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Prompt #1: Chapter 10, 11, and 12
Read the article, “A new era of health leadership” attached to the assignment. Write a response to the
article addressing the following questions:
1. Do you agree with Smith and Bhavsar that the traditional model of leadership in healthcare
needs to change? Why or why not?
2. What structural issues in this article do you see in how healthcare is delivered in the United
States?
3. How does this article interact with Hersey and Blanchard’s Situational Leadership Model (chapter
10)? What similarities do you find? Any differences?
4. Smith and Bhavsar talk about emotional intelligence. Take this survey and describe your results:
https://www.verywellmind.com/how-emotionally-intelligent-are-you-2796099. Did the result of
the survey surprise you?
5. Does taking this survey raise concerns for your perceived ability to manage a workforce? If it
does, what resources are you aware of to raise your level of emotional intelligence?
Prompt #2: Chapter 11
Read the linked article (https://www.beckershospitalreview.com/strategy/magnet-designation-howchristianacare-is-using-this-recognition-program-as-a-focal-point-for-improving-patient-outcomes.html)
and the article attached to the assignment, “Nurse Outcomes in Magnet® and Non-Magnet Hospitals”
1. What is a “Magnet Hospital”?
2. Which leadership style do you think is required to achieve such a high distinction (transactional,
transformational, charismatic, servant, or collaborative), and why do you think so? Support your
answer with either the book or an outside source.
3. Using any of the motivation theories from previous chapters, why do Magnet hospitals
outperform non-magnet hospitals? Name specific outcome comparisons with your analysis.
Prompt #3: Chapter 12
Read the following article: https://www.beckershospitalreview.com/hospital-physicianrelationships/only-40-of-physicians-recommend-career-in-medicine-survey.html
1. What is burnout? What are the common symptoms of burnout?
2. How can healthcare managers/executives manage burnout in a fast-paced and demanding
environment, such as a hospital?
3. Find a healthcare organization that has implemented a mental health wellness program. What
are the reported benefits since the organization started such a program?
NIH Public Access
Author Manuscript
J Nurs Adm. Author manuscript; available in PMC 2012 October 1.
NIH-PA Author Manuscript
Published in final edited form as:
J Nurs Adm. 2011 October ; 41(10): 428–433. doi:10.1097/NNA.0b013e31822eddbc.
Nurse Outcomes in Magnet® and Non-Magnet Hospitals
Lesly A. Kelly, PhD, RN, Matthew D. McHugh, PhD, JD, MPH, RN, CRNP, and Linda H.
Aiken, PhD, RN, FAAN
Postdoctoral Research Fellow (Dr Kelly), Assistant Professor (Dr McHugh), Claire M. Fagin
Leadership Professor of Nursing and Director of the Center for Health Outcomes and Policy
Research (Dr Aiken), University of Pennsylvania, Philadelphia.
Abstract
NIH-PA Author Manuscript
The important goals of Magnet® hospitals are to create supportive professional nursing care
environments. A recently published paper found little difference in work environments between
Magnet and non-Magnet hospitals. The aim of this study was to determine whether work
environments, staffing, and nurse outcomes differ between Magnet and non-Magnet hospitals. A
secondary analysis of data from a 4-state survey of 26,276 nurses in 567 acute care hospitals to
evaluate differences in work environments and nurse outcomes in Magnet and non-Magnet
hospitals was conducted. Magnet hospitals had significantly better work environments (t = −5.29,
P < .001) and more highly educated nurses (t = −2.27, P < .001). Magnet hospital nurses were
18% less likely to be dissatisfied with their job (P < .05) and 13% less likely to report high
burnout (P < .05). Magnet hospitals have significantly better work environments than non-Magnet
hospitals. The better work environments of Magnet hospitals are associated with lower levels of
nurse job dissatisfaction and burnout.
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Despite a strong evidence base over 2 decades showing superior work environments and
better nurse and patient outcomes in Magnet®-recognized hospitals,1 a recent study2
published in Journal of Nursing Administration generated renewed debate over whether
Magnet and non-Magnet hospitals are significantly different. Trinkoff and colleagues2 were
unable to find differences in the work environment of Magnet-credentialed hospitals
compared with others. There are multiple reasons for null findings in a particular study that
could relate to the study design, sample, measures, and statistical power and do not
necessarily negate the findings of past studies or suggest a new trend. That publication
motivated us to revisit with new data from a large study of hospitals our earlier findings3,4
suggesting better work environments and better nurse outcomes in American Nurses
Credentialing Center (ANCC) Magnet-recognized hospitals.
