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Learning Scope #383
1 contact hour
Expires April 23, 2014

You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) toADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this continuing education offering is to provide nurses with current information on research involving Magnet-designated healthcare organizations. After reading this article, you will be able to:

1. Describe the history of the Magnet Recognition Program.
2. Compare and contrast how Magnet hospital research has evolved from 1983 to the present.
3. Discuss the practice implications and future research for Magnet hospitals.

* The author has completed a disclosure form and reports no relationships relevant to the content of this article.

Many nurses remember the nursing shortage of the 1980s. Introduction of diagnostic-related groups helped lead to Medicare funding reductions, hospital budget shortfalls and large-scale nurse layoffs, a first in the U.S. Nurses who received pink slips discovered there were other careers open to women, and many never came back to nursing, even when hospitals offered cars, vacations, bonuses and money for advanced nursing education.

In the late 1990s, another national nurse deficit was gaining momentum. A number of critical factors were linked to this exodus of nurses: the "graying of nursing" in practice and academia, decreased nursing school admissions and nurse dissatisfaction in the workplace.

However, as a result of the 1980s nursing shortage, a number of innovations and programs were in place to address the crisis of the 1990s. None was more evident than the Magnet Recognition Program.

The scope of this article is limited to the research conducted and applied to nursing practice in Magnet hospitals. It does not describe the Magnet journey hospitals take to meet the requirements to achieve first-time designation by the ANCC Magnet Recognition Program. The designation is good for 4 years, but the Magnet program is dynamic and planning for re-designation begins long before the initial designation period ends.

In 1981, the American Academy of Nursing, then part of the American Nurses Association (ANA) and now an independent affiliate of the ANA, appointed a task force of four researchers to learn why some hospitals were able to retain and recruit nurses despite a nursing shortage.

The researchers studied 163 hospitals and found 41demonstrated characteristics that "enabled greater capacity to attract and retain nurses." These organizations were called "magnet" hospitals, and the 14 characteristics these hospitals shared became known as the "Forces of Magnetism." The Forces of Magnetism continue to serve as the conceptual framework for hospitals designated as Magnet hospitals.¹

In 1990, the American Nurses Credentialing Center (ANCC) was incorporated as an independent, nonprofit organization through which the ANA would offer credentialing programs and services. Six months later, the ANA Board of Directors approved a proposal for the Magnet Hospital Recognition Program for Excellence in Nursing Services, building upon the 1983 magnet hospital study.²

In 1994, the University of Washington Medical Center, Seattle, became the first Magnet-designated hospital.² Currently, there are 392 Magnet-designated organizations. This represents 6.61 percent of all hospitals, according to the American Hospital Association's Fast Facts on US Hospitals.

In the January 1999 edition of the Journal of Nursing Administration (JONA), Scott, Sochalski and Aiken published "Early Magnet Research: Findings and Implications for Professional Practice" Their research concluded the data collected from early-designated magnet hospitals, from 1983 to 1991, "illuminated the leadership characteristics and professional practice attributes of nurses within these institutions."³

The researchers note their purpose in conducting the review was to "synthesize the magnet hospital research that describes and evaluates the professional practice of nurses within these institutions" and "identify areas for future research to advance professional nursing models within current hospital organizations."

Scott, Sochalski and Aiken describe the selection criteria for the 41 original hospitals that were part of the original magnet research study, completed in 1982-83: 1) nurses within the hospitals considered them good places to practice; 2) the hospitals had low nurse turnover and vacancy rates; and 3) hospitals were located in areas where there was significant regional competition for nursing services.³

In this original research, nursing directors (identified as chief nurses and middle management nurses) and staff nurses from each hospital participated in interviews and responded to questionnaires.

