Kramer, Marlene RN, PhD, FAAN; Schmalenberg, Claudia RN, MS; Maguire, Pat RN, CNAA, MN
IN A GROUND-BREAKING 1982 study, the American Academy of Nursing identified 41 “magnet” hospitals that consistently attracted and retained nurses, that were good places to work, and that delivered excellent nursing care to patients. These attributes form part of the basis for the Magnet Recognition Program the American Nurses Credentialing Center developed in 1991.1
For over 20 years, we (and other colleagues) have studied the culture of excellence at Magnet hospitals and compared the experiences and perceptions of nurses who work there with the experiences of nurses working in non-Magnet hospitals. When attributes that staff nurses consider important to job satisfaction and productivity of quality care also are present, the work environment is magnetic.
In our 2002 study, staff nurses working in 14 Magnet hospitals identified eight attributes as essential to quality care: support for education, working with other nurses who are clinically competent, positive nurse/physician (RN/MD) relationships, autonomous nursing practice, a culture that values concern for the patient, control of and over nursing practice, perceived adequacy of staffing, and nurse-manager support.2
We'll examine each of the essentials of magnetism and its role in a magnetic work environment. We'll also discuss how staff nurses in Magnet hospitals perceive their work environment and how their perceptions differ from those of nurses in hospitals aspiring to Magnet status and those without Magnet status. Note that we didn't ask nurses to rank the eight essentials, so the discussion doesn't reflect relative importance.
Essential #1: Support for education
Magnet hospital nurses have consistently told us that educational support is highly valued for recruitment and retention, quality patient care, and job satisfaction. Both nurses and physicians consider it essential for nurses' autonomous practice and for positive RN/MD relationships.
Besides continuing education and short courses, educational support takes the form of on- and off-site degree programs. In the late 1980s and early 1990s, considerable financial support was available for degree completion. In recent years, we've seen a resurgence in student externships, new-graduate internships, and other 3- to 6-month programs, many of which had been eliminated during restructuring initiatives. Educational support is now a major factor in attracting and retaining nurses.
We developed four items to measure the extent to which staff nurses say that their organization supports education. These items measured availability, financial assistance, others' valuation of education, and organizational rewards for education. Clearly Magnet-hospital nurses have more support for education than do nurses in the other hospital types studied, Magnet-aspiring and “other,” although more than half of the Magnet- hospital nurses indicated few organizational rewards for pursuing education, which is troublesome.
Essential #2: Working with other nurses who are clinically competent
Magnet-hospital nurses have always rated this essential as “important” for quality care and “present” in Magnet hospitals; in other hospitals, staff nurses say that although it's “important,” it's often not “present.” This not only inhibits quality patient care but also is detrimental to nurse job satisfaction. Magnet-hospital staff nurses indicated that they consider specialty certification, degree education, and both formal and informal peer review and reinforcement as evidence of clinical competency.
Staff nurses in Magnet hospitals saw their co-workers as more competent than did nurses in Magnet-aspiring and “other” hospitals; nurses in Magnet-aspiring hospitals also rated their co-workers as significantly more competent than did nurses in “other” hospitals. More nurses in Magnet hospitals reported national (specialty) certification as evidence of clinical competency and were more likely to report that their hospital rewards clinical competency.
Essential #3: Positive RN/MD relationships
Physicians are increasingly dependent on nurses for the ongoing observations and assessments they need to prescribe appropriate medical care. When physicians recognize their need for the assessments and knowledge that only nurses can provide, then collegial relationships will flourish. Four-fifths of the nurses in Magnet hospitals report collegial or collaborative relationships—at least with some physicians.
Physicians and nurses ought to work collegially, on an equal footing, not only because it will increase retention and lower work stress levels for nurses but, more important, because patients will benefit.
We agree with Magnet-hospital staff nurses when they say that collegial RN/MD relationships are the key to improved patient care. Education and exquisite clinical competence are avenues to collegial RN/MD relationships and, ultimately, to better patient care.
Essential #4: Autonomy
We formulated a definition of “clinical autonomy” based on descriptions and examples provided to us in individual tape-recorded interviews with 289 staff nurses working in 14 Magnet hospitals. Autonomy is the freedom to act on what you know, to make independent clinical decisions that exceed standard nursing practice, in the best interest of the patient. Freedom is about trust and organizational sanction for autonomous practice.
