Making Sense of Magnet
BONNIE JEROME-D’EMILIA,
PH.D., MPH, RN
DEPARTMENT OF NURSING
RUTGERS UNIVERSITY-CAMDEN
JEAN ABRAHAM, PH.D.
DIVISION OF HEALTH POLICY AND MANAGEMENT
SCHOOL OF PUBLIC HEALTH
UNIVERSITY OF MINNESOTA
JAMES W. BEGUN, PH.D.
DIVISION OF HEALTH POLICY AND MANAGEMENT
SCHOOL OF PUBLIC HEALTH
UNIVERSITY OF MINNESOTA
What is Magnet?
g
 Began
B
in
i 1980’s
8 ’ severe nursing
i shortage
h t
 Some hospitals were found to be resistant to the
effects
ff
off the
h shortage
h
= llow vacancy rates
 41 hospitals were identified - notable for low vacancy
rates and high nursing job satisfaction
 Hospitals were studied to identify common
characteristics = “forces of magnetism”
Forces of Magnetism
g
1)
2)
3)
4)
5))
6)
7)
Quality of nursing
l d hi ((e.g., advocate
leadership
d
t
for staff)
Organizational structure
(e g CNO at executive
(e.g.,
e ecuti e
level)
Management style
(participative)
HR policies and program
(e.g., pay, flex staffing)
P f i
Professional
l models
d l off care
(nurses accountable for own
practice)
Quality of nursing care
Continuous quality
improvement
8)
9)
10)
11)
12)
13)
14)
Consultation and resources
(
(e.g.,
advanced
d
d practice
ti
nurses available)
Nurse autonomy (within
conte t of multidisciplinar
context
multidisciplinary
approach)
Community presence
(outreach programs)
Nurses as teachers
Image of nursing
(
(respected)
t d)
Interdisciplinary
collaboration
P f i
Professional
ld
development
l
(continuing education)
Forces Reconfigured
g
 Transformational leadership =

Quality of nursing leadership , Management style
 Structured empowerment =

Organizational structure, HR policies and program, Community
presence, Image of nursing, Professional development
 Exemplary
p yp
professional nursing
gp
practice =

Professional models of care, Consultation and resources, Nurse
autonomy, Nurses as teachers, Interdisciplinary collaboration
 New knowledge,
knowledge innovations
innovations, and improvements =

Continuous quality improvement
All of which lead to:
 Empirical quality outcomes = Quality of nursing care
(Source: Wolf , Triolo, & Ponte, 2008)
Magnet
g
Recognition
g
 Awarded
A
d d by
b American
A
i
N
Nurses C
Credentialing
d ti li C
Center
t
(ANCC), subsidiary of American Nurses Association
based on criteria developed from identified forces of
magnetism
 “Highest
“Hi h t level
l l off recognition
iti that
th t a h
healthcare
lth
organization can achieve to recognize nursing
excellence”
ll
” (American Nurses Credentialing Center, 2010).
 Endorsed by The Joint Commission
 Included as a measure of hospital quality in US News
Top Hospitals since 2004
Magnet
g
Process
 Recognition
R
iti process b
began iin 1994: fi
firstt magnett
hospital was University of Washington Medical
Center
 Four year designation; re-appraisal process similar
t iinitial
to
iti l appraisal
i l
 Mainly hospitals (97%); expanded to long term care
organizations in 1998, internationall in 2002
Diffusion of Magnet
g
Recognition
g
 1995: 3 h
hospitals
it l
 2000: 18 facilities
 2005: 181 facilities
 2010: 37
372 facilities
(American Nurses Credentialing Center, 2010)
400
350
300
250
200
150
100
50
0
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
anizatio
ons
# of magnet orga
Diffusion of Magnet Recognition, 1994-2009
SOURCE: Compiled from “Find an Organization,” American Nurses Credentialing Center,
December, 2009. http://www.nursecredentialing.org/Magnet/FindaMagnetFacility.aspx
Magnet
g
Research – What Do We Know?
St di on magnett h
Studies
hospitals
it l h
have ffound:
d
 Healthier work environments (Schmalenberg & Kramer, 2008; Ulrich, et al.,
2007; Upenieks
Upenieks, 2005)
 Higher job satisfaction, greater quality of care (Ulrich, et al., 2007;
Upenieks, 2005)
 Better physician-nurse working relationships (Schmalenberg &
Kramer, 2009)
 Better staffing (Schmalenberg & Kramer,
Kramer 2009)
 Better support systems (Lacey, et al. 2007)
 Lower mortality (Aiken,
(Aik
Smith,
S ith & L
Lake,
k 1994; Scott,
S tt Sochalski,
S h l ki & Aiken
Aik 1999))
Magnet
g
Research – What Don’t We Know?
 What
Wh t kinds
ki d off hospitals,
h
it l iin what
h t ki
kinds
d off h
healthcare
lth
markets, are most likely to achieve magnet
recognition?
 What internal organizational issues and pressures
predict
di t interest
i t
t iin pursuing
i and
d success iin achieving
hi i
recognition?
Conceptual
p
Framework for Studyy
Industrybased
competition
Firm-specific
Fi
ifi
resources
and capabilities
Strategy
Performance
Institutional
conditions
and transitions
Source: Peng, Sun, Pinkham, & Chen, 2009, p. 15
Driving Forces for Organizational Decision
Decision-making
making
 From
F
P
Peng and
d colleagues
ll
((2009):
)
Industry-based competition
 Firm-specific
i
ifi resources
 Institutional conditions