Background
During the 1980s, there was a significant nursing shortage and high turnover at hospitals.
Nurse leaders observed that some hospitals were better able to retain nurses and fill
vacancies compared with similar hospitals in the same labor markets. A study by the
American Academy of Nursing (AAN) identified 41 hospitals that acted as “magnets” for
nurses because of their more supportive work environments. 5 Research by Kramer and
Hafner6 confirmed that AAN Magnet hospitals had common organizational features not
found in other hospitals that were associated with higher nurse satisfaction and retention.
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Correspondence: Dr Kelly, Banner Good Samaritan Medical Center, 1111 East McDowell Rd, Phoenix, AZ 85006
(leslykelly@gmail.com).
The authors declare no conflict of interest.
Kelly et al.
Page 2
Aiken and colleagues7 followed with a study showing that the AAN-identified hospitals also
had better patient outcomes, namely lower hospital mortality, than matched hospitals.
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In 1990, the ANCC, an organizational component of the American Nurses Association,
developed a voluntary recognition program for formally credentialing Magnet organizations,
and the first Magnet hospital was credentialed8 in 1994. Aiken and associates 3 compared
the first 7 ANCC Magnet®-recognized facilities with the original AAN reputational Magnet
hospitals, finding the ANCC hospitals to have better nurse work environments and nurse
outcomes, such as higher job satisfaction, lower burnout rates, and lower intent to leave,
than the original AAN hospitals.
The ANCC Magnet Recognition Program® has grown exponentially in recent years. To
date, approximately 7% of US hospitals, close to 400, have achieved Magnet
Recognition.9,10 Magnet hospitals have been recognized thus far in 5 countries besides the
United States (England, Australia, New Zealand, Singapore, and Lebanon). Magnetcredentialed hospitals have consistently been shown to have better nurse work environments
and better nurse and patient outcomes.1,11–14 In addition, Magnet-recognized hospitals have
demonstrated higher nurse-physician collaboration and safer work environments.15,16
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Recent research has focused on the work environment of nurses as a potential contributor to
nurse outcomes.4,17,18 Many hospitals use the process of Magnet credentialing as a road
map for improving the quality of care and the work environment of their hospital.19 In a
case study of the first hospital outside the United States to become Magnet recognized, a
hospital in England was shown to significantly improve its work environment after Magnet
Recognition as compared with that before preparing for Magnet credentialing.20 Ulrich et
al21 examined the practice environments of Magnet hospitals, finding that the improved
environment in Magnet-credentialed hospitals is demonstrated through significantly higher
emphasis on patient care, more opportunities for advancement, and a greater ability to
influence decisions. In addition, Lake and Friese4 confirmed that Magnet-credentialed
hospitals documented better practice environments than other hospitals in a single-state
sample of Pennsylvania.
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This study was conducted to use a unique recent database derived from a survey of hospital
nurses in 4 states to determine whether organizational nursing characteristics and nurse jobrelated outcomes differ in Magnet compared with non-Magnet hospitals. We compare
differences in nurses’ work environment and nurses’ educational qualifications in Magnet
hospitals compared with nurses in non-Magnet hospitals. We also evaluated nurses’
satisfaction, burnout, and intention to leave their position in Magnet and non-Magnet
hospitals, controlling for individual nurse, hospital, and hospital-level nursing
characteristics.
Methods
Sample
Our data are from a study of hospitals in 4 states (California, Florida, Pennsylvania, and
New Jersey) in 2006 to 2007. Researchers mailed a survey to the homes of a random sample
of RNs using the state licensure lists for 2006 to 2007. Nurses who worked in hospitals were
asked to provide the name of their employer, which allowed us to aggregate responses by
hospital for the analysis. Our final sample included 567 hospitals, 46 of which were ANCC
Magnet recognized. The response rate of hospitals was 86%; most of the hospitals not
included were very small. Within participating hospitals, 4,562 nurses working in Magnet
hospitals and 21,714 nurses working in non-Magnet hospitals were surveyed by mail at their
homes, an average of 45 nurses per hospital. Thus, the nurse respondents in this study were
J Nurs Adm. Author manuscript; available in PMC 2012 October 1.
Kelly et al.
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not directly recruited from their hospitals but responded to the population-based survey of
RNs in their states and provided information on their hospital of employment and their
employer’s name. This study was approved by the institutional review board of the
University of Pennsylvania.
Measures
Nurse Characteristics—Nurse characteristics included nurses’ age, years of experience,
educational level, specialty certification, sex, and whether basic nursing education was
attained in the United States.
