Healthy workplace environments
During the lead up to Magnet application at our hospital—St Vincent's Private Hospital in Sydney, New South Wales, Australia—we assessed our cultural climate by using the Practice Environment Scale of the Nursing Work Index (modified for the Australian context) to diagnose gaps in the hospital work environment, as well as derive evidence of readiness for Magnet recognition.1–3 This tool allowed us to demonstrate how the links between workplace environment, nurse satisfaction, and, ultimately, patient care quality and safety are forged by the Magnet components of transformational leadership; structural empowerment; exemplary professional practice; and new knowledge, innovation, and improvement.
There's now a well-established direct and positive link between the nursing practice environment, nurse education, and both patient and staff satisfaction with care quality and safety. Recent evidence from robust data sets confirms the correlation between hospital culture and health service delivery outcomes. For example, an international study of the importance of work environments on hospital outcomes in nine countries indicated that hospitals with “better” work environments tend to have smaller percentages of nurses reporting negative outcomes (high nurse burnout, job dissatisfaction, lack of confidence that patients are prepared for discharge, and quality of care rated fair or poor) than hospitals with “mixed” or “poor” work environments.4
An earlier cross-national study of 319 nurses working on medical-surgical units in 303 acute care hospitals in the United States, Canada, England, and Scotland found that key features of good work environments, such as adequate nurse staffing and organizational support for nursing, are paramount for improving the quality of patient care and reducing nurse job dissatisfaction and burnout, leading to improved nurse retention in these settings.5
Another survey of 300 RNs in acute care hospitals across Ontario, Canada, reported that the combined effect of increased access to empowerment structures and higher levels of Magnet hospital characteristics was significantly related to nurses' positive perceptions of patient safety.6 In a different study examining the extent to which experienced nurses in Magnet hospitals confirm healthy work environments, it was reported that nurses' ratings of patient care quality directly correlates to the quality of their work environment and that visionary leadership, empowerment, and collaboration impact the development and maintenance of a healthy work environment.7
Journey vs. destination
At St Vincent's Private Hospital, our journey to Magnet was effectively in motion for some years before our recognition in 2011. As a hospital with strong nursing leadership, we were very successful in a number of initiatives to improve staff and patient satisfaction, including, but not limited to, introducing a career ladder for clinical nurse specialists that rewards advanced competencies with increased remuneration and clinical status; partnering with an interstate university to offer a 2-year, fast-track baccalaureate nursing program to Sydney students and providing them with clinical placement opportunities to increase recruitment and retention of quality new graduate nurses; establishing a preadmission center for our elective surgical patients, which provides health promotion and education before admission and ensures a more seamless transition into the inpatient care episode; and including patients as representatives in our key decision-making bodies to gain a consumer perspective.
The formal journey to Magnet recognition was a thoroughly collaborative exercise. Nurses at all levels collected data for the sources of evidence. Narratives were gathered to demonstrate the empirical outcomes of our initiatives to improve structural empowerment (nurse education and professional development opportunities) and engage in exemplary professional practice (hospital-wide nursing councils with key responsibilities for areas such as policy and procedure, research and innovation, education, and patient care quality and safety). Importantly, engaging staff members in this way evinced a palpable sense of pride and energy, which was reflected in the feedback from the appraisers who made the site visit.
The perception of nurses in Magnet, nonMagnet, and hospitals pursuing Magnet status has been well-researched. One study surveyed a national sample of 1,500 RNs in the United States (56% response rate) to ascertain nurses' perceptions regarding their profession, workplace, professional environment, and relationships based on the Magnet status of their organization. Interestingly, nurses at facilities that were in the process of applying for Magnet recognition rated their organizations highly on these characteristics.8 This suggests that changes introduced during the Magnet journey were sufficient to strengthen nurses' professional identity and pride.
Similarly, another study examined differences between nurses' ratings of organizational support, workload, satisfaction, and intent to stay at Magnet, nonMagnet, and Magnet-aspiring facilities.9 The authors found that although nurses at Magnet hospitals had significantly better scores on all subscales of the tool (Individual Workload Perception Scale), nurses from Magnet-aspiring hospitals had better scores than those from nonMagnet hospitals. Again, this suggests that the Magnet journey helps organizations provide professional practice environments for nurses.
