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Copyeditor: Timi Santiago JONA Volume 41, Number 7/8, pp 00-00 Copyright B 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Perceptions of Nurses in MagnetA Hospitals, Non-Magnet Hospitals, and Hospitals Pursuing Magnet Status Robert Hess, PhD, RN, FAAN Catherine DesRoches, DrPH Karen Donelan, ScD
Linda Norman, DSN, RN, FAAN Peter I. Buerhaus, PhD, RN, FAAN
Objective: The objective of the study was to compare perceptions of RNs employed in Magnet , in-process (ie, hospitals seeking Magnet recognition), and non-Magnet hospitals using data from the 2010 National Survey of Registered Nurses (NSRN). Background: The NSRN is administered biennially and measures nurses’ perceptions about their profession, workplace environment, and professional e relationships. Methods: Self-administered mail survey to a national sample of 1,500 RNs was used. Bivariate statistical techniques were used to analyze responses from 518 nurses who indicated their employer’s Magnet status and to examine associations between Magnet status and the nurses’ perceptions of career A
Author Affiliations: Executive Vice President, Global Programming (Dr Hess), Gannett Education, Gannett Healthcare Group, Voorhees, New Jersey; Instructor (Dr DesRoches), Senior Scientist in Health Policy (Dr Donelan), Massachusetts General Hospital, Boston; and Senior Associate Dean for Academics (Dr Norman), School of Nursing, Vanderbilt University, and Valere Potter Professor of Nursing, Director (Dr Buerhaus), Center for Interdisciplinary Health Workforce Studies, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee. Correspondence: Dr Hess, PO Box 412, Voorhees, NJ 08043 (
[email protected]). The study was funded by a major grant from the Johnson & Johnson national Campaign for Nursing’s Future. Johnson & Johnson played no role in the design and conduct of the study, analysis and interpretation of results, and preparation or approval of this manuscript. Financial support for the study was also received from the Gannett Healthcare Group. The views expressed in this article are those of the authors and do not represent the views of the National Health Care Workforce Commission (Dr Buerhaus). DOI: 10.1097/NNA.0b013e31822509e2
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satisfaction and perceptions of the nursing shortage, work environment, opportunities to influence the workplace, and professional relationships. Results: Nurses employed in all 3 groups (Magnet, in-process, and non-Magnet hospitals) were uniformly satisfied with being a nurse, although significantly more Magnet and in-process nurses would recommend nursing as a career than would nonMagnet RNs. Views of the workplace safety was similar across groups, with no significant differences in violence, verbal abuse, discrimination, or harassment; however, Magnet nurses reported significantly more musculoskeletal injuries. Magnet and in-process nurses rated opportunities to influence decisions about workplace organization and participate in shared governance and employer-paid continuing education, and relationships with advanced practice nurses and nursing faculty higher than did non-Magnet nurses; relationships with new nurses and physicians were not different across groups. Conclusions: The Magnet program continues to have a positive influence on nurses and their decisionmaking and professional relationships. The paucity of other differences suggests that Magnet, in-process, and non-Magnet organizations are increasingly guided by a shared set of principles that define a positive professional environment derived not only by the Magnet program, but also by other professional organizations and forces. Amid an enduring economic downtown, contentious political environment, and a lull in the American nursing shortage, the number of hospitals participating in the American Nurses Credentialing Center’s
1
(ANCC’s) Magnet Recognition Program continues to surge. Meantime, other hospitals are vying for ANCC’s Pathway to Excellence designation, some using it as a bridge toward Magnet . In previous administrations of the National Survey of Registered Nurses (NSRN), researchers analyzed the perceptions of nurses working in Magnet versus non-Magnet hospitals and found that Magnet facilities scored more favorably on a number of dimensions.1 For nurse leaders debating whether to pursue Magnet designation or introduce Magnetsupported changes in the work environment, the question lingers: Do RNs in Magnet-designated hospitals perceive important differences in their work environment compared with RNs employed in nonMagnet hospitals? The NSRN is a biennial survey that measures nurses’ perceptions about their profession, workplace, environment, and professional relationships. Many of the survey items address concepts pertaining to healthy work environments that have been explored by researchers and embraced by the