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- Patient Safety and Quality: An Evidence-Based Handbook for Nurses.
NCBI Bookshelf. Hughes RG, editor. In hospital settings, nurses fulfill two roles. Based upon expert knowledge, nurses provide care to the ill or prevent illness. Nurses also maintain and manage the environment surrounding the delivery of care, which has increasingly involved coordinating the care activities provided by other health care providers.
Of three reports published since the year by the Institute of Medicine, 1—3 the report on patient safety was the first to emphasize the connection between nursing, patient safety, and quality of care. The report specifically noted the importance of organizational management practices, strong nursing leadership, and adequate nurse staffing for providing a safe care environment.
Improved theoretical frameworks and greater methodological rigor will be needed to guide and advance the nursing research on patient outcomes. The magnet hospital concept, originating from a groundbreaking study in the early s 8 that sought to explain instances of successful nurse recruitment and retention during a severe nurse shortage, provides one framework for specifying the organizational and practice environment conditions that support and facilitate nursing excellence. The purpose of this chapter is to summarize the magnet research evidence related to nurse or patient outcomes.
The original magnet study began in when the American Academy of Nursing appointed a task force to investigate the factors impeding or facilitating professional nursing practice in hospitals.
Therefore, the research goal was set to explore the factors associated with success in attracting and retaining professional nurses. Through an extensive nominating process, 41 hospitals from across the country were selected to participate in the study based upon their known reputations as being good places for nurses to work and the evidence they submitted to document a relatively low nurse turnover rate.
Two interviews were conducted in each of eight geographically dispersed locations. In the morning, one of the task force researchers interviewed the chief nurse executives from the participating hospitals in that area. Then, in the afternoon, a second group interview session was held with staff nurses. Each staff nurse who participated in the interviews was selected by his or her chief nurse executive. Based upon their analysis of this interview data, the task force researchers identified and defined a set of characteristics that seemed to account for the success the 41 reputational magnet hospitals had enjoyed in attracting and keeping a staff of well-qualified nurses at a time when other hospitals around them were not able to do so.
The labels given to these characteristics, which have come to be known as the forces of magnetism, are listed below in Table 1.
Many of the insights they embody have a long history of study within the sociological literature related to organizational performance, leadership, worker autonomy and motivation, decentralized or participative management, work design, coordination and communication, effective groups and teams, and organizational innovation and change.
The relationship of a magnet environment to quality was recently described by one of the original task force researchers. Looking back on the original magnet study more than 20 years later, McClure wrote 12 p. We found that all these settings had a commonality: their corporate cultures were totally supportive of nursing and of quality patient care.
What we learned was that this culture permeated the entire institution. It was palpable and it seemed to be almost a part of the bricks and mortar. Simply stated, these were good places for all employees to work not just nurses and these were good places for patients to receive care. The goal of quality was not only stated in the mission of these institutions but it was lived on a daily basis.
In the early s, the American Nurses Association ANA initiated a pilot project to develop an evaluation program based upon the conceptual framework identified by the magnet research. Applicants for Magnet recognition undergo a lengthy and comprehensive appraisal process 13 to demonstrate that they have met the criteria for all of the forces of magnetism shown in the right column of Table 1.
Currently, documentation or sources of evidence are required in support of topics. The philosophy of the program is that nurses function at their peak when a Magnet environment is fully expressed and embedded throughout the health care organization, wherever nursing is practiced.
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Magnet organizations submit annual reports and must reapply every 4 years to maintain their recognition. ANCC does so by evaluating new information from multiple sources, the scholarly research literature, expert groups convened to deliberate specific issues, and feedback from Magnet facilities and appraisers, particularly in relation to identifying effective and innovative practices.
Little has changed in the essential definitions for the forces except that ANCC has revised them to reflect contemporary hospital settings and elaborated under each force a set of required documentation for applicants to submit and appraisers to evaluate.
Beginning in , however, an important change appeared in the Magnet application process. Two inclusion criteria were used. Nurse outcomes of interest were job satisfaction, burnout, and intention to leave 16 , 17 or similar variables such as mental health.
