Mills, Andrew C. PhD, RN; Gillespie, Kathleen N. PhD
INCREASING NUMBERS OF HOSPITALS are seeking recognition as Magnet hospitals to demonstrate to their constituents that they meet professional nursing standards of excellence in providing safe, quality patient care. Desirable workplace conditions and care processes are required to reflect an active professional nursing practice environment.1 To achieve Magnet status, hospitals must give evidence of having the following cluster of organizational characteristics: transformational leadership; structural empowerment; knowledge, innovation, and improvements; and exemplary professional practice. Known as the Magnet model,2 these organizational characteristics interact to form a positive work environment that should lead to better empirical outcomes.
Effective surveillance of inpatients requires, in part, sufficient numbers of registered nurses. Although adequate nurse staffing is necessary, a cluster of organizational characteristics and conditions are required to reflect an active professional practice environment.1 A model that relates work environment and nurse staffing to outcomes implies that providers in good hospitals intervene to minimize or prevent patient complications before deleterious consequences can occur.3 Thus, Magnet hospitals, which have met these conditions and implemented productive processes of care, would be expected to have better patient outcomes, including fewer avoidable patient complications.
The effect of Magnet status on nursing-sensitive patient outcomes is understudied. Therefore, the objectives of the study were to compare (1) hospital rates of pressure ulcers between Magnet and non-Magnet hospitals and (2) hospital rates of failure to rescue between Magnet and non-Magnet hospitals.
It was hypothesized that Magnet hospitals would have significantly lower rates of pressure ulcers and failure to rescue among adult, medical-surgical patients than comparable non-Magnet hospitals.
Evidence indicates that Magnet hospitals are good places for nurses to work,4 have a positive organizational climate,5 and create supportive relationships in their clinical practice.6 Although organizational and nursing benefits exist in Magnet hospitals, it is important to know whether there are associated clinical benefits. The Magnet model suggests that nurses in these good hospitals would intervene to minimize or prevent patient complications before deleterious consequences can occur.
The care in Magnet hospitals may be better than in non-Magnet facilities. Deaths among AIDS patients7 and among older adults8 are lower or less likely to occur within 30 days of admission to a Magnet hospital. Fall rates9 and patient and family complaints10 are lower in Magnet than in non-Magnet hospitals, and patient satisfaction7 and nurses' perception of better quality care11 are higher in Magnet hospitals. No differences in patient deaths from congestive heart failure or myocardial infarction are found between Magnet and non-Magnet hospitals.12 On the contrary, lower nurse staffing levels may suggest why Magnet hospitals, reported in a study, have statistically higher rates of postoperative metabolic/physiologic complications, postoperative sepsis, and selected hospital-acquired infections.12
More data are needed to determine whether nursing-sensitive outcomes are better in Magnet hospitals.13 Two nursing-sensitive outcomes known to be indicators of patient safety are the hospital rates of pressure ulcers and failure to rescue.14 They are influenced, if not preventable, by quality nursing care.
Pressure ulcers have been reported as one of the most frequent patient safety complications among Medicare patients in US hospitals from 2007 to 2009 (26.6 per 1000 at-risk hospitalizations), with a 9.23% mortality rate among Medicare admissions; almost $2 billion of excess costs of hospitalization are attributable to this negative outcome of care.15 Although the prevalence of pressure ulcers in medical-surgical patients has been identified as a nursing-sensitive measure of patient outcomes by the National Quality Forum,16 there is no certain evidence published to indicate whether Magnet hospitals, known for superior nursing care, have lower rates of pressure ulcers than non-Magnet hospitals.
FAILURE TO RESCUE
“Failure to rescue” is a term associated with patient deaths due to the unsuccessful treatment of an unexpected complication or emergency. It has the highest incidence rate in US hospitals among Medicare patients (92.7 per 1000 at-risk hospitalizations from 2006 to 2008), with, by definition, a 100% mortality rate.17 Nurse staffing has been associated with failure to rescue. Patients in hospitals units with more registered nurses,18 increased nurse-to-patient ratios,19 and more baccalaureate-prepared nurses20 have a better chance of surviving an untoward event. Although the evidence indicates that failure to rescue is a nursing-sensitive outcome,21 only 1 published study has compared Magnet and non-Magnet hospitals and reported no difference in the outcome.12
A retrospective design using secondary data analysis was undertaken to compare rates of pressure ulcers and failure to rescue in Magnet hospitals and non-Magnet hospitals. Statistics were calculated using IBM SPSS for Windows version 19 (International Business Machines Corp, Armonk, New York). Approval to conduct the study was received from the appropriate institutional review board.