Magnet program and other professional organizations. The perceptions of nurses from Magnet facilities, organizations in the process of applying for Magnet, and non-Magnet facilities were compared using the NSRN for the first time in 2006.1 At the time, only 230 hospitals had achieved Magnet designation. Since then, the number of designated and redesignated hospitals has steadily risen, with 100 designated in 2009 alone. The Magnet Recognition Program currently recognizes more than 380 hospitals (almost 7% of US hospitals), including 4 international hospital organizations.2,3 As interest in Magnet continues to grow, understanding how Magnet, in process to become Magnet, and non-Magnet hospitals compare is as important as ever. In this article, we report the results of the 2010 NSRN, comparing perceptions of RNs employed in Magnet-designated organizations with those employed in organizations working toward designation or that have not been designated, examining differences across facilities and what the differences might mean for nurse leaders, healthcare organizations, and the nursing profession. A
TM
A
Magnet Program and Its Hospitals In 1983, the American Academy of Nursing identified 41 hospitals distinguished by their ability to attract and retain high-quality nurses. These hospitals were designated as ‘‘magnets’’ for professional nurses and superior nursing care.4 Subsequently, the establishment of the ANCC led to the development of a formal Magnet model with 14 Forces of
2
Magnetism that captured qualities associated with the original Magnet hospitals. In 2007, ANCC commissioned an analysis of the appraisal scores of the 2005 applicants to the Magnet Recognition Program. This led to an alternate, leaner framework that regrouped the 14 Forces into 5 model components: transformational leadership; structural empowerment (SE); exemplary professional practice (EP); new knowledge, innovation, and improvements; and empirical quality results.5,6 Evidence suggests that the model components in Magnet hospitals make them different from nonMagnet organizations. For example, the model component of SE mandates that nurses have control over their nursing practice. Nurses in Magnet hospitals have been shown to have more control over their practice than have nurses in non-Magnet facilities.7-9 Structural empowerment also requires Magnet facilities to provide nurses with opportunities for teaching, role development, and a professional practice characterized by a commitment to professional development with continuing education (CE), interdisciplinary care and collaboration, and a culture that promotes workplace safety.6 Other evidence suggests that differences between Magnet and non-Magnet facilities may be minimal. For example, a recent secondary analysis of 2004 data from the Nurses Worklife and Health Study examined the responses of nurses working in Magnet and non-Magnet facilities about their working conditions. The investigators found that nurses from Magnet hospitals were significantly less likely to work jobs requiring overtime or mandatory oncall time, although their hours worked did not differ from the non-Magnet nurses.10 The Magnet nurses also reported significantly lower physical demands, although the mean scores for physical demands of the Magnet and non-Magnet groups were similar. No significant differences were found between the 2 groups regarding the nursing practice environment and perceived patient safety. The authors concluded that working conditions experienced by nurses in Magnet and non-Magnet facilities varied little. The NSRN examined perceptions of nurses categorized by Magnet status for the first time in 2006, comparing the perceptions of nurses in Magnet facilities to those of nurses in facilities that were ‘‘in process’’ to become Magnet or were non-Magnet.1 Significant differences were discovered. For example, significantly more nurses from in-process organizations (23%) rated their opportunities to influence decisions about workplace organization as excellent or very good as compared with nurses in Magnet (19%) or non-Magnet hospitals (14%). Likewise, the percentage of nurses rating their opportunities
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to influence decisions about patient care as very good or excellent was greater in both Magnet (27%) and in-process (27%) organizations compared with nonMagnet facilities (16%). When asked about relationships between nurses and professional colleagues (including other nurses, licensed practical nurses, physicians, support staff, nurse managers, and management), 79% of nurses from Magnet hospitals rated relationships between nurses excellent or very good, compared with 68% of nurses in non-Magnet hospitals, another significant difference. The 2008 NSRN also included questions designed to assess the effects of Magnet hospital designation, but because of the survey’s focus on policy issues and the presidential election, it did not report results showing whether RNs in 2008 continued to hold positive views associated with Magnet designation. The survey also did not ask about relationships between experienced RNs and new nurses, nurses and advanced practice nurses (APNs), and nurses and faculty. 