Lundmark v mepnp

Chapter 46. Magnet Environments for Professional
Nursing Practice
Vicki A. Lundmark

Background
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 2000 by the Institute of
Medicine,1–3 the 2004 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. The report also noted how frequently the patient safety
practices identified by the literature “were the same as those recommended by organizations
studying the nursing shortage, worker safety, and patient satisfaction”3 (p. 317).
While it seems logical to assume that safe and effective patient care depends on the presence
of “an organizational context that enables the best performance from each health
professional”4 (p. 186), remarkably little knowledge has accumulated about how the organization
and delivery of nursing services influences patient outcomes. One explanation for this situation is
that health services research so firmly turned its focus to organization/environment and
organization/market questions following the rise of health economics and health maintenance
organizations (HMOs) in the 1970s that it was caught somewhat unprepared when quality issues
began to emerge in the latter part of the 1990s. As a result, few conceptual tools exist “to address
the heart of quality concerns: the internal work processes and arrangements inside health care
organizations . . . that contribute to variations in quality”5 (p. 318).
Another limiting factor has been the inherent challenges of measuring organizational practice
environments and the complexity of nursing’s effects on patient outcomes. Improved theoretical
frameworks and greater methodological rigor will be needed to guide and advance the nursing
research on patient outcomes.6, 7 Nursing research has already been leading the way in this effort,
which may not be surprising given the deep knowledge nurses have of the internal workings of
health care organizations.5
The magnet hospital concept, originating from a groundbreaking study in the early 1980s8
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.

Magnet Hospitals and the Attraction and
Retention of Professional Nurses
The original magnet study began in 1981 when the American Academy of Nursing appointed
a task force to investigate the factors impeding or facilitating professional nursing practice in

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

hospitals. The four researchers on the task force were working from the knowledge that despite a
nursing shortage for a large number of hospitals, a certain number “had succeeded in creating
nursing practice organizations that serve as ‘magnets’ for professional nurses; that is, they are
able to attract and retain a staff of well-qualified nurses and are therefore consistently able to
provide quality care”8 (p. 2). 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.9
Subsequently, a series of group interviews was held with representatives from each hospital.
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.10

Table 1. The Magnet Characteristics of a Professional Practice Environment

Forces of Magnetism 1983 (McClure)8 Forces of Magnetism 2005 (ANCC)11
Administration
Quality of leadership 1. Quality of nursing leadership
Organizational structure 2. Organizational structure
Management style 3. Management style
Staffing 4. Personnel policies and programs
Personnel policies and programs [staffing embedded in #4]

Professional practice
Professional practice models 5. Professional models of care
Quality of care 6. Quality of care
Quality assurance 7. Quality improvement
Consultation and resources 8. Consultation and resources
Autonomy 9. Autonomy
Community and the hospital 10. Community and the hospital
Nurses as teachers 11. Nurses as teachers
Image of nursing 12. Image of nursing
Nurse-physician relationships 13. Interdisciplinary relationships

Professional development
Orientation 14. Professional development [original
In-service and continuing education subgroups embedded]
Formal education
Career development

Note: Order shown in the left column has been slightly rearranged for ease of comparison.

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Magnet Recognition Program Impacts

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 wrote12 (p. 199),
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.

The Magnet Recognition Program® of the American Nurses
Credentialing Center (ANCC) *
In the early 1990s, the American Nurses Association (ANA) initiated a pilot project to
develop an evaluation program based upon the conceptual framework identified by the 1983
magnet research. The program’s infrastructure was established within the newly incorporated
American Nurses Credentialing Center of the ANA, and the first facility to receive Magnet
recognition was named in 1994.11 Interest in MagnetTM has been increasingly accelerating. While
only about 225 organizations have achieved Magnet recognition since the program’s inception,
nearly two-thirds of them did so within the last 3 years, and the applicant list continues to
expand.
Applicants for Magnet recognition undergo a lengthy and comprehensive appraisal process13
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 164 topics.11 Organizations that receive high scores on written documentation move to the
site-visit stage of the appraisal and a period of public comment. 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. Magnet
organizations submit annual reports and must reapply every 4 years to maintain their recognition.
In the context of a rapidly evolving health care system, ANCC has the responsibility as a
credentialing body to continuously refine and improve the criteria it uses for Magnet recognition
in order to “separate true magnets from those that simply want to achieve the
recognition”14 (p. 123). 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.
Continuity between the original magnet research and ANCC’s Magnet program is provided
by the conceptual framework for the forces of magnetism. 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 2005, however, an important change appeared in the

*
The Magnet Recognition Program® and ANCC Magnet Recognition® names and logos are registered trademarks of
the American Nurses Credentialing Center. MagnetTM is a trademark of the American Nurses Credentialing Center.
Magnet is capitalized in this chapter when it refers to the ANCC Magnet Recognition Program or to organizations
that have been designated Magnet by the Magnet Recognition Program.