A third study surveyed 1,783 American RNs (53% response rate) about their perceived work environment at Magnet, nonMagnet, and Magnet-aspiring hospitals (25% Magnet, 34.6% in process, and 40.4% nonMagnet).10 Organizations that were in the process of applying for Magnet recognition were significantly more likely to be rated by their RNs as “excellent” or “very good.”
It's worth noting that two articles have been published in the last 3 years that contradict the evidence discussed here. The first study reported secondary analysis of data from 837 nurses working in 171 hospitals (14 Magnet, 157 nonMagnet). A comparison of the perceived nursing practice environment and perceived patient safety found no significant difference between the two groups.11 However, the researchers acknowledged that the study had limitations, including its relatively small sample size.
Similarly, the second study, using bivariate and multivariate analyses of clinical and operational databases from the University Health Systems Consortium in the United States, found that nonMagnet hospitals had better outcomes and lower staffing numbers than Magnet hospitals.12 However, the data used were from 2005 before the Magnet model changed to include rigorous requirements demonstrating clinical outcomes. The study also had a limited sample size of 19 hospitals and many were academic medical centers that would very likely have better than average patient outcomes and higher staffing hours due to patient acuity and complexity.
So is the case for Magnet recognition justified? Several studies demonstrate that Magnet facilities have superior quality and safety indicator scores. For example, Magnet hospitals have a reported 10.3% lower fall rate than nonMagnet hospitals.13 Regarding human resources, it has been noted that Magnet hospitals are more likely to retain nurses than nonMagnet hospitals.13 And from the consumer angle, Magnet recognition confers a competitive advantage in the healthcare marketplace and should be used strategically in light of this reality.14
Making the international case
Healthcare facilities across the globe share a number of challenges: the increasing acuity of the patient case mix with a marked likelihood of comorbidities, rendering each episode of inpatient care more prone to adverse outcomes; patients are more vulnerable to unexpected deterioration and at risk for extended lengths of stay, increasing both the clinical and financial burden on care providers; and a more diverse nursing skill mix with four generations of nurses working alongside each other, each with different needs, aspirations, and challenges regarding recruitment and retention of quality nursing staff.
The Magnet Recognition Program has now been tested in relation to its relevance and applicability in six international settings. Each of these hospitals has a different political, economic, cultural, and clinical context. There's compelling empirical evidence of the relationship between the quality of the nursing practice environment and patient care outcomes in multiple jurisdictions and geographic locations. Moreover, Magnet is a robust, evidence-based framework for ensuring high levels of quality governance in nursing. At a time when patients' expectations of the care they receive are more demanding than ever, the international healthcare system owes it to them to provide evidence of high-quality care.
We suggest that the Magnet advantage is yet to be fully appreciated internationally. For this reason, the American Nurses Credentialing Center should seriously consider ways in which to promote the program beyond the borders of the United States.
1. Middleton S, Griffiths R, Fernandez R, Smith B. Nursing practice environment: How does one Australian hospital compare with magnet hospitals. Int J Nurs Pract
2. Walker K, Duff J, Di Staso R, et al. Perioperative nursing shines! Magnet designation reflected in staff engagement, empowerment and excellence. J Perioprative Nurs Australia. 2011;24(3):34,36–38,40–42.
3. Walker K, Middleton S, Rolley J, Duff J. Nurses report a healthy culture: results of the Practice Environment Scale (Australia) in an Australian hospital seeking Magnet recognition. Int J Nurs Pract
4. Aiken LH, Sloane DM, Clarke S, et al. Importance of work environments on hospital outcomes in nine countries. Int J Qual Health Care
5. Aiken LH, Clarke SP, Sloane DM International Hospital Outcomes Research Consortium. Hospital staffing, organization, and quality of care: cross-national findings. Int J Qual Health Care
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10. Ulrich BT, Buerhaus PI, Donelan K, Norman L, Dittus R. Magnet status and registered nurse views of the work environment and nursing as a career. J Nurs Adm
11. Trinkoff AM, Johantgen M, Storr CL, et al. A comparison of working conditions among nurses in Magnet and non-Magnet hospitals. J Nurs Adm
12. Goode CJ, Blegen MA, Park SH, Vaughn T, Spetz J. Comparison of patient outcomes in Magnet® and non-Magnet hospitals. J Nurs Adm
13. Drenkard K. The business case for Magnet. J Nurs Adm
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14. Tropello PG. Magnet status as a competitive strategy of hospital organizations: marketing a culture of excellence in nursing services. J Hosp Mark Public Relations