2010 Survey Methods The survey was conducted from May through August 2010. The Johnson & Johnson Campaign for Nursing’s Future and Gannett Healthcare Group funded the survey, and Harris Interactive conducted the survey fieldwork. Harris Interactive mailed a cover letter, the 8-page NSRN questionnaire, and an incentive for participation to a random sample of 1,500 RNs. The sample was drawn from a national database of RNs consisting of data from state boards of nursing and maintained by Gannett Healthcare Group. Up to 3 additional mailings were sent to nonresponders to encourage participation. Response enhancement incentives included 1 year of unlimited online CE through Gannett Education and a $10 prepaid check sent to RNs who had not completed the survey after the third round of mailing. After exclusion of retired nurses or those not working at the time of the survey, we obtained a 56% response rate among eligible respondents. The Partners Healthcare System reviewed the project and determined it to be exempt. Survey Instrument The development of the 2002, 2004, 2006, and 2008 surveys has been reported elsewhere.11 The core research team that developed these surveys also developed the 2010 survey. With each survey, the team has worked to preserve continuity, while also editing, adding, or deleting items in response to current affairs. The team also attempts to control survey length by sometimes omitting questions asked in previous surveys, making way for new ones. The ma-
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jority of the items in the 2010 survey, as in previous surveys, were close-ended, using response categories such as ‘‘yes/no’’ and ‘‘excellent, very good, good, fair, or poor.’’ The survey contained 116 questions. Unless otherwise noted in the text, the wording of the individual survey questions is as shown in the figures accompanying the Results section. Magnet Status of Respondents RNs who worked in hospitals were asked to identify whether their hospital had earned ANCC designation as a Magnet or Pathway to Excellence facility. Response options included yes; no, but the hospital or organization is in the process of applying for such recognition; no; and not sure. Of a total of 518 nurses responding to this item, 151 (29%) reported working in a Magnet organization, 69 (13%) reported working in an organization that was in the process of applying for recognition, and 298 (58%) responded that their organization was neither Magnet nor in the process of applying for Magnet recognition. The sample size of nurses who worked in a Pathway to Excellence hospital was too small to evaluate. Statistical Analysis We used bivariate statistical analysis to examine associations between Magnet status and our outcomes of interest. Specifically, we used # 2 analysis and tests for differences in proportion to determine whether our 3 groups of nurses differed on career satisfaction and perceptions of the nursing shortage, work environment, opportunities to influence the workplace, and professional relationships.
Results Our analyses of nurses’ perceptions regarding their profession, workplace, and professional environment and relationships based on the Magnet status of their organization revealed a number of similarities as well as both observable and significant differences, which are reported as P G .05. The sample’s demographic characteristics are reported in Table 1. No significant differences were found in the 3 groups regarding sex, ethnicity, race, marital status, and highest nursing degree. The non-Magnet group was significantly older than the other 2 groups. The Magnet group was better educated than the other 2 groups, although not significantly different. Perceptions of the Nursing Profession Because of the current easing of the nursing shortage, the research team streamlined the number of questions about the shortage and its effects, keeping
3
T1
Table 1. Demographics of RNs Reporting Magnet, In-process, and Non-Magnet Status Magnet (n = 175), %
In Process (n = 84), %
Non-Magnet (n = 348), %
47.9
48.7
51.8a
93 7
92 8
95 5
2 92 6
2 92 6
3 93 4
80 4 7 1 1 2 5
79 3 9 1 1 1 4
78 6 5 1 1 2 6
76 23 2
77 22 V
71 26 2
8 16 35 15 27
9 21 33 11 25
12 19 31 13 24
Average age, y Sex Women Men Ethnicity Hispanic Non-Hispanic Refused Race White African American Asian or Pacific Islander Native American or Alaskan Native Mixed racial background Other Refused Marital status Married Single/divorced/separated/widowed Refused Highest nursing degree Diploma Associate Baccalaureate Master’s/doctorate Refused a
Significantly different from Magnet and in-process at P e .05.