The results from these data sources are published as attributes (characteristics) of the nurse leaders and staff nurses. Honing these characteristics into an instrument that could be conceptualized to describe a magnet environment from the large amount of data collected was difficult.⁴ Eventually, researchers agreed a magnet hospital was one "where nurses have greater autonomy, have control over nursing practice and have good nurse-physician relationships.⁴

After reviewing 8 years of narrative data on the early magnet research, Scott, Sochalski and Aiken concluded the data was "a collection of multisite nursing research projects that began to link the processes of nursing practice to outcomes, specifically job satisfaction."³

The researchers note the study results were enhanced because the sites, located across the country, identified similar qualities of a professional practice model. They add the findings "substantiated the need to quantify empirically these attributes and measure their effects on patient outcomes."³

Since the 1980s, when the original magnet research study began, Linda Aiken, PhD, RN, FAAN, FRCN, director of the Center for Health Outcomes and Policy at the University Of Pennsylvania School of Nursing, has been a major proponent of the Magnet Recognition Program in this country and internationally. She was directly involved in the early research, often as the principal investigator. Aiken has mentored nurse researchers who continue to validate the Forces of Magnetism in their work that affects the nursing profession, allied healthcare professions and the public.

When Aiken's study, "Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction," was published in the Oct. 23, 2002, edition of JAMA, physicians, nurses and the public recognized the implications of its findings.⁵ In this study, funded by the National Institute of Nursing Research of the National Institutes of Health, Aiken and her colleagues document that in 1998-99, in 168 Pennsylvania hospitals, 232,342 surgical patients were cared for by 10,184 nurses. The major finding of the study: If the hospital staffed at one nurse for eight patients as opposed to four patients per nurse, the risk of hospital deaths would increase by 31 patients for patients undergoing routine surgical procedures.

More recent research published by Aiken in the October 2011 edition of JONA, "Nurse Work Environments Better at Magnet Hospitals," shows Magnet hospitals have "better work environments, a more highly educated nursing workforce, superior nurse-to-patient staffing ratios and higher nurse satisfaction than non-Magnet hospitals."⁶

Aiken and her colleagues surveyed more than 26,250 RNs at 567 hospitals in California, New Jersey, Florida and Pennsylvania. Of the hospitals in the study, 46 had received Magnet Recognition.

The study states: "Nurses practicing in Magnet hospitals had more specialty-certified nurses and also a greater proportion of nurses with a BSN degree or higher than the other nurses surveyed. Additionally, the nurse-to-patient staffing ratio in Magnet hospitals was significantly lower than in other hospitals; the nurses were 18 percent less likely to be dissatisfied; 13 percent less likely to have high levels of burnout and much less likely to report intent to leave their current position."

"Our results are consistent with a substantial and growing research base that has accumulated over several decades showing better work environments," Aiken comments. "Three decades of evidence showing superior outcomes for Magnet hospitals place this organizational innovation in a class of its own as best practice, which deserves the attention of hospital leaders, nursing and the public."

In 2003, Aiken received the Ernest Amory Codman award for measuring healthcare performance from the Joint Commission. She was introduced as "the single most influential nurse leader and researcher in the field of nursing outcomes research." Aiken's accomplishments were cited. Two of these were: 1) "developing testing measures and research methods to document nurses' contributions to the delivery of quality outcome measures" and 2) "using performance measurement in the study of Magnet hospitals that established the evidence base behind the movement . and has propelled the concept into the mainstream of hospital quality improvement in the U.S. and abroad."⁷

In a 2008 Agency for Healthcare Research and Quality publication, Patient Safety and Quality, Vicki Lundmark, PhD, director of research with the ANCC, contributed the chapter "Magnet Environments for Professional Nursing Practice." Lundmark describes the background of the ANCC Magnet Recognition Program and its conceptual framework. She states the purpose of the chapter is to "summarize the magnet research evidence related to nurse or patient outcomes."⁴

Lundmark notes the studies were retrieved from PubMed and the Cumulative Index to Nursing and Allied Health Literature. To be accepted for the review, articles had to contain magnet or "magnetism" in the abstract. The inclusion criteria used were: 1) The articles had to report findings from analyses of primary and secondary data and 2) investigate relationships between magnet variables and nurse or patient outcomes.