 We collapse firm-specific resources and institutional
conditions into an “organizational driver”
Driving
g Forces for Adoption
p
O
Organizational
i ti
l fforce –
 pursuit of magnet is an intra-organizational decision based on
internal political dynamics and the slack resources
 Competitive force –
 the recruitment and retention of nurses becomes a challenge
due to a limited supply
 numerous options for patients looking for care and for
physicians to provide that care
Research Question
Q
 What are the market and organizational drivers of
magnet recognition
i i among h
hospitals?
i l ?
Data
 Sample
S
l = 3,657
6 generall h
hospitals
it l iin th
the U
U.S.
S iin 2008
8
located in metropolitan or micropolitan areas
 Of this group, 8% (n=277) had magnet status at the
time of the analysis (2009)
Variables and Data Sources
Driving Force
Category of Variable
Variable
Data Source
Market
Market characteristics
Population of
metro/micropolitan
area, 2007
Area Resource File
% change in population
of metro/micropolitan
area, 2000-2007
Area Resource File
Another magnet
hospital
p
(not in same
system) in
metro/micropolitan
area, 2009
American Nurses
Credentialing
g Center
Hospital competition
(Herfindahl-Hirschman
Index based on beds) in
metro/micropolitan
area, 2007
American Hospital
Association (AHA)
Annual Survey
Variables and Data Sources,, continued
Driving Force
Category of Variable
Variable
Market
Nursing labor market # of accredited RN
schools in county
characteristics
Data Source
American Association of
Colleges of Nursing
(
(2009)
9) per
p 100,000
,
population
RNs in
metro/micropolitan
area (2007) per100,000
population
Bureau of Labor
Statistics
Occupational
Employment Statistics
% of RNs who are union
members in state, 2004
National Sample Survey
of Registered Nurses
(Health Resources and
Services
Administration)
Variables and Data Sources,, continued
Driving Force
Category of Variable
Variable
Data Source
Organizational
Hospital structural
characteristics
Ownership, system
membership, teaching
affiliation ((COGMEapproved teaching
program - Y/N), bed
size, payer mix
(Medicaid p
patient days,
y
Medicare patient days)
(2008)
AHA Annual Survey
Hospital
performance
f
Is hospital a Thomson
Reuters 100 Top
Hospital? (Y/N) (2009)
Thomson Reuters 100
Top Hospitals/Health
Systems
Cost per adjusted
admission (admissions
adjusted for outpatient
visits)
AHA Annual Survey
Does the state prohibit
mandatory overtime for
nursing personnel?
(Y/N) (2008)
Thomson MedStat:
Thomson-MedStat:
Major Health Policies 50
State Profiles
State regulations
Analysis
y
 Dependent
D
d t variable
i bl = bi
binary iindicator
di t ffor whether
h th a
hospital has magnet recognition as of 2009
 Logistic
i i regression
i models
d l to estimate
i
the
h
association of magnet status with organizational and
market
k t attributes:
tt ib t


Model 1 - “magnet-specific” competition if at least one
independent hospital in the local market has also achieved
“independent”
magnet status
Model 2 - market competition
p
corresponding
p
g to the
Herfindahl-Hirschman Index (HHI)
Results of Logistic Regression Using Two Models of Competition
Variable
Marginal
Effect
SE
Model 2
Marginal
Effect
ln(population (100000s)
-0.0028
0.002
-0.0007
0.0028
% change in population
0.0005
0.0003
0.0006
0.0003
Any competitor in
micro/metropolitan area has
ag et status
magnet
0.027
0.007
….
….
HHI
…
…
0.000001
0.000001
Accredited RN schools per
100 000 population
100,000
l ti
0 0102
0.0102
0 0037
0.0037
0 011
0.011
0 0038
0.0038
RNs per 100,000 population
0.000015
0.00001
0.000019
0.00001
% RNs unionized
-.0389
0389
.0186
0186
-.046
046
.0191
0191
Not for profit1
0.024
0.0071
0.0252
0.0073
For profit1
-0.023
0.023
0.008
-0.0232
0.0232
0.0078
Model 1
SE
Variable
System membership (with affiliated hospitals in
market)
Model 1
g
Marginal
Effect
SE
Model 2
Marginal
g
SE
Effect
0.008
.005
0.008
.006
201-300 beds2
0.0359
0.0116
0.036
0.012
301-400 beds2
0.113
0.024
0.111
0.024
More than 400 beds2
0 171
0.171
0 029
0.029
0 163
0.163
0 028
0.028
Teaching affiliation
0.015
0.006
0.0154
0.0066
% inpatient days - Medicaid
-0.0007
0.0002
-0.0007
0.0023
% inpatient days –Medicare
-0.0002
0.0002
-0.00008 0.00019
Thomson Reuters 100 Top Hospital
0.0615
0.0232
0.060
Cost per adjusted admission ($1000s)
State regulation prohibits mandatory overtime of
nurses
0.000034 0.000000 -0.00001 0.000000
Number of observations
n=3657
n=3657
Pseudo R2
0.243
0.245
0.0049
0.0059
0.006
Bold results indicate marginal effects statistically significant at p< .05 significance.
0.023
0.006
Significant
g
Results
M
Magnet-recognized
t
i dh
hospitals
it l are more lik
likely
l if
if:
 not-for- profit, large hospitals, teaching hospitals and
Thomson Reuter 100 Top Hospitals
 Presence of a competitor magnet hospital in the market area
((Model 1))
 More nursing schools in the area
 Magnet recognition less likely if:
 Higher
g
p
percentage
g of Medicaid p
patient days
y
 Increased level of nursing unionization
No Relationship
p Found:
 Supply
S
l off nurses
 Hospital competition measured by the HHI
((Model 2))
What Does This Mean?
 Larger,
L
not-for-profit
tf
fit hospitals
h
it l are more likely
lik l tto
achieve magnet status.