F1
2 items that explored whether nurses thought there was a shortage at all. Survey respondents were asked to rate the adequacy of RNs available to work in the United States and their own communities on a 5-point scale, ranging from much less than the demand to much more than the demand. As noted in Figure 1, responses about the adequacy of the number of RNs available to work in patient care in the United States were fairly uniform across the groups. Regardless of their organization’s involvement with the Magnet program, about two-
thirds of the nurses believed the number of nurses available nationally was somewhat or much less than the demand. However, when nurses were asked about the supply of RNs working in the communities in which they practice, nurses working in nonMagnet organizations were significantly more likely than those from in-process organizations to report an inadequate supply (54% vs 39%). There were no significant differences between nurses in Magnet hospitals and those in non-Magnet or in-process facilities.
Figure 1. Perceptions of the nursing profession.
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Nurses in all 3 groups were uniformly ‘‘very’’ or ‘‘somewhat’’ satisfied with being a nurse (91% of nurses from in-process facilities, 89% from Magnet facilities, and 83% from non-Magnet facilities). This high level of satisfaction was also reflected in nurses’ responses to whether they would advise a high school or college student to pursue a nursing career, although significantly more nurses from inprocess facilities (90%) or with Magnet status (87%) said they would advise students to pursue nursing than nurses from non-Magnet facilities (79%).
F2
Perceptions of the Workplace Five survey items focused on workplace conditions, asking nurses to indicate whether they had personally experienced back or musculoskeletal injuries, violence, verbal abuse, discrimination, or harassment in the workplace (Figure 2). Nurses in Magnet hospitals were almost as likely as those in non-Magnet or in-process hospitals to have experienced violence, verbal abuse, discrimination, and harassment. Whereas nurses from in-process facilities reported the highest percentage of physical violence (26%), reports by the other groups were close (17% from Magnet organizations and 19% from non-Magnet organizations), and the differences between the groups were not statistically significant. About half of respondents from all 3 groups reported having personally experienced verbal abuse. Reports of discrimination based on sex, age, or race and sexual harassment or a hostile workplace were less common among Magnet nurses (21% and 22% respectively), although reports by the other groups were similar, and again, the differences between the groups were not statistically significant. Regarding back or musculosketal injuries, Magnet nurses reported significantly more injuries (39%) than did non-Magnet nurses (30%).
Influencing the Professional Environment Four items in the survey addressed work/professional environment issues, asking nurses to rate opportunities to influence their workplace organization and decisions about patient care, opportunities to participate in shared governance, and employerpaid access to CE (Figure 3). Nurses in hospitals with Magnet status (35%) or in-process for Magnet (36%) were significantly more likely than nurses in non-Magnet hospitals (26%) to rate their opportunities to influence decisions about workplace organization as very good or excellent. A similar though not statistically different pattern was found in nurses’ ratings of opportunities to influence decisions about patient care. ‘‘Shared governance’’ was included in an item for the first time in 2010, when the survey asked nurses to rate opportunities to participate in shared governance. Shared governance is an organizational innovation that legitimizes healthcare professionals’ decision-making control over their practice, while extending their influence to administrative areas previously controlled by managers.12 The percentage of Magnet nurses giving very good or excellent ratings to opportunities for shared governance was 37%, just above opportunities to influence decisions about the workplace organization (35%) and just below opportunities to influence decisions about patient care (40%). Among in-process nurses, excellent and very good ratings for shared governance (32%) were lower than that for influencing decisions about the workplace organization (36%) and patient care (43%). More noteworthy was the small percentage of nurses (16%) from non-Magnet facilities who rated their opportunities to participate in shared governance as excellent or very good. Nurses from Magnet and in-process hospitals were significantly more likely
Figure 2. Percentage of RNs who have personally experienced the following workplace conditions in the past year.