Source of data
Five years (2001-2005) of patient- and hospital-level data were obtained from 5 separate Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) databases of US hospitals, with all-payer patient data developed by the Agency for Healthcare Research and Quality (AHRQ).22 Additional hospital data from the annual surveys conducted by the American Hospital Association (AHA) were merged with the 5 HCUP databases.
Released annually with a 2-year time lag, the HCUP NIS is the largest collection of data on all-payer inpatient stays in geographically dispersed US hospitals. The database contains patient-level demographics, clinical information, and resource variables usually found on discharge abstracts. The HCUP NIS is designed to be a 20% sample of US community hospitals as defined by the AHA. The sample is a stratified probability sample of hospitals, with sampling probabilities proportional to the number of US community hospitals in each stratum. The number of participating states each year ranged from 33 to 37 (representing from 986 to 1054 hospitals, with 7.4-8.0 million discharges annually). However, several participating states withheld hospital identifiers.
Sampled hospitals from the 5 years of separate databases were pooled. Because the focus was on adult inpatients in community hospitals, children's hospitals and federal hospitals were excluded from further study. In addition, linking to the AHA data requires hospital names, so hospitals from states that did not provide hospital identifiers were excluded. Duplicate and triplicate listings across the databases were removed.
Pressure ulcers were defined as the secondary diagnosis of a decubitus ulcer specified by the International Classification of Diseases, Ninth Revision, Clinical Modification, codes of 707.00 to 707.09. Patients did not have pressure ulcers on admission; all pressure ulcers were hospital acquired. The database included medical-surgical patients (18 years and older) discharged after a length of stay of 5 days or more. Patients admitted from a long-term care facility and those transferred from an acute care facility were excluded because of their greater likelihood of having pressure ulcers from the prior facility admission.23 The AHRQ assessed construct validity of the measure by an expert panel review and 2 empirical studies. The AHRQ also reported the measure's signal to noise ratio to be 85.6%, indicating high reliability for the risk-adjusted rate when applied to detect differences across hospitals.
Failure to rescue
Failure to rescue was defined as deaths due to complications of care related to pneumonia, deep vein thrombosis/pulmonary embolus, sepsis, acute renal failure, shock/cardiac arrest, or gastrointestinal hemorrhage/acute ulcer. The database included medical-surgical patients between 18 and 74 years of age. Patients 75 years and older were excluded because of the increased likelihood of having a do-not-resuscitate status. Patients transferred to or from an acute care facility and those admitted from a long-term care facility were also excluded to avoid possible effects on the patients' status from other institutions. The AHRQ determined construct validity on the basis of a review of the literature and an empirical analysis of the measure. The measure's signal to noise ratio was 66.6%, indicating a moderately high reliability.
In addition to expected rates for both outcomes, 2 risk-adjusted rates were calculated. Because the HCUP NIS data are patient discharge-level information, rates of pressure ulcer and failure to rescue were risk adjusted to reflect the patient's state at the point of hospital admission. Following the AHRQ's recommended algorithm, risk-adjusted rates were calculated by controlling for patient age, sex, severity of illness by diagnosis, and the presence of comorbidities and comparing with a reference population database of 38 states that comprises the AHRQ State Inpatient Database. The risk-adjustment procedure incorporated regression coefficients and variable means predetermined by the AHRQ from its reference population database. The risk-adjustment procedure also produced a smoothed rate using a multivariate signal extraction technique based also on the State Inpatient Database. A smoothed rate is considered more reliable over time and across hospitals, showing less fluctuation from year to year.
