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Making Informed Employment Decisions: Questions to ask and issues to consider.

Monarch, Kammie JD, MS, RN

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AJN, American Journal of Nursing: 2003 - Volume 103 - Issue - p 29-32

Are you a new nursing school graduate looking for your first job or an experienced nurse exploring employment opportunities? How should you begin? Should your choice of a hospital be based on the patient population or on the most appealing practice specialty? Although such criteria are important, your decision should be also based on additional information; namely, the extent to which the work environment seeks to achieve excellence. Understanding a prospective employer’s commitment to excellence will help you to make a more informed decision, resulting in a satisfying employment experience. How can you ascertain this information? The nursing profession has studied the issue.

In 1983, Margaret L. McClure, EdD, RN, FAAN, and colleagues, published the results of an American Academy of Nurses study of hospitals that were successful in recruiting and retaining nurses and the factors that contributed to that success. 1 Because of their ability to attract and retain nurses, these hospitals were designated “magnet” hospitals, and the factors that distinguished them became known as the “forces of magnetism”(see below). During your job search, research the institution, ask questions, and speak with the staff, community members, and representatives of state professional nursing organizations to determine whether the hospital you are considering meets these criteria.


  1. Respected nursing leadership. What qualities do the nurses in leadership positions have that attract staff nurses to work at the institution? Are they viewed as knowledgeable, strong, respected, accessible risk-takers who lead according to a meaningful philosophy? Is their management style participatory?
  2. Organizational structure. Does the chief nurse executive serve at the highest decision-making level and have authority in patient care and nursing practice? Is a horizontal team structure in place instead of the traditional vertical hierarchy with many levels between the bedside caregiver and the chief nurse executive? Do staff nurses know the chief nurse executive, and other nursing leaders? Is there open communication among nurses, between departments, and among health care disciplines throughout the organization?
  3. Management style. Do nurse leaders have a participatory management style? Do they seek the counsel and perspectives of staff nurses? Do staff nurses participate in decision-making that affects nursing practice and the provision of patient care? If so, what examples can be given?
  4. Personnel policies and programs. Do the employees create personnel policies and procedures? Are staff nurses voting members of the personnel committee and of the committee that develops nursing policies? What is the policy approval process? What programs are in place to support employees? Are organizational benefits viewed as being favorable to employee?
  5. Professional models of care. Are models of care used that give RNs responsibility for patient care? A growing body of research reveals a direct relationship between nurse staffing and patient outcomes, particularly in regard to mortality, postoperative infections, falling, pressure ulcers, urinary tract infections, the development of thrombosis, medication errors, failure to rescue, and patient satisfaction. 2 Does the model of care used seem to reflect this?
  6. Quality of care. Is quality of care the highest priority of the staff and the nursing leaders? Which patient outcomes reflect this organization’s commitment to excellence? Does the nursing staff believe that it is able to provide high-quality care? How satisfied are the patients?
  7. Quality improvement. Are quality improvement studies used to improve the care provided to patients? Do staff nurses participate in data collection and data analysis? Are they free to recommend changes in practice that may be warranted by the findings? Are staff nurses remunerated for involvement in quality-improvement and other professional activities (such as membership on a community governing board or professional nursing organization, or speaking to community or health care professionals about health-care related issues).
  8. Access to clinical experts. Are staff nurses able to consult clinical experts (clinical nurse specialists and nurse practitioners)?
  9. Contribution to the community. Does the institution have an ongoing, significant relationship with the community? What has it done to contribute to it?
  10. Ask residents of the community, as well as representatives of state professional nursing organizations whether the hospital is viewed as having a favorable influence on the community.
  11. Autonomy. Are staff nurses permitted and expected to practice in accordance with the breadth of the scope of nursing practice as it is identified in the state nurse practice act? What steps does the organization take to ensure that only RNs undertake these responsibilities? How satisfied is the nursing staff with the practice environment? What is the turnover rate at the institution?
  12. Image of nursing. Ask staff nurses whether nursing is viewed as integral and vital to the institution’s mission and daily operations. Ask other health care professionals to describe the contributions that nurses make.
  13. Nurses as teachers. What does the prospective employer do to promote the teaching component of nursing practice? Is time allotted for the teaching of patients and peers?
  14. Collegial relationships. Is there mutual respect among nurses, physicians, and other health care professionals? A study recently published in AJN revealed that the daily interaction between nurses and physicians strongly influences morale, and that disruptive behavior of physicians (“any inappropriate behavior, confrontation, or conflict, ranging from verbal abuse to physical and sexual harassment”) is inversely related to the levels of nurse satisfaction and retention. 3 Ask staff nurses if their relationships with the physicians who admit patients to their units are professional, respectful, and favorable. Where physicians participate in the interview process, ask what they expect of nurses, and how they contribute to developing and maintaining mutually respectful relationships with them.
  15. What investment has the institution made to provide orientation, continuing education, formal education, and other career development opportunities to nurses? What incentives are in place to promote specialty certification? What investment does the employer make to foster the continued competence of nurses? How does it encourage their professional development and reward them for it?


The Magnet Recognition Program, established in 1993, bestows national recognition on dynamic, innovative, health care organizations that focus on achieving and maintaing general excellence and that both demonstrate sustained nursing care excellence and make a significantly favorable difference in the lives of patients, nurses, and other health care professionals. The program is administered by the American Nurses Credentialing Center (ANCC), a subsidiary of the ANA that is the nation’s largest and foremost nursing credentialing organization, and is governed by the ANCC Commission on Magnet Recognition, a nine-member board comprised of representatives of the American Organization of Nurse Executives, the American Academy of Nursing, ANA’s Congress on Nursing Practice and Economics, a staff nurse, an advanced practice nurse, a patient care manager, a chief nurse executive, a health care consumer, and a long-term care expert.

