marlene Kramer, RN, PhD, FAAN and Claudia Schmalenberg, RN, MS titled Magnet Hospitals: Institutions of Excellence Part I and II. The purpose of this study was to ascertain to what extent magnet hospitals possessed characteristics similar to the best-run companies in the corporate community. The method used was a descriptive analysis using the eight functional attributes or principles of operations identified as key success factors within the corporate community developed by Peters and Waterman, 1982. The definitions provided included those of the magnet hospitals, best run companies, and principles of operation. Data sources and collection included interviews with over 800 staff nurses, questionnaires to provide statistical data, interviews with Chief Nurse Executives (CNEs), and observational visits to all shifts at each of the hospitals.
The validity of the study was decreased due to self-reporting of the statistical data. The limited disclosure of data collection techniques in both the interviews and during observations made it impossible to accurately assess the study’s true validity and reliability. The analysis, of the results and the conclusions appeared to be based on both the interviewers and observers’ professional expertise. However, the assessment was not made against any specific measurement criteria.
Their conclusions were that many of the basic principles of the excellent companies are clearly present in magnet hospitals.
In 1990 a follow-up to the 1988 study titled The Magnet Hospitals: Excellence Revisited was conducted by Marlene Kramer. The purpose of this study was to assess the magnet hospitals recruitment and retention success since their evaluation in 1988. The study design involved a descriptive analysis that evaluated variables such as staff mix, nursing service structure, governance, nursing care delivery system and work force extenders (i.e. supplement staff). All terms used in the study referred to previous 1986 study. Data collection included hospital records and a telephone survey of the CNE.
The validity of the study was decreased due to self-reporting procedures. Reliability of the study is in question based on the uncertainty of a survey protocol as well as the uncertainty of the number of surveyors. The subjects included 16 of the original 41 magnet hospitals. This fact plus the willingness to participate in the study served as both the inclusion and exclusion criteria. The descriptive based its comparisons on the 1988 study. The study concluded that little change has occurred in the core practices or performances of magnet hospitals from previous studies.
In 1991, a descriptive study titled Job Satisfaction and Retention: Insights for the 90s was published by Marlene Kramer and Claudia Schmalenberg. The purpose of this study was to evaluate how successful magnet hospitals have been in retaining nurses compared to other hospitals. It also sought to compare the nurse experience of magnet hospitals with experiences at non-magnet facilities. The method used was a descriptive study that looked at variables such as organizational structure, professional practice, management style, quality of leadership, and professional development. Each of the variables were defined and remained consistent throughout the study. The data sources and collection involved a 4-point Likert scale survey involving over 1800 nurses across the country. Of those nurses, 939 were from magnet hospitals and 808 respondents were from and approximate pool of 5000 Nursing89 subscribers employed in hospitals. The respondent profile (i.e. education levels, experience) of both the magnet nurses and the control panel of nurses were almost identical, strengthening the validity of the study. However, using subscribers of a nursing magazine could possibly bias the sample as well as decreasing the studies validity. This is because there is no way to insure that magnet nurses were not part of the control panel that was selected. The researchers found that magnet hospitals continue to maintain an edge in nursing recruitment and retention, as evidenced by lower vacancy rates, lower turnover rate, and higher RN to patient ratios. The important aspects of nursing continue to be organizational structure, professional practice, management style, quality of leadership, and professional development. In all five categories magnet hospital nurses rated their satisfaction higher than that of the control panel nurses. The most dramatic finding of the survey was that the nurses’ self-image differs markedly from what was perceived as the hospital’s image of the nurse. Both magnet hospital and control panel nurses presented a lower estimated perception of how they feel the physicians, administrators and the public views them. Although it was one of the smaller studies presented, it provided a large amount of insight and usable information.
A study by Linda H. Aiken, PhD, Herbert L. Smith, PhD and Eileen T. Lake, MPP in 1994 was titled Lower Medicare Mortality Among a Set of Hospitals Known for Good Nursing Care. It tried to determine if magnet hospitals had lower Medicare mortality than otherwise similar hospitals. The study was designed as a quasi-experiment. The independent variables included average daily census, occupancy rate, number of beds, and geographic area size. The dependent variable was Medicare mortality rate. The only term defined within this study was that of mortality being defined as death within 30 days of admission. Data sources included the American Hospital Association (AHA) survey in which demographic data were obtained. Health Care Financing Administration (HCFA) reports provided the Medicare mortality rates. T-tests were performed within the framework of the random-effects analysis-of-variance (ANOVA). Significance was listed as P< .001. The reliability of the estimated mortality reduction effect was 0.75. The subjects included 39 of the original magnet hospitals and 195 control hospitals. Each of the magnet hospitals were matched using multivariate matching procedure to arrive at five comparative control hospitals for each magnet hospital. An inclusion criterion was the fact that the control hospitals must have a minimum of 100 Medicare discharges. A possible weakness to the study was the fact that magnet hospitals were not held to that same standard. The findings included 5 less deaths per thousand in magnet hospitals than in the control hospitals. After controlling for the increased RN to patient ratio in magnet hospitals, it was found that nursing autonomy and control over practice was a contributing factor to lower mortality rates seen in magnet hospitals.