may b
be more hi
highly
hl iincented
t d
more willing to invest in the application process
O
Organizational
i ti
l culture
lt
off th
the tteaching
hi h
hospital
it l
 more supportive of the professional model of nursing.
 Unionization
U i i i effect
ff
The Effect of Competition
p
 Is
I the
th pursuit
it off magnett recognition
iti b
based
d on:

Desire to increase recruitment and retention of nurses?
(But Magnet is more likely if more nursing schools in area.)

Competition among hospitals for patients?
(M
(Magnet
t iis 30% more likely
lik l if any competitor
tit iis magnet.)
t)
Limitations
 Cross-sectional
Cross sectional design makes for no or weak causality





tests
Weak measures of hospital finances
Low number of magnets makes it hard to control for
g
initial yyear of recognition
Difference between desire to be magnet and achievement
of magnet
Multiple definitions of market boundaries, some too
narrow or too broad
G
Generalizability
li bilit limits,
li it especially
i ll tto rurall and
d small
ll
hospitals
Future Research
 Consider
C
id hospitals
h
it l th
thatt b
begin
i magnett recognition
iti
process rather than focusing on hospitals that have
already achieved magnet status
 Separate early and later adopters
 Given rapid diffusion of magnet – how will the
competitive dynamics surrounding nursing labor and
patient choice
h
change
h
as the
h number
b off magnet
hospitals within markets increases?
References
 Aiken,
Aiken L.H.
L H , Smith,
Smith H
H.L.,
L Lake,
Lake E.T.
E T (1994).
(1994) Lower Medicare Mortality among





a Set of Hospitals Known for Good Nursing Care. Medical Care, 32(8): 771-787.
American Nurses Credentialing Center. (2010). Growth of the program.
Retrieved from
http://www.nursecredentialing.org/Magnet/ProgramOverview/GrowthofthePr
ogram.aspx.
Lacey, S.R., Cox, K.S., Lorfing, K.C., Teasley, S.L., Carroll, C.A., Sexton, K.
(2007). Nursing support, workload, and intent to stay in Magnet, MagnetAspiring, and Non-Magnet hospitals. Journal of Nursing Administration,
37(4): 199-205.
P
Peng,
M.W.,
M W Sun,
S
S.,
S Pi
Pinkham,
kh
B
B., Ch
Chen, H
H. (2009).
(2009) The
Th institution-based
i tit ti b d view
i
as a third leg for a strategy tripod. Academy of Management Perspectives,
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Rogers E
Rogers,
E.M.
M (1962)
(1962). Diffusion of Innovations.
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Press. New York
York.
Schmalenberg, C., Kramer, M. (2009). Nurse-Physician relationships in
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References,, continued
 Schmalenberg ,C.,
C Kramer,
Kramer M.
M (2008).
(2008) Essentials of a productive nurse work




environment. Nursing Research, 57(1):2-13.
Scott, J.G., Sochalski ,J., Aiken, L. (1999). Review of Magnet hospital research:
findings and implications for professional nursing practice.
practice Journal of Nursing
Administration., 29:9-19.
Ulrich, B.T., Woods, D., Hart, K.A, Lavandero, R., Leggett, J., Taylor, D.
(200 ) C
(2007).
Critical
iti l care nurses’’ work
k environments
i
t value
l off excellence
ll
iin B
Beacon
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Upenieks, V. (2005). Recruitment and retention strategies: a Magnet hospital
prevention
ti model.
d l MedSug
M dS N
Nursing.
i
Wolf, G., Triolo ,P., Ponte, P.R. (2008). Magnet recognition program: the next
generation. Journal of Nursing Administration, 38(4):200-204.