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Magnet application process. Whereas previous application manuals had itemized evidence
requirements according to ANA’s Scope and Standards for Nurse Administrators,15 the new
manual version11 reorganized the criteria into the framework of the forces of magnetism. This
transition should help to clarify the correspondence between the elements ANCC’s Magnet
program evaluates in its appraisal process and the magnet characteristics that nursing and health
services researchers study.

Reviewing the Evidence
Research studies were retrieved for this review by searching PubMed® and CINAHL® for
articles referencing magnet or magnetism in the title or abstract. Two inclusion criteria were
used. (More details can be found below, in “Search Strategy.”) The articles had to (a) report
findings from analyses of primary or secondary data, and (b) investigate relationships between
magnet variables and nurse or patient outcomes. Nurse outcomes of interest were job
satisfaction, burnout, and intention to leave16, 17 or similar variables such as mental health. 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.

Limitations of the Research
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
1983 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 1983 magnet research study.18 It was intended to
measure four variables: work values related to staff nurse job satisfaction, work values related to
perceived productivity, staff nurse job satisfaction, and perceived productivity (the perception of

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an environment conducive to quality nursing care). Content validity for the instrument was
assured by having three of the four original magnet researchers review it for inclusiveness.19 The
NWI consisted of 65 items and asked respondents to make three Likert-scale judgments on each
item.
Aiken20 subsequently adapted the NWI to measure only organizational features by dropping
the judgment statements related to job satisfaction and perceived productivity. Compared to the
NWI, the NWI-Revised (NWI-R) contained fewer items, but otherwise remained the same
except that one item was modified and two more were added. Four NWI-R subscales were
conceptually derived from an item subset.21
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. Hinshaw22 described clinical autonomy and organizational
autonomy as interactive concepts. Both types of autonomy were evident in the findings from the
original magnet study.8, 23
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. 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. Given nursing’s history as
a subordinated profession,24 one can understand that these three dimensions of the magnet
concept attracted the most initial attention.
In the last 5 years, three additional versions of the NWI have appeared. Except for minor
changes in wording, all use items from the NWI or the NWI-R as originally written. However,
each version consists of different, empirically derived scale or subscale formations. Lake25
created the 31-item Practice Environment Scale of the NWI (PES/NWI) with five subscales and
an overarching composite scale. Estabrooks and colleagues26 created a single-factor, 26-item
scale called the Practice Environment Index (PEI). Choi and colleagues27 created the Perceived
Nursing Work Environment scale (PNWE) † with 42 items and 7 subscales. Neither the PEI nor
the PNWE measures appear in the studies reviewed here.

Research Evidence
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 1983 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

†
Subscales for the PNWE are labeled professional practice, staffing and resource adequacy, nurse management,
nursing process, nurse-physician collaboration, nurse competence, and positive scheduling climate.

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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 1980s. 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 1983 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 colleagues28-35 within a decade of the
publication of the original magnet study. For the Medicare mortality study28, 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. As Aiken has summarized it, these “findings suggest
that the same factors that lead hospitals to be identified as effective from the standpoint of the
organization of nursing care are associated with lower mortality”20 (p. 72).
Guided by a conceptual framework originating in the sociology of organizations and
professions,20 the second compelling study29-35 was formulated to examine how certain
modifications to the organization of nursing in hospitals introduced by the AIDS epidemic
affected patient and nurse outcomes. The AIDS epidemic in combination with high nurse
vacancy rates caused a number of urban hospitals to grant “unusual discretion to nurses to
redesign general medical units into dedicated AIDS units”20 (p. 63). 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 studies shown in Evidence Table 2 consistently display positive results relating magnet
characteristics (as measured by the NWI-R or PES/NWI subscales) to nurse job satisfaction,
burnout, intention to leave, and perceived quality of care. The exception to this finding is the
mixed results shown for the nurse-physician relationship subscale. Havens’s36 study with chief
nurse executives found higher levels on the NWI-R subscales to be associated with reports of
higher patient care quality, less recruitment difficulty, and fewer patient/family complaints. The
studies shown in the first two rows of Evidence Table 2, which demonstrated more favorable
results for the ANCC Magnet group compared to the reputational magnet group, also supported
the view expressed by McClure and Hinshaw that magnet status “is not a permanent institutional
characteristic but rather one that requires constant nurturing”14 (p. 119).
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 colleagues37 and Smith, Tallman, and Kelly38 found that some magnet characteristics linked
significantly to intentions to leave in freestanding dialysis units and to job satisfaction in rural