Lundmark's review is divided into three categories or tables. Evidence table 1 covers the early studies conducted by the 41 "reputational magnets" from the 1983 original study. Table 2 compared healthcare organizations with or without ANCC Magnet Recognition status, and table 3 includes studies that investigate the relationship of various magnet characteristics to outcomes.⁴

Lundmark notes the magnet research studies she reviewed were cross-sectional survey studies, with convenience samples of organizations and staff nurse respondents. Most of these studies included data from the 41 organizations from the original 1983 magnet study, hospitals that received ANCC Magnet Recognition, and results from survey scales believed to measure magnet characteristics traits or factors.

Consequently, the researcher concludes, "With few exceptions, the majority of the research had suffered from two major limitations: biased sampling at both organizational and respondent level; and a scarcity of comprehensive, valid and reliable measures for assessing the level of magnet characteristics in any setting."

Lundmark notes because ANCC Magnet Recognition Program recipients are voluntary samples in the research studies reviewed, it cannot infer there are not hospitals with magnet characteristics that have chosen not to apply for Magnet Recognition Program recognition

"There is a compelling need to improve the measure and methods used to research magnet characteristics and environments before the links that connect organizational context to nurse and patient outcomes can be understood.," she writes.

Nurses who practice in healthcare organizations that achieved Magnet Recognition prior to 2008 will likely report the re-designation journey is much more challenging than the first time.

In fact, the focus for Magnet designation prior to 2008 was on the structure and processes of an organization and its nursing department. At the time, there was an assumption if the structure and processes were in place, good outcomes would follow, according to ANCC.

In 2008, ANCC announced it was "pleased to present the next generation model for its esteemed Magnet Recognition Program. This new model is designed to provide a framework for nursing practice and research in the future." The reason for the change: "to provide clarity and direction, as well as eliminate redundancy within the 14 Forces and organize them into five Model Components."

These components are:

• transformational leadership;

• structural empowerment;

• exemplary professional practice;

• new knowledge, innovations and improvements; and

• empirical quality results.⁸

In the current Magnet model, the outcomes are categorized into clinical outcomes related to nursing: workforce outcomes, patient and consumer outcomes, and organizational outcomes. For example, many of the indicators required for Magnet re-designation are also required by the Joint Commission, Centers for Medicare and Medicaid Services, and other quality databases such as ANA's National Database of Nursing Quality Indicators (NDNQI). As of 2007, there were more than 1,100 hospitals reporting unit-level nurse-sensitive indicators to NDNQI. The data is then compared to other member hospitals of similar size and demographics.

Magnet outcome measures must be quantifiable and documented. The question that must be documented is, "What difference have these outcomes made in patient care, nursing practice and the organization's standards and culture?"

In 2010, several Magnet program directors talked to ADVANCE about the re-designation process. "Excellence is not a destination; it is a journey that never ends," one director said. "With every re-designation the bar is set higher."⁹

Another program director preparing for a fourth re-designation in 2012 also voiced how outcome measurement, specifically evidence-based practice, is part of all Magnet requirements.

"In a previous re-designation, hospital administration identified tuition reimbursement as a benefit for nurses," explained the program director.⁹ "When the Magnet program was evaluated 4 years later, the Magnet appraisers checked the outcome of this benefit: how many employees took advantage of the opportunity. If they did, how many received academic degrees and how many received promotions as a result of the benefit."

In the manual for the 2008 Magnet model, the requirements that define and differentiate research and outcome measurement are cited. They are:

• evidence-based practice is the use of literature to implement practice changes;

• quality indicator studies measure specific outcomes, but are not controlled;

• quality improvement research doesn't reach the standard for research studies; and

• research begins with a full literature review and must receive approval from the hospital's institutional review board.

A Magnet program director contacted for this article noted the biggest challenge is to make nurses bedside scientists. Even nurses with extensive research experience agree the new criteria are more rigorous.

"The current Magnet model is really a blueprint, a framework for shared prioritizing, summarized Lisa Roman Fischetti, MSN, RN, OCN, Magnet program/nursing quality director, Fox Chase Cancer Center, Philadelphia.

For a printer-friendly version of the exam you can print out, complete and mail in to ADVANCE, click here.

To view the Course Outline and take the test online, click here.

References for this article can be accessed here.

Kay Bensing is senior staff nurse consultant at ADVANCE.