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F3
Figure 3. Percentage of RNs rating work/professional environment issues as excellent or very good.
than those in non-Magnet hospitals to rate as excellent or very good their opportunities to participate in shared governance (37% for Magnet, 32% for in-process, and 16% for non-Magnet) and their employer-paid access to CE (35% for Magnet and 30% for in-process vs 21% for non-Magnet).
F4
Professional Relationships The survey also asked nurses to rate the quality of relationships between experienced RNs and new nurses, and between nurses and physicians, APNs, and nursing faculty (Figure 4). Ratings by nurses in Magnet, in-process, and non-Magnet settings were not significantly different with 2 exceptions: Nurses in Magnet and in-process hospitals were significantly more likely than those in non-Magnet hospitals to rate relationships between RNs and APNs
as excellent or very good (51% for Magnet, 45% for in-process, 33% for non-Magnet) and to rate relationships between RNs and nursing faculty as excellent or very good (36% for Magnet, 40% for in-process, 23% for non-Magnet).
Discussion This study analyzes data from a recent national survey of RNs, comparing how nurses from Magnetdesignated organizations, organizations working toward Magnet designation, and non-Magnet organizations rate the following: the nursing shortage and career satisfaction, the work environment, the professional environment, and professional relationships. Like the earlier NSRNs, which were conducted over the past decade to help evaluate the effectiveness of
Figure 4. Percentage of RNs rating relationships as excellent or very good.
6
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the Johnson & Johnson Campaign for Nursing’s Future, the 2010 NSRN revealed significant differences in the perceptions of nurses working in Magnet, inprocess, and non-Magnet hospitals. At the same time, the snapshot of nursing practice and work life provided by the survey reveals unexpected commonalities, raising the question of whether these are due to the influence of Magnet or to a more complex combination of factors influencing healthcare environments today.
AQ1
Nursing Shortage and Career Satisfaction Perhaps one of the most important findings is not so much related to an employer’s Magnet status, but to changes in how nurses perceive the national environment in which they practice. About twothirds of nurses in all 3 groups agreed that the supply of RNs available to care for patients in the United States is inadequate. However, this is in contrast to (unreported) findings from the 2008 survey, in which 90% of nurses across all 3 groups believed the national RN supply was inadequate. Similarly, nurses perceived less of a nursing shortage in their communities in 2010 as compared with 2008. However, nurses working in facilities that were in-process to become Magnet rated the supply of nurses in their community more favorably than the other 2 groups. Researchers involved in the 2006 NSRN suggested that simply pursuing Magnet designation can have positive effects on an organization.1 It is possible that some in-process facilities ‘‘beef up’’ their resources to ensure favorable staffing for the Magnet journey, thus influencing their nurses’ perceptions of the local RN supply. Support for the effects of Magnet and its journey is more evident in nurses’ ratings of their career satisfaction. Over the last 3 surveys, nurses in Magnet facilities reported consistently high satisfaction with being a nurse, whereas ratings by nurses at in-process facilities trended upward. It is no surprise that favorable perceptions of nurses in Magnet and inprocess facilities with the local RN supply and career satisfaction would extend to a professed proclivity to advise qualified high school or college students to pursue a nursing career. The high ratings by nurses at in-process facilities are particularly interesting and suggest that changes introduced during the Magnet journey serve to strengthen nurses’ professional identity and pride. Magnet and the Work Environment To earn Magnet status, organizations must furnish evidence of fulfilling 5 model components. One of these, EP, requires evidence of both a culture of safety and workplace advocacy.6 For example, Magnet