6


Canadian hospitals, respectively. Rondeau and Wagar39 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.
Using multiple measures, a variety of samples and respondent groups, and more powerful
analyses, Laschinger and her colleagues40-44 have been testing a theoretical model linking
structural empowerment and magnet characteristics (as measured by the NWI-R or PES/NWI) to
nurse and patient outcomes with variables such as trust and burnout posited as mediators. 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 1983 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 colleagues45 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. However, the authors
also noted, “What we do know about changes in organization and structure of hospitals and the
potential for those changes to affect patient outcomes pales by comparison to what we do not
know”45 (p. 103).
Reviewing the magnet research presented in this chapter leads to similar conclusions. The
evidence almost uniformly shows consistent positive relations between job satisfaction or nurse-
assessed quality of care and the magnet characteristics measured by subscales of the NWI-R or
PES/NWI. But the connections from those results based on staff nurse surveys to patient
outcomes measured objectively by other means have seldom been studied.
In a recent systematic review of the hospital nursing environment’s effect on patient
mortality, Kazanjian and colleagues6 found associations between unfavorable environment
attributes and higher patient mortality rates in 19 of 27 studies. 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 authors
concluded it would be difficult to determine “how to design optimal practice settings until
mechanisms linking practice environment to outcomes are better understood”6 (p. 111).

Evidence-Based Practice Implications
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. The practice implications suggested by these findings have
been delineated in detail by the Institute of Medicine’s 2004 report on patient safety, which

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included a comprehensive review of the research that clarifies how nurse outcomes reflect and
interact with working conditions to affect patient safety and quality.3
Keeping Patients Safe: Transforming the Work Environment of Nurses cited conditions in the
work environments of nurses as “the primary sources” of threats to patient safety that “must be
addressed if patient safety is to be improved”3 (p. 47). The report presented a series of
recommendations for improving leadership, management, and organizational support practices
that emphasizes the increased participation of employees in work design, problem-solving, and
organizational decisionmaking as a “key ingredient to successful organizational
change”3 (p. 260). The report noted that high involvement in decisionmaking for nurses “has
been studied under a number of constructs, including shared governance, nursing empowerment,
control over nursing practice, and clinical autonomy”3 (p. 122).
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 colleagues8 and currently elaborated
for contemporary settings in the appraisal criteria for Magnet recognition.11 For example, of the
27 goals the report listed as “Necessary Patient Safeguards in the Work Environment of
Nurses”3 (p. 16–17), 20 are addressed by the current evidence requirements for Magnet
recognition.11 The multidimensionality of the magnet framework reflects the highly complex,
variable, multilevel, and multifaceted nature of nursing practice environments, but it also poses
measurement challenges for researchers interested in studying the influence of magnet
environments on outcomes.

Research Implications
Mick and Mark5 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. Many of the
suggestions they make for doing so are echoed in the research implications generated by this
review. Greater attention needs to be paid to addressing sampling bias issues, improving critical
measures, collecting objective data from sources other than nurse self-reports, and designing
multilevel and longitudinal studies. As Table 1 reveals, the conceptual definition of a magnet
environment encompasses many fields and disciplines from which theoretical insights may be
borrowed and tested.
Taking better account of multiple organizational perspectives and hierarchical levels in the
research will build knowledge about how the relationships between magnet characteristics and
patient outcomes differ by role or practice location. For example, Laschinger, Almost, and Tuer-
Hodes41 found that magnet characteristics and empowerment related differently to each other and
to job satisfaction for nurse practitioners than for staff nurses, and Friese’s46 results differed
significantly on some magnet characteristics only for oncology nurses. Distinguishing unit
locations may be particularly important. Mick and Mark have claimed that “it is the exploration
of work structures and processes at the nursing unit level that is contributing to the lion’s share
of advancing knowledge about what does and does not have an impact on patient and
organizational outcomes”5 (p. 319).

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Finally, while the NWI-R and later versions of the NWI have yielded a wealth of useful data,
questions have also been raised as to the measurement adequacy of at least three of them.47
Variable, unpredictable, contextually sensitive, and multifaceted,25, 47 “the nursing practice
environment is a complex construct to conceptualize and measure”25 (p. 177). Yet developing,
improving, and refining measures to reliably capture all of the factors of a magnet environment
may be the most important next step.

Conclusion
The magnet concept defines a framework for facilitating the professional practice of nursing
that has demonstrated effectiveness in attracting nurses and shows promise for contributing to
optimal patient outcomes. There is a compelling need to improve the measures and methods used
to research magnet characteristics and environments before the links that connect organizational
context to nurse and patient outcomes can be sufficiently understood.

