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Do Magnet Hospitals Really Work?
The magnet hospital program, established in the early 1980s, seeks to identify hospitals embodying the best practices for recruitment and retention. The criteria for selection as a magnet are complex. Furthermore, while staffing ratios and skill mix are taken into account in granting magnet status, there are not strict numerical criteria for being named a magnet. For these reasons, it is somewhat difficult to distinguish which attributes of magnet hospitals — staffing level, skill mix, pay rates, participative management or other employment practices — are responsible for their superior performance. Unquestionably, however, magnet hospitals have proven superior both for delivering high-quality patient care and for addressing the key factors nurses identify as most critical for recruitment and retention.
"Magnet hospitals fare substantially better than other hospitals in recruiting and retaining nurses," states JCAHO President Dennis O'Leary. The characteristics that account for this achievement include "higher nurse-to-patient ratios, greater nurse autonomy and control over the practice setting, positive nurse and physician relationships, nurse participation in organization policy decisions, and strong nursing leadership."148 Perhaps for this reason, the American Hospital Association's most recent strategy document recommends that its member hospitals "embrace the characteristics of the magnet hospital program and incorporate them in work innovations."149
Ultimately, the proof of magnets' success is in their significantly lower turnover. In 2000, the median turnover rate for RNs employed at magnet hospitals was 7.6 percent, compared to 14 percent for non- magnet hospitals.150 Nurses in magnet hospitals have also been found to have less burnout and greater job satisfaction than those in non-magnet hospitals.151
In July 2002, the University of Oregon's Labor Education and Research Center conducted a telephone survey of magnet hospitals. Of 41 currently designated magnet hospitals, slightly more than half provided information on their staffing levels, vacancy rates and turnover. As shown in the table on the next page, the average vacancy rate reported by magnet hospitals in 2002 is 8.3 percent, significantly better than the national average of 13.4 percent. Similarly, the average RN turnover among magnet hospitals was 9.9 percent, compared with a national average of 17.1 percent.152 The additional information provided by these hospitals points to the source of their success: competitive salaries, reasonable scheduling options, support for continuing education, and little or no use of agency nurses. Of the 21 hospitals surveyed, 17 (80 percent) never use mandatory overtime. Of the remaining four, one hospital reserves this practice for snow days, and another limits it to a maximum of one hour, if needed to finish cases in the operating room. Perhaps most importantly, the staffing ratios in medical/surgical and intensive care units — the two types of units suffering the greatest national shortages — reflect a commitment to controlling nurse workloads.153 Medical/surgical staffing ratios range from a high of 1:9 to a low of 1:3. Nine of the 12 hospitals that provided this data maintain medical/surgical staffing ratios that are at or below the California mandate of one nurse for every six patients. Indeed, it is striking that the hospitals with the best staffing ratios are consistently those with the lowest vacancy rates.154 One hospital's human resources director boasted that her facility had the best nurse-to-patient ratios in the area and asserted that this had proved the single best recruitment tool for the hospital.155
The original magnet hospitals were based on superior staffing ratios, with a hospital-wide average of 1.1 RN per patient.156 They also boasted significant administrative support for nurses and a high ratio of RN-to-nonprofessional staff on the hospital floor.157 These staffing ratios, in turn, enabled magnet hospitals to establish effective scheduling policies and professional standards of care. As described by the American Academy of Nursing:
In magnet hospitals there is a low patient-to-registered nurse ratio, with adequate staff to provide total nursing care to all patients. Furthermore, the quality and complexity of patient care needs are taken into consideration when the staffing is planned; this is important in minimizing stress. The nurse does not feel overworked and has an opportunity to meet all of the patient's needs — psychological, interpersonal, and physical. There is also time for interaction among nurses so that continuity of care is insured and nurse-to-nurse consultation is encouraged. The nurses express great satisfaction in their opportunity to provide good care and in administration's support for it.158
The nurses interviewed as part of the original selection process for identifying magnet hospitals summarized their experiences by identifying "the most important" factors "in promoting recruitment and retention of staff." Four of the top five factors either directly or indirectly rely on staffing ratios. The single most important factor was identified as "a nurse-patient ratio which assures quality patient care"; second was "flexible staffing to support patient care needs"; third was "flexible scheduling"; and fourth was the practice of "primary nursing."159 The staffing ratios, above all, enabled nurses to care for their patients in a manner they deemed professional and found satisfying. "The nurses speak of being able to deliver safe, adequate care as a result of these staffing patterns," the American Academy of Nursing concluded.160
Management at the original magnet hospitals broadly agreed with nurses regarding the central factors that had an impact on recruitment and retention. They, too, cited "adequate staffing and flexible scheduling," "good salaries and benefits," "participative management with active involvement of staff in planning and decision making," "primary nursing" and "a predominantly RN staff that is fully supported by nursing administration."161 As with staff nurses, nursing executives commented on the importance of RNs being able to carry out skilled nursing tasks themselves, without turning work over to less trained individuals. In addition, the magnet hospitals were founded on a commitment to maintaining an adequate in-house employee staff; virtually none ever hired nurses from temporary agencies.162
Twenty years later, some of the original magnet practices may seem impossibly ambitious. Nevertheless, these practices remain as relevant as ever for pointing to the types of strategies that alone offer a hope for reversing the current crisis in nursing.
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