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applicant institutions must describe and demonstrate structures and processes used to improve workplace safety for nurses. In the 2010 NSRN, nurses in the Magnet group reported significantly more back or musculoskeletal injuries than did nurses in the nonMagnet group, and the scores of the Magnet and inprocess nurses were almost identical. However, relying on a single item to characterize a work environment can be insufficient or spurious. Furthermore, the level of scrutiny and reporting would be expected to be more intense in Magnet and in-process facilities, where the Magnet model promotes a culture of safety and a proactive approach to risk assessment and reporting. Another source of evidence for EP requires applicants to describe and demonstrate structures and processes to identify and manage problems related to incompetent, unsafe, or unprofessional conduct. In contrast to their reports of physical injury, nurses from Magnet hospitals reported less physical violence; discrimination based on sex, age, or race; and sexual harassment than did nurses from non-Magnet hospitals. Because differences were not significantly different, one cannot conclude that a safety culture or safer environment exists in Magnet organizations compared with other organizations in the eyes of the RNs we surveyed. Another component of the Magnet model is SE, which was addressed by several items in the 2010 NSRN and previous surveys. Sources of evidence for Magnet applicant hospitals require demonstrations of structures and processes that enable nurses from all settings and roles to actively participate in organizational decision-making groups, such as committees, councils, and task forces. This requirement may account for the greater likelihood that nurses in Magnet and in-process hospitals consistently reported more opportunity to influence decisions regarding the workplace organization and patient care. Although there is considerable room for improvement, the extent to which perceptions for both groups have trended upward over the past 3 survey administrations is noteworthy. In Magnet hospitals, the percentage of nurses giving excellent or very good ratings to their opportunities for influencing workplace organizations increased from 19% in 2006, to 26% in 2008, to 35% in 2010. Ratings of opportunities to influence patient care also rose from 27% to 33% to 40%. Shared governance programs often occur in Magnet hospitals,13 which might explain the finding that nurses employed in Magnet hospitals perceived opportunities to influence decisions about workplace organization and patient care and their opportunities to participate in shared governance similarly. At in-process hospitals, the percentage of excellent and very good ratings increased from 23% to 24% to 36% for workplace organization
7
and from 27% to 34% to 43% for patient care. Again, in some instances, in-process nurses rated their opportunities for decision making greater (although not significantly so) than did Magnet nurses, suggesting that the effects of the Magnet journey might sometimes exceed the effects of arrival, that is, of achieving Magnet status. At the same time, in-process nurses perceived less opportunity to participate in shared governance than that for influencing decisions about the workplace organization and patient care. These results are consistent with the time it takes for shared governance models to mature, and hospitals that are in-process might be in the early stages of implementing a shared governance model. The SE component of the Magnet model also requires applicants to provide evidence of their commitment to professional development and to describe structures and processes used to develop and provide CE programs for nurses. Providing employer-paid access to CE is one example of supporting ongoing learning. Results suggest that Magnet facilities are more likely than other organizations to use this option. Nurses in Magnet organizations rated their employer-paid access to CE higher than did the other groupsVand significantly higher than did nonMagnet nurses.
affect these relationships as much as the presence of a Magnet journey, obfuscating any apparent connection to the journey.