In 1997, a study titled Hospital Nurses’ Occupational Exposure to Blood: Prospective, Retrospective, and Institutional Reports was conducted by Linda H. Aiken, PhD, Douglas M. Sloane, PhD, and Jennifer L. Klocenski, MA. The purpose of this study was to examine nurses’ risk of exposure to blood resulting from injury, methods to estimate those risks, and factors affecting risk. This was assessed in an attempt to determine how the organization of inpatient hospital care is related to nurse and patient outcomes. The method used included an analysis and comparison of prospective and retrospective data as well as institutional reports. The variables included frequency of handling blood, frequency of recapping needles, frequency of precautions to avoid contact with blood/body fluid, hospital type, and unit type. A statistical analysis was performed that included a two-tailed exact significance test, two-way cross-classification, and logistic regression techniques. The only definition provided within the research report was that of injury, the key dependant variable. The data sources and collection involved questionnaires, prospective reporting over a 30-day period, and institutional reports. The subjects included 920 staff nurses as part of the prospective data collection and 865 of the 920 staff nurses the participated in the prospective data collection were also involved in the retrospective questionnaire. The results included the fact that magnet nurses were less likely, by a factor of 0.37 in the prospective study and 0.18 in the retrospective study, to incur an injury than their counterparts.
The latest magnet hospital study was published in 1999 by Linda H. Aiken, PhD, Douglas M. Sloane, PhD, Eileen T. Lake, MSN, MPP, Julie Sochalski, PhD, and Anita L. Weber, PhD titled Organization and Outcomes of Inpatient AIDS Care. The purpose of the study was to compare differences in AIDS patients’ 30-day mortality and satisfaction with care in dedicated AIDS units, scattered-bed units in hospitals with and without dedicated AIDS units, and in magnet hospitals known to provide good nursing care. The design included a multi-site internal replication with both matched-control hospitals and internal control units. The dependent variables included mortality and patient satisfaction. No definitions were specifically defined. Data sources included the AHA annual survey that established hospital structure and demographics. Research nurses conducted patient survey interviews. The use of multiple researchers could introduce bias therefore decreasing the study’s validity. However, logistic regression procedures served to strengthen the argument that the observations across different sites were not independent. The subjects included 1205 consecutively admitted patients to 40 units within 20 hospitals. Nurses surveyed totaled 820. This included both RNs and licensed practical nurses (LPNs). Adding LPNs to the survey results decrease the validity of the survey results since to be included in the study they are not viewed in terms of professional nursing. Because the hospital sample included only 2 magnet hospitals, the conclusions as they relate to magnet hospitals could be drastically skewed. An inclusion criterion was the fact that the hospitals had to be located in cities with a high prevalence of AIDS. Exclusion criteria for the subjects included any admission less than 3 days in length and any individual’s subsequent readmission. There was a decrease in mortality by a factor of 0.40 for magnet hospitals. There was increased patient satisfaction in magnet hospitals that was directly correlated to nurse control and autonomy.
Magnet hospitals have been identified as institutions that have strong and visible leaders, good collaboration, flexible work schedules, good nurse-physician relations, and increased nurse autonomy. As a result, magnet hospitals are high in several factors, including nursing satisfaction with practice, patient satisfaction with care, decreased Medicare mortality, and decreased nursing needlestick injury and blood exposure. Specific magnet hospital traits have been correlated with particular outcomes. For example, the degree of nurse control and autonomy seems to be positively related to patient satisfaction. High nurse satisfaction also appears to be a direct result of nurse control and autonomy. Decreased nursing needlestick injury and blood exposure has been attributed to the low nursing turnover and agency nurse use in magnet hospitals.
It is important to have researchers such as Kramer and Aiken as drivers of the research of magnet hospitals. Their intimate working knowledge of magnet hospitals provides a framework for other researchers to follow. It is also important for new perspectives within a unique body of knowledge. Therefore, it would be highly advantageous to introduce new researchers within this field of study to bring in new techniques and innovations.
Many of the magnet hospital studies have been descriptive in nature. In the initial research, descriptive analysis was essential in the identification of the phenomenon occurring within magnet hospitals. Subsequent studies should begin to reflect more rigorous, quantitative research designs such as logistic regression in which researchers could use to predict outcomes of nursing practice. With the emergence of the information age, databases can decrease cost and increase applicability of measurable data.
The arrival of managed care opens the possibilities of future research that correlates magnet hospitals with overall hospital cost savings. For example, a correlational study could be conducted to assess the readmission of patients to magnet hospitals versus similar non-magnet facilities. This readmission rate could then be quantified into actual hospital costs. There are several advantages to conducting research of this type. First, a database already exists in which this data is being captured. A second advantage is that this type of research would potentially show a direct correlation between magnet hospitals and cost savings. Cost has increasingly become an issue with the emergence of managed care.
The magnet hospital research studies are some of the few studies that actually quantify the importance of nursing care by correlating nursing care with patient outcomes. Magnet hospital research studies began out of necessity amidst a national nursing shortage. Our nation is again on the cusp of a nursing shortage that has been defined by many as one that will be larger and last longer than has been seen in the past. Therefore, the studies conducted since 1983 hold a particular relevance in the present healthcare environment. Researchers would do well to continue expanding this body of knowledge. Expanded knowledge is needed in the areas of patient outcomes and cost containment as well as its initial purpose of identifying nursing recruitment and retention strategies.
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