Today's RNs need to know exactly what to do if a patient has a problem. As one nurse we interviewed put it, “You can't just say, ‘the doc ordered or didn't order something’ and shrug it off. That's not good enough; it doesn't work that way anymore.” Nurses in several Magnet hospitals cited “evidence-based” practice as the major source of the knowledge needed for autonomous practice.
Twenty years ago, autonomy was defined simply as carrying out the job activities of the nurse without undue supervision. Today, Magnet-hospital staff nurses consider that to be standard practice for RNs.
Essential #5: Control over nursing practice
Control over nursing practice (CNP) is a participatory process enabled by a visible, organized, viable structure through which nurses have input and engage in decision making about practice policies and issues, as well as personnel issues affecting nurses. The effectiveness of the structure is apparent in outcomes achieved and recognition of nursing's CNP by others. The enabling structure that permits CNP must be visible, viable, and supported.
Essential #6: Nurse-manager support
The support of nurse-managers affects productivity, nurse attraction, retention, and job satisfaction—the four outcomes of a magnetic work environment for nurses. Probably no role in nursing has changed as much in the last 20 years as that of the nurse-manager. In the 1980s, the job title and role responsibilities were that of a “head nurse,” the expert clinician who ran the unit and gave direct patient care. With the upheaval and increasing complexity of health care in the 1990s, however, head nurses became “managers” of one or several units, responsible for budgeting, managing or directing patient placement, and personnel management of an increasingly educated workforce.
Although the title hasn't changed, many more leadership behaviors are now expected than in the past: counseling staff, orienting physicians, providing opportunities for growth, procuring and allocating resources, and facilitating a highly professional staff to work together.
Essential #7: Adequacy of staffing
We tested staffs' perceptions of the adequacy of staffing with a single-item global indicator: The nurses in my unit feel that, most of the time, we are adequately staffed to give quality patient care. We found a significant difference among the three kinds of hospitals in the staffs' perceptions of whether staffing was adequate. In the 16 Magnet hospitals, 61% of 2,355 staff nurses said they were adequately staffed, compared with 54% of the 925 nurses in Magnet-aspiring hospitals and 49% of the 1,040 nurses in other hospitals.
Nurse-managers, the unit personification of hospital nurse leadership, are in the best position to assess staffs' perceptions of support and adequacy of staffing, to initiate dialogue between staff and other leaders, and to formulate and implement needed changes.
Essential #8: Culture of concern for patients
Culture drives both the quality of nurses' work lives and the quality of patient care. It's the normative glue that preserves and strengthens the group and provides the healing warmth essential to quality patient care.
A “culture of excellence” has always gone hand in hand with the concepts “magnetic work environment,” “highly successful,” and “excellent care.”
What exactly does “organizational culture” mean? It's a patterned, shared system of values guiding members as they solve problems, adapt to change, and manage relationships. These beliefs and shared understandings guide behavior in the work setting. An organization's culture has two major components:
* shared values—the persistent concerns, goals, and beliefs ascribed to by most people in a work group that shape the group's behavior
* norms—guides to “right” action that serve to control and regulate proper and acceptable behavior. Norms are common ways of behaving that exist and persist in a group because these responses are taught and reinforced by group members.
Cultural norms aren't published. They are things nurses know or find out by interactions with others, by feedback—a frown, for example, or a puzzled look.
Over 90% of all Magnet-hospital nurses tested said that “concern for the patient is paramount,” compared with 78% in Magnet-aspiring and 58% in other hospitals. When asked to judge “concern for the patient” against the competing value of “cost of care” we found a 13% to 14% drop in the percentage of nurses responding affirmatively in all three groups, indicating that staff in all three groups of hospitals feel the pressure of cost as a value competing with concern for the patient.
Creating a culture that values and enables the essentials of magnetism not only will increase nurses' satisfaction with work but also will improve the quality of patient care. At the end of the day, nurses, patients, and hospitals all come out ahead.
© 2008 Lippincott Williams & Wilkins, Inc.