Nurse Staffing—Staffing was created from the nurse’s report of the number of patients
he/she cared for on his/her last shift. Responses from nurses in all clinical areas including
ICUs were averaged to determine the average patient-to-nurse ratio for the hospital.
Previous research on nurse workload has shown this measure of staffing to have better
predictive validity for staff nurses in the hospital than administrative data that often include
nurses who do not directly care for patients.22,23
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Work Environment—The work environment was measured using the 31-item Practice
Environment Scale of the Nursing Workforce Index,24 endorsed by the National Quality
Forum. Nurses are asked to indicate the degree to which various organizational features are
present in their practice setting. We created hospital-level measures by aggregating nurses’
responses to items comprising 5 subscales and calculating a continuous hospital-level
summary measure. Subscales include nurse participation in hospital affairs; nursing
foundations for quality care; nurse manager ability, leadership, and support; staffing and
resource adequacy; and nurse-physician relations.
Education—A hospital-level measure of proportion of nurses with a baccalaureate degree
or higher was created from individual nurse reports of highest education in nursing.25
Hospital Characteristics—Hospital characteristics describing the features of the nurse’s
hospital included teaching status designation, where teaching hospitals were designated as
hospitals with postgraduate trainees, whether the hospital was a high-technology facility
defined by having open heart surgery or organ transplantation or both, number of hospital
beds set up and staffed, and not-for-profit status. We also included a variable indicating the
state where the hospital was located to capture differences attributable to state-specific
policies or markets.
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Outcomes—Job-related burnout was measured using the emotional exhaustion subscale of
the Maslach Burnout Inventory Human Services Survey (MBI-HSS).26 The MBI-HSS is a
highly reliable and valid instrument that contains 22 Likert-type items that assess 3 domains:
emotional exhaustion, depersonalization, and personal accomplishment. As in previous
work,22,27 we used the emotional exhaustion subscale of the MBI-HSS as it best reflects our
theoretical and practical interests in factors that could erode nurse vigilance and satisfaction.
We used standardized cutoff points, developed by Maslach et al,26 to categorize nurses with
high burnout as those with a score equal to or greater than 27. Job dissatisfaction and intent
to leave were derived from single survey items. To measure job satisfaction, we used a
single-item question asking nurses “How satisfied are you with your current job.” Response
options on a 4-point Likert scale were dichotomized with either “very dissatisfied” or “a
little dissatisfied” categorized as “dissatisfied.” Nurses reporting being “moderately
satisfied” and “very satisfied” were categorized as “satisfied.” Intent to leave was
characterized by nurses answering yes, that they intended to leave their current employer
within 1 year.
J Nurs Adm. Author manuscript; available in PMC 2012 October 1.
Kelly et al.
Page 4
Analysis
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We used t tests for continuous variables and χ2 tests for categorical variables to estimate
differences between Magnet and non-Magnet hospitals. We tested differences between the
groups at the hospital level to estimate differences between the hospitals (Magnet and nonMagnet). To estimate differences between nurse job dissatisfaction, burnout, and intent to
leave in Magnet and non-Magnet hospitals, we implemented a series of logistic regression
models. In the first step, we estimated the likelihood of outcomes in Magnet hospitals when
controlling only for nurse characteristics (age, experience, etc). Next, we estimated models
controlling for nurse and hospital characteristics (eg, teaching status, bed size). The final
model estimated the effects of Magnet status while accounting for individual nurse factors,
hospital characteristics, and hospital-nursing characteristics (staffing, work environment,
and education). We estimated these models sequentially to understand the effects of Magnet
status in relation to each of the controls. All analyses were conducted with STATA version
11 (StataCorp, College Station, Texas).
Results
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Our sample included 26,276 registered direct patient care nurses working in 567 hospitals
(Table 1). Within that sample, 4,562 nurses were working in 46 Magnet hospitals and
21,714 nurses were working in non-Magnet hospitals. Magnet hospitals nurses were
demographically similar to non-Magnet hospitals. On average, Magnet hospitals were larger
in bed size and had a higher proportion of teaching facilities and amount of technology
(Table 1).
In Table 2, we provide results from testing differences between Magnet and non-Magnet
hospitals. Magnet hospitals were more likely to be teaching institutions (χ2 = 3.93, P = .05),
have high technology (χ2 = 14.90, P < .001), have nonprofit status (χ2 = 11.11, P < .001),
and have a smaller average number of beds (t = −5.04, P
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