Identification of Magnet hospitals
The number of hospitals in 2005 recognized with Magnet status was about 3.5% (n = 201) of the total number (N = 5747) of US hospitals meeting the criteria of the AHA for a hospital facility.24 Magnet hospitals identified from the ANCC Magnet Recognition Program Web site were cross-linked with hospitals in the HCUP NIS databases. Magnet hospitals were verified by name, city, state, AHA number, and the year Magnet status was achieved.
Recognition as a Magnet hospital is considered current for 4 years after being designated by the American Nurses Credentialing Center. Therefore, sampled hospitals that had been recognized with Magnet status within the 4-year Magnet designation period and listed in any of the 5 HCUP NIS databases were included in the study. Magnet hospitals were also included that would have been 1 or 2 years in progress of seeking Magnet status prior to their actual designation. Including hospitals up to 2 years prior to their formal recognition acknowledged that the journey for Magnet status is based on a record of sustained achievement.25 For multiple entries in the pooled databases, the listing closest to the actual Magnet designation year was retained.
None of the Magnet hospitals had missing data on the study variables. After removing non-Magnet hospitals with missing data, a total of 1713 potential comparison hospitals were identified in 27 states. Because of the study's retrospective design, there was no control over the assignment of hospitals to Magnet status. Magnet hospitals were identified ex post facto in these databases. An inherent bias would have been introduced into the study had all potential non-Magnet hospitals been used as a comparison group. Therefore, non-Magnet hospitals were matched with Magnet hospitals to reduce possible bias estimates, balance the effects of the covariates between groups, and avoid possible confounding of results.26
Twelve hospital characteristics were used in the matching process to control for possible organizational effects on patient outcomes or adverse events: geographic region, urban/rural, community population, patient discharges, bed size capacity, control/ownership, teaching status, average length of stay, Medicare patients (%), Medicaid patients (%), private insurance and health maintenance organization patients (%), and average patient charges. The hospital's average length of patient stay and patient charges for all inpatients were expected to affect the nurse-sensitive outcomes as proxies for a hospital's use of nursing resources. The selection of covariates for the model was not to draw statistical inference but to incorporate those that might influence the probability of being a Magnet hospital. The matching process included interaction and quadratic terms among the covariates. Thus, all available hospital characteristics traditionally used in organizational studies were included in the matching process. Nursing personnel information, staffing levels, and work environment variables were not available for additional analysis.
A total of 80 Magnet hospitals in 23 states were identified in the pooled databases of sampled hospitals; 80 non-Magnet hospitals were matched in 22 states on the basis of their characteristics. An attempt to match a second set of non-Magnet hospitals failed because of statistical dissimilarities in covariates. Thus, a total of 160 hospitals were used for the analysis.
Of the 4 regions of the country, the northeast region had the largest clustering of Magnet hospitals. Most of the 80 Magnet hospitals were not for profit and located in urban areas with large populations. Only 1 Magnet hospital was investor owned. The average community population in which the hospitals were located was more than 1 000 000 people. Most Magnet hospitals were not classified as teaching hospitals and tended to be large in bed capacity and in the number of annual patient discharges. The average number of staffed beds was 422 beds, with more than 23 000 annual discharges. In the distribution of hospital payer mix, most patients in Magnet hospitals had private insurance and/or were in a health maintenance organization followed by Medicare as the expected payer. The average patient stay was 4.8 days, with patient charges of nearly $25 000.
As would be expected from the matching procedure, there were no statistical differences (P > .05) across the 12 hospital characteristics. Of the 80 matched non-Magnet hospitals, 12 hospitals have since received Magnet status and 13 of the Magnet hospitals have lost their designation, as of 2012.27
Two patient outcomes
Statistical analyses for rates of pressure ulcer rates and failure to rescue demonstrated no differences (P > .05) between Magnet and non-Magnet hospitals (Table). Expected, risk-adjusted, and smoothed rates for both patient outcomes showed no differences on the basis of Magnet status.