Search Strategy
A series of searches was carried out in October 2006 using the National Library of
Medicine’s PubMed database and the Cumulative Index of Nursing and Allied Health Literature
(CINAHL) database. Several search terms and phrases including the word “magnet” or
“magnetism” were tested in both cases. The most effective were “magnet[Title/abstract] and
nursing[Title/abstract]” in PubMed and “magnet” in [TI Title] OR “magnet” in [AB Abstract or
Author-Supplied Abstract] with advanced search in CINAHL. Supplementary backup searches
were also performed substituting the word “magnetism” for “magnet” in CINAHL and the word
“hospitals” for “nursing” in PubMed. The PubMed searches yielded 134 unique titles to review.
Cross-checking the CINAHL results against the PubMed lists yielded two additional titles.
The overwhelming majority of articles identified by these searches fell into editorial,
interpretive, or narrative categories—especially narratives describing how an individual
organization prepared for or achieved ANCC Magnet recognition. If an abstract was ambiguous
about whether the article reported results from a primary or secondary data analysis, the article
itself was retrieved in order to make a determination. The article by Laschinger and Leiter44 was
previously known and not identified by the search strategy.

Author Affiliations
Vicki A. Lundmark, Ph.D., director, research, American Nurses Credentialing Center. E-
mail: Vicki.lundmark@ana.org.

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30. Aiken LH, Sloane DM. Effects of specialization and Winter;15(4):19-23.
client differentiation on the status of nurses: the case
of AIDS. J Health Soc Behav 1997;38:203-22. 43. Armstrong KJ, Laschinger H. Structural
empowerment, Magnet hospital characteristics, and
31. Aiken LH, Sochalski J, Lake ET. Studying outcomes patient safety culture: making the link. J Nurs Care
of organizational change in health services. Med Care Qual 2006 Apr-Jun; 21(2):124-32.
1997; 35(suppl):NS6-N18.
44. Laschinger HK, Leiter MP. The impact of nursing
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inpatient AIDS care: a national comparison of mediating role of burnout/engagement. J Nurs Adm.
dedicated and scattered-bed units. Med Care 2006 May;36:259-67.
1997;35:948-62.
45. Lundstrom T, Pugliese G, Bartley J, et al.
33. Aiken LH, Lake ET, Sochalski J, et al. Design of an Organizational and environmental factors that affect
outcomes study of the organization of hospital AIDS worker health and safety and patient outcomes. Am J
care. Res Sociol Health Care 1997;14:3-26. Infect Control 2002 Apr; 30(2):93-106.

34. Aiken LH, Sloane DM, Klocinski JL. Hospital nurses’ 46. Friese CR. Nurse practice environments and
occupational exposure to blood: prospective, outcomes: implications for oncology nursing. Oncol
retrospective, and institutional reports. Am J Public Nurs Forum 2005 Jul 1; 32:765-72.
Health 1997;87(1):103-107.
47. Cummings GG, Hayduk L, Estabrooks CA. Is the
35. Aiken LH, Sloane DM, Lake ET, et al. Organization Nursing Work Index measuring up? Moving beyond
and outcomes of inpatient AIDS care. Med Care estimating reliability to testing validity. Nurs Res 2006
1999;37:760-72. Mar-Apr; 55(2):82-93.

36. Havens, DS. Comparing nursing infrastructure and 48. Kramer M, Schmalenberg C. Magnet hospitals talk
outcomes: ANCC Magnet and nonmagnet CNE’s about the impact of DRGs on nursing care—Part I.
report. Nurs Econ, 2001;19:258-66. Nurs Manage 1987 Sep;18(9):38-42.

37. Thomas-Hawkins C, Denno M, Currier H, et al. Staff 49. Kramer M, Schmalenberg C. Magnet hospitals talk
nurses’ perceptions of the work environment in about the impact of DRGs on nursing care—Part II.
freestanding hemodialysis facilities. Nephrol Nurs J Nurs Manage 1987 Oct; 18(10):33-6, 38-40.
2003 Aug: 30(4):377-86. [Previously published
Apr:30(2):169-78.] 50. Kramer M, Schmalenberg C. Magnet hospitals: Part I.
Institutions of excellence. J Nurs Adm 1988
38. Smith H, Tallman R, Kelly K. Magnet hospital Jan;18(1):13-24.
characteristics and northern Canadian nurses’ job

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51. Kramer M, Schmalenberg C. Magnet hospitals: Part II. 56. Aiken LH, Havens DS, Sloane DM. The Magnet
Institutions of excellence. J Nurs Adm 1988 nursing services recognition program. Am J Nurs 2000
Feb;18(2):11-9. Mar;100(3):26-35; quiz 35-6.