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Nurse perceptions of patient care quality has been a frequently used measure in the magnet-related survey research, and one study used nurse perceptions of safety climate as the dependent variable. But studies that included patient outcome variables measured from other sources were seldom found, although patient mortality and patient satisfaction are represented in the evidence tables. Overwhelmingly, the magnet research has been dominated by cross-sectional survey studies with convenience samples of organizations and staff nurse respondents.
The basic approaches used to capture magnet environments in the research have been to include organizations from the magnet study or with ANCC Magnet recognition in the hospital sample or to administer survey scales believed to measure magnet characteristics, traits, or factors.
Usually, but not always, these approaches have been used in combination. Analyses have typically been limited to simple comparisons of survey items or subscale results between two groups. With few exceptions, the majority of this research has suffered from two major limitations: biased sampling at both the organizational and respondent level; and a scarcity of comprehensive, valid, and reliable measures for assessing the level of magnet characteristics present in any setting.
Unless magnet characteristics are measured adequately across the organizations participating in a study, the degree to which their presence differs between the comparison groups cannot be assessed. Because the organizations that have attained ANCC Magnet recognition constitute a voluntary sample, it is possible that high levels of some or many magnet characteristics may also exist in other organizations that have not chosen to apply for the recognition.
Overwhelmingly, the survey scales most frequently used to measure magnet characteristics have all derived from the Nursing Work Index NWI. Because these scales have dominated the magnet research, it is important to understand how they are constituted and how they have evolved over time. The first version of the NWI was designed to inclusively and comprehensively reflect the findings of the magnet research study.
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Content validity for the instrument was assured by having three of the four original magnet researchers review it for inclusiveness. Aiken 20 subsequently adapted the NWI to measure only organizational features by dropping the judgment statements related to job satisfaction and perceived productivity. Four NWI-R subscales were conceptually derived from an item subset. Two of the NWI-R subscale domains, nurse autonomy and nurse-physician relationships, are readily recognizable in comparison to the forces of magnetism listed in Table 1.
The other two domains, organizational support and control over nursing practice, are represented by sets of items that could be classified across several forces of magnetism. Control over nursing practice is defined as organizational autonomy or the freedom to take the initiative in shaping unit and institutional policies for patient care.
Hinshaw 22 described clinical autonomy and organizational autonomy as interactive concepts. Both types of autonomy were evident in the findings from the original magnet study. Since the NWI-R was developed nearly a decade before any subsequent NWI-derived scale versions appeared, the NWI-R has been the most frequently used measure of magnet characteristics in magnet research. An advantage of this fact has been the ability to compare findings across studies.
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A disadvantage may have been the formation of a wide impression that the magnet hospital concept is more circumscribed than it actually is.
In the literature reviewed here, the phrase most frequently used to introduce the magnet concept to readers directly cites the NWI-R subscales; magnet is said to describe hospitals where nurses have greater autonomy, control over nursing practice, and good nurse-physician relationships. In the last 5 years, three additional versions of the NWI have appeared. However, each version consists of different, empirically derived scale or subscale formations.
The evidence tables in this chapter are divided into three parts. Evidence Table 1 covers the early research period and itemizes studies conducted with hospitals from the group of 41 reputational magnets that participated in the study. Evidence Table 2 includes studies that compared health care organizations with and without designation as ANCC-recognized Magnets. Finally, Evidence Table 3 itemizes studies that investigated the relationship of various magnet characteristics to outcomes.
Insofar as possible, the evidence tables are arranged in chronological order to illustrate how magnet research has progressed since the concept of a magnet environment first appeared in the literature in the s. In addition, each row or panel in the tables represents a single data collection event. If multiple articles were generated from a single data collection effort, they are cited together in the same panel of the table.
The purpose of this arrangement is to present a clearer picture of the body of evidence as a whole, revealing that the total number of data sources with their associated measures and methods that have constituted the magnet research since is relatively small.
In addition, this arrangement draws attention to which articles are better read as a set by anyone wishing to understand the research in detail. Methodological information related to a single data collection effort can sometimes be scattered across multiple publications.