Table. Comparison of...Image Tools
The results of this study provide no conclusive evidence that the rates of pressure ulcer and failure to rescue are better in hospitals known for their excellence in nursing care than in their matched counterparts. Although the percentage of susceptible inpatients who developed pressure ulcers in this study may seem low, approximately 2.0%, the clinical impact is not inconsequential. The actual percentage from all US hospitals is probably somewhat higher. It is known that nosocomial pressure ulcers extend patients' lengths of stay, add to hospitals costs, increase patients' discomfort, and even threaten their lives. Patients with pressure ulcers remain hospitalized more than 8 days longer than patients with average hospitalization and incur almost double the average hospital charge.21 Hospitals that achieve lower rates reduce the physical and emotional discomfort experienced by patients and families, human and fiscal resources expended, and financial burden placed on payers, especially Medicare and Medicaid, which assume the largest portion of reimbursements to hospitals for pressure ulcer care.
Of equal concern is the average rate of failure to rescue in Magnet and non-Magnet hospitals. Not only are patients' lives threatened but also approximately 12% of the patients at risk for medical complications actually die. Failure to rescue not only involves a patient's severity of illness but also includes the capacity of providers to prevent or intervene in a timely and knowledgeable manner. Risk adjustment of the variable addresses the former in the analysis. The Magnet journey supports increasing levels of baccalaureate-prepared nurses with the implication that more educated nurses have better capacity to act knowledgeably. Indeed, they are known to have an impact on rates of failure to rescue20; yet, because nursing personnel data were not available for analysis, an inference from the current study cannot be made about Magnet hospitals having more baccalaureate-prepared nurses to make a difference in rates of failure to rescue.
More systematic, comprehensive actions have been shown to be effective with pressure ulcers and failure to rescue, such as nurses taking a “bundled” approach toward pressure ulcers,28 and prevention strategies for impending failure to rescue, such as early warning systems, active surveillance, and the use of rapid response teams during medical emergencies.29 However, the HCUP NIS databases do not contain information on whether hospitals incorporate these effective nursing interventions.
Secondary data analysis using the HCUP databases incorporated variables for which they were not originally intended—to compare outcomes in Magnet and non-Magnet hospitals. The variables were defined, measured, and collected prior to this study. An understanding of the study's results might be clearer had additional empirical data been available in the databases on nurse staffing, nurse education levels, work place environment, and other essential conditions of the Magnet model. In addition, some concern has been raised whether clinical data recorded in patients' discharge abstracts, such as failure to rescue, are sufficiently captured and coded consistently across hospitals.30
Current evidence indicates that the value of achieving Magnet recognition is primarily at the organizational level by creating a superior practice environment for nurses. Ideally, a better nursing environment would lead to better patient outcomes. This study examined the relationship between Magnet status and 2 clinical outcome measures that have been associated with nursing care and found no significant differences between Magnet and non-Magnet hospitals. Going forward, researchers should continue to examine the link between Magnet status and patient outcomes. Perhaps, more complex models are needed that measure the intermediate Magnet outcomes of increased nurse satisfaction and retention as factors influencing patient outcomes.
It may be that some non-Magnet hospitals choose not to allocate their resources toward the Magnet journey yet attain nursing-sensitive outcomes at the same level as Magnet hospitals. At the time of the study, 201 hospitals had achieved Magnet status. Today, there are more than 390 hospitals.27 Their increasing numbers suggest that these hospitals recognize an inherent benefit to earning the designation. Researchers should continue to examine whether Magnet status has an impact on other clinical indicators of patient safety and quality nursing care. As more hospitals are recognized as Magnet facilities and greater emphasis is placed on measuring and achieving excellent patient outcomes, clearer differentiation may emerge between those holding the designation and those that do not.
1. Kramer M, Maguire P, Brewer BB. Clinical nurses in Magnet hospitals confirm productive, healthy unit work environments. J Nurs Manag. 2010;19(1):5–17.
2. Wolf GA, Triolo P, Ponte PR. Magnet Recognition Program. J Nurs Adm. 2008;38(4):200–204.
3. Aiken L, Sochalski J, Lake ET. Studying outcomes of organizational change in health services. Med Care. 1997;35(11):NS6–NS18.
4. Kelly LA, McHugh MD, Aiken LH. Nurse outcomes in Magnet and non-Magnet hospitals. J Nurs Adm. 2011;42(1):33.
5. Stone PW, Mooney-Kane C, Larson EL, Pastor DK, Zwanziger J, Dick AW. Nurse working conditions, organizational climate, and intent to leave in ICUs: an instrumental variable approach. Health Serv Res. 2007;42(3 I):1085–1104.