52. Kramer M, Schmalenberg C, Hafner LP. What causes 57. Upenieks VV. The interrelationship of organizational
job satisfaction and productivity of quality nursing characteristics of magnet hospitals, nursing leadership,
care? In: Moore TF, Simendinger EA, eds. Managing and nursing job satisfaction. Health Care Manag
the nursing shortage: a guide to recruitment and (Frederick) 2003 Apr-Jun;22(2):83-98.
retention. Rockville, MD: Aspen; 1989. p. 12-32.
58. Upenieks VV. Assessing differences in job
53. Peters TJ, Waterman RH. In search of excellence. satisfaction of nurses in magnet and nonmagnet
New York: Harper Row Publishers; 1982. hospitals. J Nurs Adm 2002 Nov; 32:564-76.

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retention. Insights for the ‘90s. Part 1. Nursing 1991 Recognition program: implications for nursing leaders.
Mar; 21(3):50-5. J Nurs Adm 2005 Sep; 35:397-403.

55. Kramer M, Schmalenberg C. Job satisfaction and
retention. Insights for the ‘90s. Part 2. Nursing 1991
Apr; 21(4):51-5.

12

Evidence Table 1. ‡ Studies With Reputational Magnet Hospitals
Environment Study Design
Source Issue/Attribute Related Design & Study Outcome Study Setting Key Finding(s)
to Clinical Practice Type Measure(s) & Study Population
Kramer and Nursing Work Index (NWI), 65 Cross- Cross-sectional survey, 1985–86 data collection Staff nurses in magnet hospitals
Hafner 198919 items designed to measure sectional interviews, 16 reputational magnets had significantly higher scores on
work values representing the studies observations, proportionate by region, 8 • job satisfaction
Kramer and findings from the 1983 original document review comparison county, • perceived productivity of
Schmalenberg magnet study Outcomes: community, and medical quality care
198748-51 Other measures: from NWI: center hospitals in Virginia Causal model testing to predict
• culture of excellence, 8 • job satisfaction Survey n = 2,236 staff outcomes with 31 variables
Kramer, items suggested by Peters • perceived nurses, 1,634 in reputational produced no findings.
Schmalenberg, and Waterman53 productivity of magnet and 702 in
and Hafner • locus of control quality patient care comparison group; interview
52
1988 • autonomy-patient advocacy n = 800+ staff nurses, 632
• self-concept/self-esteem nurse managers/executives
• role behavior scales
Kramer and Magnet factors: Cross- Cross-sectional survey 1989–90 data collection Nurses in magnet hospitals had
Schmalenberg • perceived adequacy of sectional Outcome: Survey n = 939 nurses in 14 significantly more positive scores
13

199154, 55 staffing studies Overall job satisfaction: reputational magnets (from on
• image of nurses • organizational 1985–86 sample), 808 • job satisfaction
• how nursing is valued (how structure (7 items) nurses in comparison “panel” Nurses in magnet hospitals
important, how active, how • professional sampled from 5,000 reported higher levels for
powerful) practice (5 items) Nursing89 subscribers • a culture of excellence
Other measures: • management style • perceived adequacy of
• culture of excellence, 39 (5 items) staffing
items to represent 7 • quality of leadership • image of nursing
attributes (4 items) • value of nursing
• professional

development (3
items)

‡
To illustrate how this research has developed and expanded over time, the evidence tables in this chapter are arranged in chronological order by the data
collection date for each study, when available, or publication date.


Aiken, Smith, Status as a reputational Cross- Cross-sectional; 1988 Medicare data Magnet hospitals had a 4.5%
and Lake magnet hospital sectional multivariate matched 39 reputational magnet lower mortality rate (95% CI
199428 studies sampling procedure to hospitals (census of all (confidence interval) = 0.9 to 9.4
control for relevant available or eligible), 195 fewer deaths per 1,000
hospital characteristics control hospitals (5 matches discharges).
(e.g., teaching status, for each magnet) from all
technology availability, nonmagnet U.S. hospitals
board certification of with >100 Medicare
physicians, emergency discharges
room presence),
adjusting for
differences in predicted
mortality for Medicare
patients
Outcome:
Medicare mortality rate
(within 30 days of
14