Evidence Table 1 includes two of the most compelling studies to have come out of the magnet literature, those initiated by Aiken and her colleagues 28—35 within a decade of the publication of the original magnet study.
For the Medicare mortality study 28 , magnet characteristics were not directly measured. However, the use of risk adjustment techniques for predicted mortality and multivariate matched sampling methods to control for factors that might affect mortality provided strong support for concluding that the set of reputational magnet hospitals was uniquely different as a group.
Guided by a conceptual framework originating in the sociology of organizations and professions, 20 the second compelling study 29—35 was formulated to examine how certain modifications to the organization of nursing in hospitals introduced by the AIDS epidemic affected patient and nurse outcomes.
Since the comparison group of hospitals for this study included two reputational magnet hospitals and a third hospital believed to be magnet-comparable, the researchers were able to discern that many of the same positive results achieved in dedicated AIDS units could apparently be attained by making changes at the organizational level. Magnet characteristics as measured by the NWI-R subscales were associated with significantly better outcomes for nurse safety, job burnout, patient satisfaction, and mortality 30 days from admission.
The exception to this finding is the mixed results shown for the nurse-physician relationship subscale. Evidence Table 3 lists three studies that explored the degree to which magnet characteristics could be found in hospitals outside the United States or in nonhospital settings. Thomas-Hawkins and colleagues 37 and Smith, Tallman, and Kelly 38 found that some magnet characteristics linked significantly to intentions to leave in freestanding dialysis units and to job satisfaction in rural Canadian hospitals, respectively.
Rondeau and Wagar 39 found significant associations between magnet characteristics and resident satisfaction and nurse satisfaction, turnover, and vacancy rates in long-term care organizations in western Canada. The remaining studies shown in Evidence Table 3 are important for a number of reasons.
Patient Safety and Quality: An Evidence-Based Handbook for Nurses.
The empowerment dimensions being measured—perceptions of formal and informal power and access to opportunity, information, support, and resources—also appear to overlay some descriptions of magnet characteristics from the original research.
By testing relationships with a set of theoretically selected variables and multivariate statistical methods, the studies of Laschinger and colleagues have been progressively building knowledge about how factors in the complex nursing practice environment interact with each other to affect outcomes. The work that will be required to explicate how the organization and delivery of nursing services functions as a mechanism to improve patient safety and the quality of care has only just begun.
The literature review conducted by Lundstrom and colleagues 45 found a number of studies that start to suggest the mechanisms by which organizational and work environment factors influence worker performance and ultimately patient outcomes.
Reviewing the magnet research presented in this chapter leads to similar conclusions. But the connections from those results based on staff nurse surveys to patient outcomes measured objectively by other means have seldom been studied.
However, other studies of the same attributes showed contrary or neutral results. Too much variability existed in measures, settings, and methodological rigor across studies to permit any pooling of results. The magnet framework outlined in Table 1 specifies a set of factors important for establishing positive work environments that support professional nursing practice. As the evidence reviewed in this chapter shows, few studies have explored the relationship of magnet characteristics to patient outcomes.
Since the associations found were consistently positive, this constitutes a promising body of work, but one that is just beginning to emerge. In contrast, more evidence has accumulated to demonstrate links between magnet characteristics or Magnet recognition and favorable outcomes for nurses such as lower burnout, higher satisfaction, and fewer reports of intentions to leave.
In keeping with the realization that threats to patient safety result from complex causes, 2 Keeping Patients Safe identified a multifactor approach to creating favorable work environments for nurses.
Many of the strategies and goals described in the report correspond to the descriptions of magnet environments initially provided by McClure and colleagues 8 and currently elaborated for contemporary settings in the appraisal criteria for Magnet recognition.
Mick and Mark 5 have argued that while nursing research has contributed substantially to the knowledge about how internal structures and work processes relate to patient safety and quality outcomes in health care organizations, there is a compelling need to improve the methodological sophistication of the research and to expand the theoretical frameworks that guide it.