6. Hess R, Desroches C, Donelan K, Norman L, Buerhaus PI. Perceptions of nurses in Magnet® hospitals, non-Magnet hospitals, and hospitals pursuing Magnet status. J Nurs Adm. 2011;41(7/8):315–323.
7. Aiken LH, Sloane DM, Lake ET, Sochalski J, Weber AL. Organization and outcomes of inpatient AIDS care. Med Care. 1999;37(8):760–772.
8. Aiken LH, Smith HL, Lake ET. Lower Medicare mortality among a set of hospitals known for good nursing care. Med Care. 1994;32(8):771–787.
9. Lake ET, Shang JJ, Kaus S, Dunton NE. Patient falls: association with hospital Magnet status and nursing unit staffing. Res Nurs Health. 2010;33(5):413–425.
10. Havens DS. Comparing nursing infrastructure and outcomes: ANCC Magnet and non-Magnet CNEs report. Nurs Econ. 2001;19(6):258–266.
11. Schmalenberg C, Kramer M. Essentials of a productive nurse work environment. Nurs Res. 2008;57(1):2–13.
12. Goode CJ, Blegen MA, Park SH, Vaughn T, Spetz J. Comparison of patient outcomes in Magnet® and non-Magnet hospitals. J Nurs Adm. 2011;41(12):517–523.
13. McClure ML, Hinshaw AS. The future of Magnet hospitals. In: McClure ML, Hinshaw AS, eds. Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses. Washington, DC: American Nurses Publishing; 2002:117–127.
15. Reed K, May R, Nicholas C, Taylor H, Brown A. HealthGrades Patient Safety in American Hospitals Study. Denver, CO: HealthGrades Inc; 2011.
16. National Quality Forum. National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. Washington, DC: National Quality Forum; 2004.
17. HealthGrades. HealthGrades Seventh Annual Patient Safety in American Hospitals Study. Denver, CO: HealthGrades Inc; 2010.
18. Blegen MA, Goode CJ, Spetz J, Vaughn T, Park SH. Nurse staffing effects on patient outcomes: safety-net and non-safety-net hospitals. Med Care. 2011;49(4):406–414.
19. Ghaferi AA, Osborne NH, Birkmeyer JD, Dimick JB. Hospital characteristics associated with failure to rescue from complications after pancreatectomy. J Am Coll Surg. 2010;211(3):325–330.
20. Kendall-Gallagher D, Aiken LH, Sloane DM, Cimiotti JP. Nurse specialty certification inpatient mortality, and failure to rescue. J Nurs Scholarsh. 2011;43(2):188–194.
21. Schmid A, Hoffman L, Happ MB, Wolf GA, DeVita M. Failure to rescue: a literature review. J Nurs Adm. 2007;37(4):188–198.
22. Agency for Healthcare Research and Quality. HCUP databases. Healthcare Cost and Utilization Project (HCUP): overview of the Nationwide Inpatient Sample (NIS). http://www.hcup-us.ahrq.gov/nisoverview.jsp
. Published 2006. Accessed August 1, 2006.
25. Lundmark VA, Hickey JV. The Magnet Recognition Program: understanding the appraisal process. J Nurs Care Qual. 2006;21(4):290–294.
26. Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effects. Biometrika. 1983;70:41–55.
28. Gray-Siracusa K, Schrier L. Use of an intervention bundle to eliminate pressure ulcers in critical care. J Nurs Care Qual. 2011;26(3):216–225.
29. Shever LL. The impact of nursing surveillance on failure to rescue. Res Theory Nurs Pract. 2011;25(2):107–126.
30. Bobay KL, Fiorelli KL, Anderson AJ. Failure to rescue: a preliminary study of patient-level factors. J Nurs Care Qual. 2008;23(3):211–215.
failure to rescue; hospital mortality; Magnet hospital; nursing-sensitive patient outcomes; outcomes assessment; pressure ulcer
© 2013 Lippincott Williams & Wilkins, Inc.