The Magnet Recognition Program is designed to recognize excellence in:

  • management, philosophy, and practices of nursing services;
  • adherence to national standards for the improvement of the quality of patient care;
  • nurse administrator leadership that supports professional practice and continued competence of nurses; and
  • the understanding of and respect for the cultural and ethnic diversity of patients, their families and significant others, and health care providers. 4

Since 1994, when the University of Washington Medical Center in Seattle received the inaugural Magnet award, the ANCC has worked to ensure that the program continues to recognize excellent facilities. Emerging research confirms that it has been.

In a study published in AJN, Linda H. Aiken, PhD, RN, FRCN, FAAN, and colleagues found that the Magnet Recognition Program validly identifies hospitals that provide high-quality nursing care and that these Magnet hospitals performed better in every area of investigation. The investigators found that such hospitals employ a significantly greater percentage of nurses holding bachelor’s degrees (50%, compared with 34% at non-Magnet hospitals), and that nurses at these institutions rated their practice environments higher than nurses at non-Magnet hospitals did theirs. Sixty-three percent of the Magnet-hospital nurses rated support services as adequate (compared with 43% at non-Magnet hospitals) and 70% indicated that there were enough RNs to provide high-quality patient care (compared with 47% at non-Magnet hospitals). In addition, Magnet-hospital nurses were less likely to report feeling burned out (20.4%) and dissatisfied (16%); almost 30% of non-Magnet nurses reported burnout and 28% reported dissatisfaction. In fact, 33% of nurses at Magnet hospitals indicated that they were very satisfied with the practice environment, compared with 22% of nurses at non-Magnet hospitals. 5

Another study revealed that at Magnet hospitals there are higher levels of support of nursing autonomy, control of practice, and collaboration with physicians, 6 variables that have been found to affect job satisfaction and the perceived quality of patient care. 7

Fifty-eight acute-care organizations have achieved Magnet status in the United States. The states with the greatest number of Magnet facilities are New Jersey (12), Wisconsin (6), and Florida (5). (Go to for a complete listing.)


According to the ANCC 8:

  • 97.5% of Magnet facilities are affiliated with nursing education programs, 90% with allied health programs, and 82.5% with schools of medicine.
  • 100% of chief nurse executives hold graduate or higher degrees.
  • 54% of nurses in leadership positions have at least one graduate degree; of those, 30% are advanced practice nurses; 18% have been certified by a national certification body.
  • 92% of the staff attend at least one CE program annually.
  • 27.99% of all nurses providing direct care are certified.
  • The average number of licensed beds is 481, in a range of 100 to 1,951. (Magnet status can be attained at very large teaching hospitals and at small rural organizations.)
  • 21% of all Magnet facilities are organized for collective bargaining.
  • The average turnover rate is 11.57%.
  • The average vacancy rate is 8.19% (The national average is approximately 11 %; however, some non-Magnet hospitals have vacancy rates as high as 20%.) 9
  • The average length of employment of RNs on staff is 8.94 years.

A number of research findings have concluded that Magnet hospitals experience better outcomes for nurses and patients. One study revealed significantly lower Medicare patient mortality rates at Magnet hospitals. 10 Another revealed that patients with AIDS who were provided care at Magnet hospitals had less chance of dying. 11 A third study showed that patient satisfaction was higher at Magnet hospitals. 12 Among nurses, a lesser incidence of needle stick injuries has been reported. 12

Does the hospital at which you contemplate practicing reflect a commitment to such excellence? If not, think twice about working there. But if it appears to be innovative, dynamic, and oriented toward excellence, accepting employment there might prove to be the best professional decision you’ve made.


1. McClure ML, et al., American Academy of Nursing. Task Force on Nursing Practice in Hospitals. Magnet hospitals: attraction and retention of professional nurses. Kansas City (MO): American Nurses Association; 1983.
2. Buerhaus P, Needleman J. Policy implications of research on nurse staffing and patient outcomes. Policy, Politics, and Nursing Practice 2000; 11( 1):5–15.
3. Rosenstein AH. Nurse-physician relationships: impact on nurse satisfaction and retention. AJN 2002; 102( 6):26–34.
4. American Nurses Credentialing Center. Profile of a magnet facility. Washington (DC): American Nurses Credentialing Center; 2002.
5. Aiken LH, et al. The Magnet Nursing Services Recognition Program: a comparison of two groups of magnet hospitals. AJN 2000; 100( 3):26–35.
6. Havens DS. Comparing nursing infrastructure and outcomes: ANCC magnet and nonmagnet CNEs report. Nursing Economics 2001; 19( 6):258–66.
7. Laschinger HKS, et al. Impact of magnet hospital characteristics on nurses’ perceptions of trust, burnout, quality of care, and work satisfaction. Nursing Economics 2001; 19( 5):209–19.
8. American Nurses Credentialing Center. Profile of the magnet hospital. Washington (DC): American Nurses Credentialing Center; 2002.
9. Tieman J. Industry pushes call button: nursing shortage plagues nation, but some hospitals find career image is key. Mod Healthc 2001; 31( 51):26–8.
10. Aiken LH, et al. Lower Medicare mortality among a set of hospitals known for good nursing care. Med Care 1994; 32( 8):771–87.
11. Aiken LH, et al. Satisfaction with inpatient acquired immunodeficiency syndrome care: a national comparison of dedicated and scattered-bed units. Med Care 1997; 35( 9):948–62.
12. Aiken LH, et al. Hospital nurses’ occupational exposure to blood: prospective, retrospective, and institutional reports. Am J Public Health 1997; 87( 1):103–7.
© 2003 Lippincott Williams & Wilkins, Inc.