admission)
Aiken and Nursing Work Index-Revised Cross- Cross-sectional survey, 1991 data collection Patients with AIDS in magnet
29,
Sloane 1997 (NWI-R), 57 items, with sectional needlestick reports for 40 medical units, 2 in each of scattered-bed units had lower
30
subscales for studies a 30-day period, patient 20 urban hospitals located odds of dying than in any other
• nurse autonomy (5 items) interviews, patient chart throughout U.S., 10 hospitals setting; higher nurse-to-patient
Aiken, • control over nursing practice abstraction with dedicated AIDS units, ratios were determined to be the
Sochalski, and setting (7 items) Outcomes: 10 matched comparable major explanatory factor.
Lake 199731 • nurse relations with Nurse — hospitals without AIDS units Patient satisfaction was highest
physicians (2 items) • job burnout (scattered-bed), 2 in magnet hospitals; control over
Aiken, Sloane • organizational support (10 • safety (needlesticks) comparison hospitals were nursing practice setting was
and Lake items from previous 3 Patient — reputational magnets, 1 determined to be the single most
199732 subscales) • satisfaction with more was considered important explanatory factor.
care magnet based on researcher Nurses in magnet hospitals
Aiken, Lake, (multi-item scale knowledge of facility sustained significantly fewer
Sochalski and a single-item Survey n = 820 RNs from all needlestick injuries.
199733 overall rating) employed on units ≥16 hours Nurses in magnet hospitals and
• mortality 30 days per week (86% response dedicated AIDS units had
Aiken, Sloane, from admission rate); interview n = 594 significantly more positive scores
and Klocinski patients; chart outcomes for for emotional exhaustion,
199734 1,205 AIDS patients autonomy, nurse control over
resources, and nurse-physician
Aiken, Sloane, relations.
35
Lake 1999

Scott, Literature Search method Summarizes findings cited in this
Sochalski, and review, unstated. table and synthesizes insights
Aiken 199923 narrative from these and additional
magnet studies to illuminate the
leadership characteristics and
professional practice attributes
found within reputational magnet
hospitals.
15


Evidence Table 2. Studies Comparing Health Care Organizations With and Without ANCC Magnet Recognition

Aiken, Havens, NWI-R single items and Cross- Cross-sectional, 1998 data collection Nurses in ANCC Magnets were
and Sloane subscales, Aiken et al.: sectional comparative multisite 7 ANCC Magnets (census as significantly more likely to report
200056 • nurses’ autonomy studies observational of study date), 13 • higher ratings of care quality
• nurses’ control over the Outcomes: reputational magnets (12 • higher job satisfaction
Friese 200546 practice setting • perceived quality of from Kramer et al.’s 1985–86 • less frequently feeling burned
• nurse relations with care sample) with 2 additional out, emotionally drained, and
physicians • job satisfaction teaching hospitals included frustrated by their job
Practice Environment • intent to leave in Friese’s secondary Oncology nurses in ANCC
Scale/Nursing Work Index • burnout (Maslach analysis Magnets reported nearly half the
(PES/NWI), Friese: Burnout Aiken et al. survey n = 2,045 exhaustion levels of oncology
• nurse participation in Inventory) RNs in medical or surgical nurses in the 13 reputational
hospital affairs (9 items) units, 1,064 in ANCC Magnet magnets and 2 teaching
• nursing foundations for and 981 in reputational hospitals.
quality of care (10 items) magnet group In both analyses, most NWI-
• nurse manager ability, Friese analysis n = 1,956 of related subscale scores were
16

leadership, and support of which 305 = oncology nurses significantly higher for nurses in
nurses (5 items) (155 in ANCC Magnet and the ANCC Magnet group;
• staffing and resource 150 in comparison group) exceptions were that scores for
adequacy (4 items) and 1,651 = nononcology nurse-physician relations and
nurses (755 in ANCC nurse manager ability,
• collegial nurse-physician
Magnet and 896 in leadership, and support differed
relations (3 items)
comparison group) significantly, favoring ANCC
Other measures:
• job characteristics (hours Magnets only for oncology
worked, workload, nurses.
supervisory responsibilities,
nonnursing duties)
Havens 200136 NWI-R subscale: Cross- Cross-sectional survey; 1999–2000 data collection Chief nurse executives in the
• organizational support sectional comparative 21 ANCC Magnets, 35 ANCC Magnet group reported
Other measures: studies reputational magnet less difficulty recruiting RNs and
• degree restructuring Outcomes: hospitals (census samples of were significantly more likely to
implemented, 9 items • difficulty recruiting both groups) report
staff RNs (1 item) Survey n = 43 chief nurse • high quality patient care
• quality of patient executives, 19 in ANCC • fewer patient/family
care (global ratings Magnet and 24 in complaints
and reports of reputational magnet group • organizational support for
complaints) autonomy, control over
practice, and nurse-physician
collaboration

Upenieks 2002, Power and empowerment – Cross- Cross-sectional survey Convenience sample of 2 Nurses in the ANCC Magnet
57, 58
2003 Conditions of Work sectional Outcome: ANCC Magnets, 2 group had significantly higher
Effectiveness Questionnaire-II studies Job satisfaction - comparable comparison scores on
(CWEQ-II) 20 items: NWI-R subscales: hospitals • job satisfaction
• 2 global items • autonomy Survey n = 305 medical- • power and empowerment
• 4 subscales to measure • nurse control over surgical nurses
perceived access to practice setting
opportunity, information, • relations between
support, and resources nurses and
physicians
Plus 3 researcher-
designed subscales:
• self-governance (7
items)
• organizational
structure (6 items)
• education
opportunities (6
17

items)
Brady-Schwartz Status as ANCC-recognized Cross- Cross-sectional survey; 3 ANCC Magnets, 3 Nurses in ANCC Magnet group
59
2005 Magnet sectional quantitative, descriptive comparison hospitals had significantly higher overall
studies correlational Survey n = 470 RNs, 173 in job satisfaction, including
Outcome: ANCC Magnet and 297 in significant subscale differences
• overall job comparison group for professional opportunities,
satisfaction (total control/responsibility, and
McCloskey Mueller extrinsic rewards.