Magnet and Professional Relationships The SE component of the Magnet model also addresses teaching and role development among nurses, including how nursing facilitates the effective transition of new graduate nurses and how nurses support academic practicum experiences and serve as preceptors, instructors, adjunct faculty, or faculty. It is not surprising that nurses in Magnet and in-process facilities rated their relationships with new nurses higher (though not significantly) than did nurses in nonMagnet facilities. Nurses in Magnet and in-process hospitals also rated their relationships with faculty and APNs significantly more favorably than did nonMagnet nurses. The higher ratings of relationships with APNs may reflect how APNs are used in Magnet and in-process facilities, or simply that more APNs are available. The Magnet model also emphasizes interdisciplinary care and collaboration. Although there were no significant differences in how nurses from the 3 groups rated relationships between nurses and physicians, data from the 2006, 2008, and 2010 surveys reveal a slight upward trend among Magnet hospital nurses (42%, 46%, and 47%, respectively), although there was a slight downward trend among in-process hospital nurses (45%, 42%, and 41%). Perhaps changes in professional roles and economics
A number of findings from the 2010 NSRN suggest the Magnet journey and achieving Magnet status are good for nurses and nursing. Nurses in Magnet and in-process hospitals rated their opportunities to influence the workplace organization and participate in shared governance, their relationships with APNs and faculty, and employer-paid access to CE significantly higher than did nurses in non-Magnet hospitals. Nurses in Magnet and non-Magnet hospitals also rated their opportunities to influence patient care higher than their non-Magnet colleagues, although not significantly so. The pride that nurses in Magnet and in-process hospitals feel about being a nurse is evident in their willingness to advise students to pursue nursing as a career. In other areas, though, an organization’s Magnet status seemed to have minimal impact. Nurses from Magnet, in-process, and non-Magnet facilities were all highly satisfied with being a nurse. Except that more nurses in Magnet hospitals experienced musculoskeletal injuries, nurses’ ratings of their work environment were also similar, as were their ratings of relationships with physicians and nurses. And as noted earlier, differences in how they rated their opportunities to influence decisions about patient care did not reach statistical significance. All of this leads one to question why the differences between Magnet
8
Limitations The NSNR, like all surveys, is subject to sources of sampling and nonsampling error. Sampling error is minimized with larger samples, but increases with analysis of subsamples, as was performed for this study. Nonsampling errors can result from a variety of factors, including differences in response among subgroups, differences in understanding or interpreting survey questions, and errors in data collection. The researchers tried to eliminate errors through quality checks and testing and adjusted for nonresponse bias, at least in part, by weighting the sample as reported in the Methods section. Yet another limitation is that some nurses may not have been aware of the Magnet status of the organization in which they worked and reported it inaccurately. Because the researchers were not able to validate the Magnet status of the respondents’ employers, some respondents may have been assigned to the wrong group.
Implications and Conclusion
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AQ2
and in-process hospitals and their non-Magnet counterparts are not more pronounced. Perhaps it is because the messages of the Magnet program have influenced and permeated the thinking and behaviors of nursing and healthcare leaders regardless of their organization’s Magnet status. They may also have been influenced by the growing body of research that highlights the importance of creating positive work environments and demonstrates how involving nurses in decisions about practice and the work environment contributes to a greater sense of empowerment,14,15 job satisfaction,14,16 and an enhanced self-concept among nurses.17 Other influences include the many other professional organizations that share Magnet principles. Given all these factors, the next step in the Magnet program’s evolution might be the successful and universal propagation of its principles, perhaps even to the extent that the program itself is no longer necessary. Beyond identifying similarities and differences among Magnet, in-process, and non-Magnet hospitals, the NSRN highlights areas that still need attention. Empowering nurses and involving them in decision making are a key principle of the Magnet framework; however, with only 37% of Magnet nurses and 32% of in-process nurses rating their opportunity to participate in shared governance very good or excellent, it is clear there is ample opportunity
for improvement in this area. Other key areas needing attention include workplace safety, where verbal abuse was reported by 50% or more of nurses, and relationships between nurses and physicians, rated excellent or very good by fewer than half of all respondents. Among the key challenges facing researchers are teasing out Magnet’s influence and finding a way to evaluate its singular effect on healthcare institutions and nurses. Yet another challenge involves gaining a better understanding of in-process organizations. The 2010 NSRN data suggest that the ‘‘journey’’ to become Magnet has a pronounced impact on nurse perceptions. A more careful examination of in-process hospitals would go a long way toward helping nurse leaders understand what the Magnet journey entails and what must happen and how long it takes before real change is accomplished and Magnet’s benefits are felt by nursing staff.