Satisfaction Scale Higher overall job satisfaction
score; subscales: correlated with stronger
extrinsic rewards, perceptions of voluntarily
scheduling, family/ remaining in current position.
work balance,
coworkers,
interaction,
professional
opportunities, praise
and recognition,
control/
responsibility)
• intention to leave
(Anticipated
Turnover Scale)

Evidence Table 3. Studies of Magnet Characteristics


Laschinger, Magnet characteristics— Cross- Cross-sectional survey Ontario, Canada Model testing with these
Shamian, and NWI-R subscales: sectional Outcomes: Survey n = 3,016 staff variables explained 39–40% of
Thomson • nurse autonomy studies • job satisfaction nurses from medical-surgical the variance with either job
200140 • nurse control over practice • perceived quality of settings (subsample from a satisfaction or nurse-assessed
setting care stratified random sample) in quality as the outcome.
• nurses’ relations with • perceived quality of 135 hospitals Magnet characteristics
physicians unit influenced job satisfaction and
Other measures: perceptions of care quality with
• trust and confidence in trust in management and
management — emotional exhaustion as
Interpersonal Trust at Work important mediators.
Scale Higher levels of magnet
• burnout—The Human characteristics were associated
Services Survey, 3 with higher levels of trust in
management and lower levels of
18

components (emotional
exhaustion, burnout.
depersonalization,
decreased personal
accomplishments)
Thomas- Magnet characteristics – Cross- Cross-sectional survey United States Nurses who intended to leave
Hawkins, PES/NWI subscales (some sectional Outcome: 1,000 staff nurses working in their jobs reported significantly
Denno, Currier items adapted to reflect setting): studies intentions to leave job freestanding hemodialysis lower levels of magnet
37
2003 • nurse participation in in next year (1 item) facilities (random sample characteristics represented by all
hospital affairs from American Nephrology of the PES/NWI subscales
• nursing foundations for Nurses’ Association except for collegial relations
quality of care members) between nurses and physicians.
• nurse manager ability,
leadership, and support of
nurses
• staffing and resource
adequacy
• collegial nurse-physician
relations


Laschinger, Magnet characteristics—NWI-R Cross- Cross-sectional survey Ontario, Canada For staff nurses, empowerment
Almost, and subscales: sectional data from 3 Study 1: survey n = 233 and magnet characteristics were
Tuer-Hodes • nurse autonomy studies independent studies; randomly selected staff significant independent
200341 • nurse control over practice predictive, nurses from urban tertiary predictors of job satisfaction; for
setting nonexperimental care hospitals throughout nurse practitioners, the
• nurses’ relations with Outcomes: Ontario combination of empowerment
physicians • Global Job Study 2: survey n = 263 and magnet characteristics
Other measures: Satisfaction randomly selected staff significantly predicted job
Empowerment Questionnaire nurses from 3 rural satisfaction.
• CWEQ-II, 4 subscales: (Studies 1, 3) community hospitals in a Average ratings on
access to opportunity, • Nurse Job western Ontario network of 8 empowerment and magnet
information, support, and Satisfaction Study 3: survey n = 55 acute characteristics were moderate for
resources Questionnaire care nurse practitioners from staff nurses and higher for nurse
• Job Activities Scale-II, 3 (Study 2) urban tertiary care hospitals practitioners.
items: perceptions of formal throughout Ontario Total scores on empowerment
power and magnet characteristics were
• Organizational strongly correlated for all three
19

Relationships Scale-II, 4 samples; the most strongly
items: perceptions of related empowerment features
informal power were access to resources for
staff nurses and access to
information for nurse
practitioners.
All empowerment dimensions
related significantly to
perceptions of autonomy; access

to resources related most
strongly to control over practice
environment; and informal power
related most strongly to nurse-
physician relationships.



Tigert and Magnet characteristics – NWI- Cross- Cross-sectional, Ontario, Canada; The combined effects of
Laschinger R subscales: sectional correlational survey Data collected 2001 empowerment and magnet
200442 • nurse autonomy studies design Survey n = 75 critical care characteristics explained 19% of
• nurse control over practice Outcomes: nurses, a subsample of 239 the variance in burnout and 12%
setting mental health nurses working in teaching of the variance in state of mind.
• nurses’ relations with • State of Mind hospitals (randomly selected Empowerment related
physicians subscale (5 items) from College of Nurses of significantly and positively to
Other measures: from the Pressure Ontario) perceptions of magnet
Empowerment Management characteristics; however, only
• CWEQ-II, 4 subscales: Indicator empowerment was a significant
access to opportunity, • Emotional independent predictor of
information, support, and Exhaustion emotional exhaustion, and only
resources subscale (6 items) magnet characteristics were a
• Job Activities Scale-II, 3 from the Maslach significant predictor of state of
items: perceptions of formal Burnout Inventory mind.
power
20

• Organizational
Relationships Scale-II, 4
items: perceptions of
informal power
Rondeau and Magnet similarity represented Cross- Cross-sectional survey Canada Higher scores on magnet
39
Wagar 2006 by employer-of-choice strength sectional Outcomes: Data collected 2003 employer-of-choice strength were
(7 items, e.g., how studies • resident satisfaction Survey n = 114 nurse significantly associated with
establishment views, values, (3 items) executives sampled from all • higher resident satisfaction
treats its nursing personnel; • nurse turnover and long-term care organizations • lower turnover and vacancy
how staff and community view vacancy rates (nursing homes) in western rates
its treatment of nurses) • nurse satisfaction (3 Canada with ≥35 beds • higher nurse satisfaction
Other magnet characteristics items) • high involvement work
measures: practices
• high involvement (high • progressive decisionmaking
commitment) work practices • nurse training opportunities
(10 items) and assistance
• progressive, participatory
decisionmaking workplace
culture (3 items)
• training support (10 items)


Smith, Tallman, Magnet characteristics Cross- Cross-sectional survey, Canada All magnet characteristics items
and Kelly categories: sectional interviews Survey n = 123 nurses in were significantly but modestly
200638 • supportive management (5 studies Outcome: diverse clinical areas from 13 correlated with job satisfaction
items) job satisfaction rural northwestern hospitals except for the 2 items measuring
• professional autonomy and (3 items from Job recruited via circulating nurse-physician relationship and
responsibility (4 items) Diagnostic Survey) letter/flyer 1 of the 4 autonomy items.
• nurse-physician working
relationship (2 items)
• nurse-manager working
relationship (2 items)
Armstrong and Magnet characteristics – Cross- Cross-sectional survey; Canada The combination of structural
Laschinger PES-NWI subscales: sectional exploratory; predictive, 40 staff nurses working in a empowerment and magnet
200643 • nurse participation in studies nonexperimental small community hospital in characteristics was a significant
hospital affairs Outcome measure: central Canada predictor of perceptions of patient
• nursing foundations for Safety Climate Survey safety climate.
quality of care Overall empowerment
• nurse manager ability, significantly positively related to
21

leadership, and support of all magnet characteristics, with
nurses total empowerment most strongly
• staffing and resource related to use of a nursing model
adequacy of care and good nursing
• collegial nurse-physician leadership on the unit.
relations
Other measures:
Structural empowerment –

CWEQ-II, 2 global items and 6
components: access to
opportunity, information,
support, resources, formal
power, and informal power



Laschinger and Magnet characteristics – Cross- Cross-sectional survey Canada With all measured components
Leiter 200644 PES-NWI subscales: sectional Outcome measure: Survey n = 8,597 nurses included in the model, structural
• nurse participation in studies adverse events (4,606 from a stratified equation modeling analysis
hospital affairs (nurse-reported random sample of licensing showed direct and indirect effects
• nursing foundations for frequency of registry lists in Ontario and of all environment factors on
quality of care occurrence of negative 3,991 from a census sample patient safety outcomes partially
• nurse manager ability, patient events in past of acute care nurses in mediated by burnout.
leadership, and support of year: Alberta), Both staffing adequacy and use
nurses • falls a subset of participants in of a nursing model of care
• staffing and resource • nosocomial the International Survey of directly affected patient safety
adequacy infections Hospital Staffing and outcomes.
• collegial nurse-physician • medication errors Organization of Patient Staffing adequacy directly
relations • patient complaints) Outcomes conducted in 5 affected emotional exhaustion,
Other measures: Maslach countries and use of a nursing care model
Burnout Inventory–Human directly affected personal
Service Scale, 3 subscales: accomplishment.
22

• emotional exhaustion (9 Nursing leadership played a
items) fundamental role in relation to
• depersonalization (5 items) policy involvement, staffing
adequacy, RN-MD relationships,
• personal accomplishment (8
and support for a nursing (vs.
items)
medical) model of care.

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