Acknowledgment The authors thank Sandra Applebaum, who led the fieldwork team from Harris Interactive and provided assistance in survey design throughout this project, for the efforts and dedication she provided to their program of survey research on the nursing workforce.
References 1. Ulrich B, Buerhaus P, Donelan K, Norman L, Dittus R. Magnet status and registered nurse views of the work environment and nursing as a career. JONA. 2007;37(5):212-220. 2. American Nurses Credentialing Center. Designations and redesignations as of September 2010. 2010. Available at http:// www.nursecredentialing.org/Magnet/ProgramOverview/ GrowthoftheProgram.aspx. Accessed February 22, 2011. 3. American Nurses Credentialing Center. Find a Magnet facility. 2010. Available at http://www.nursecredentialing.org/ Magnet/FindaMagnetFacility.aspx. Accessed February 22, 2011. 4. McClure M, Poulin M, Sovie M, Wandelt M. Magnet Hospitals: Attraction and Retention of Professional Nurses. Kansas City, MO: American Academy of Nurses; 1983. 5. Wolk G, Triolo P, Ponte PR. Magnet recognition program: the next generation. JONA. 2008;38(4):200-204. 6. American Nurses Credentialing Center. The Magnet Model Components and Sources of Evidence. Silver Spring, MD: ANCC; 2008. 7. Brady-Schwartz DC. Further evidence on the Magnet Recognition Program: implications for nursing leaders. JONA. 2005;35(9):397-403. 8. Laschinger HKS, Shamian J, Thompson D. Impact of Magnet hospital characteristics on nurses’ perceptions of trust, burnout, quality of care, and work satisfaction. Nurs Econ. 2001;19(5): 209-219. 9. Scott JG, Sochalski J, Aiken L. Review of Magnet hospital
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research: findings and implications for professional nursing practice. JONA. 1999;29:9-19. Trinkoff A, Johantgen M, Storr C, Han K, Liang Y, Gurses A, Hopkinson S. Comparison of working conditions among nurses in Magnet and non-Magnet hospitals. JONA. 2010; 40(7/8):309-315. Buerhaus P, Donelan K, DesRoches C, Hess R. Still making progress to improve the hospital workplace environment. Results from the 2008 National Survey of Registered Nurses. Nursing Economic$. 2009;27(5), 289-301. Hess R. Shared governance: nursing’s 21st century Tower of Babel. JONA. 1995:25(5):14-17. Hess R. From bedside to boardroomVnursing shared governance. Online J Issues Nurs. 2004;9(1):Manuscript 1. Available at http://www.nursingworld.org/mods/mod680/ govabs.htm. Accessed February 22, 2011. Anderson E. Empowerment, Job Satisfaction, and Professional Governance of Nurses in Hospitals With and Without Shared Governance [dissertation]. New Orleans, LA: Louisiana State University Medical Center, School of Nursing; 2000. Barden AM. Shared Governance and Empowerment in Nurses Working in a Hospital Setting [dissertation]. Cleveland, OH: Case Western Reserve University; 2009. Lee C, Yang K, Wu S, Lee L. The effectiveness of implementing a unit-based shared governance model [in Chinese]. J Nurs Res [China]. 2001;9(2):125-136. Pettitt L. Nursing Governance and Staff Nurses Self-concept [thesis]. Boiling Springs, NC: Gardner-Webb University; 2002.
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QUERIES Corresponding author: Robert Hess, PhD, RN, FAAN PLEASE ANSWER ALL QUERIES AQ1 0 Author: Please check use of the phrase ‘‘in contrast to.’’ The statements both say ‘‘RN supply was inadequate.’’ AQ2 0 Author: Does this refer to ‘‘2010 Survey Methods’’ section? There is no only ‘‘Methods’’ section. Please check. END OF QUERIES
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