JONA Volume 44, Number 12, pp 653-658 Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Supporting a Healthy Culture Results of the Practice Environment Scale, Australia in a A Magnet Designated Hospital Kim Walker, PhD, RN Katherine Fitzgerald, MPH, RN Jed Duff, PhD, RN The Magnet Recognition Program requires evidence that nursing practice environments support staff to provide optimal care, access professional development opportunities, and participate in hospital affairs. The research presented in this article aimed to assess clinical nurses’ work environment at a recently designated, private Magnet hospital in Sydney, Australia. Authors compare results with baseline data collected for a gap analysis before application for recognition. The outcomes challenge previously reported data suggesting that hospitals on the journey to Magnet recognition outperform already designated hospitals in this respect. A
A
In May 2011, a private hospital in Sydney, Australia, received Magnet designation for nursing excellence. This internationally recognized credential requires hospitals to meet strict criteria related to excellence in nursing care in 4 major domains: transformational leadership, structural empowerment, exemplary professional practice, and new knowledge, innovations, and improvements.1 Well-defined empirical outcomes in each of these domains must be demonstrated to achieve Magnet recognition. Of the more than 400 hospitals carrying the Magnet designation, at the time of this writing, only 6 are outside the United States.2 A
Author Affiliations: Professor of Healthcare Improvement (Dr Walker), St Vincent’s Private Hospital, Sydney, University of Tasmania, Darlinghurst; Research Assistant (Ms Fitzgerald), St Vincent’s Private Hospital, Sydney; Clinical Research Fellow (Dr Duff), Clinical Senior Lecturer, St Vincent’s Private Hospital, Sydney, University of Tasmania, Darlinghurst, NSW, Australia. The authors declare no conflicts of interest. Correspondence: Dr Walker, St Vincent’s Private Hospital, Sydney, University of Tasmania, 406 Victoria St, Darlinghurst, NSW 2010, Australia ([email protected]). DOI: 10.1097/NNA.0000000000000143
JONA Vol. 44, No. 12 December 2014
Magnet-recognized hospitals are required to demonstrate a healthy nursing culture, evidenced by the ability to recruit and retain high-quality nursing staff, high levels of staff engagement and satisfaction, high levels of patient satisfaction, a strong ethos of commitment to professional development among staff, and above-benchmark outcomes for identified nursing sensitive indicators such as pressure ulcer prevention, patient falls, healthcare-acquired infections, and medication safety.3 A healthy and robust nursing practice environment (PE) enables the achievement of these laudable outcomes.1 The PE is strongly indicative of nursing culture, and it greatly affects those who work in healthcare organizations.2 Understanding the PE, however, has inherent difficulties because of it being an abstruse construct to conceptualize and measure.3 Despite this, the PEs of nurses have been explored to increase understanding and to influence nurse job satisfaction and turnover.4 The Practice Environment The PE Scale of the Nursing Work Index (PES-NWI), designed to measure characteristics in the nursing PE,3 was a modification of the original NWI developed by Kramer and Hafner in 1989.5 The NWI was based on the original Magnet hospital characteristics described by McClure et al in 1983.6 These researchers explored common attributes of hospitals that were successful in recruiting and retaining nurses during a severe nursing shortage in the 1980s. In 2002, Lake3 revised the original NWI using a 5-stage approach to shorten the scale from 66 to 31 items. The Practice Environment Scale, Australia (PES-AUS) is a modified,
653
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
30-question version of the PES-NWI, developed by Middleton et al,7 that has been adapted for the Australian context, as discussed below.
Research Aims The research aims were (1) to assess clinical nurses’ perceptions of the PE at 1 hospital, (2) to compare results with baseline data obtained in 2009, and (3) to benchmark results with data from other Magnet organizations.
Methods The PES-AUS survey was administered in September/ October 2012. The eligible sample (n = 522) comprised registered nurses (RNs), enrolled nurses (EN), and assistants in nursing (AINs). Enrolled nurses refer to those nurses who possess a Diploma of Enrolled Nursing from a registered training organization, which provides vocational education and training. Enrolled nurses are the professional equivalent of a licensed practical nurse outside the United States and most Canadian provinces. Enrolled nurses work under the supervision of an RN to provide patients with basic nursing care. Within their scope of practice, ENs are accomplished in the practical skills of nursing, with advanced ENs able to undertake more complex procedures. Assistants in nursing assist RNs and ENs in the provision of nursing care. The appropriate qualification for AINs is at Certificate III level of the Australian Qualifications Framework; these nurses are the international equivalent of nursing assistants (NA). Eligible staff members were grouped into 13 clinical units for reporting purposes, with each clinical unit working under the direction of 1 nurse manager (NM). Nurse managers (n = 17) and full-time clinical nurse educators (n = 12) were excluded from the study as many of the items pertained directly to their role and function in the PE. Data were collected via the online software program Survey Monkey. This was made available to all nurses through a specially designed portal available on the clinical workstations of the hospital’s information technology system, to which all nurses had access during their working hours. Staff could also access the survey via this portal from their home computer, and NMs were given the survey link, which could be forwarded to staff on extended leave to ensure that they had the opportunity to participate. Evidence suggests that Web-delivered surveys do not always have robust response rates when compared with paper-based surveys.8 Clinical nurses in hospitals face a unique work complexity that inhibits survey participation.8 To address this potential source of bias, a number of evidence-based strategies
654
were used to enhance response rates. Strategies were tailored around the framework of precontact, follow-up, incentives, timing, and a tailored method of implementation.9 Strategies included, but were not limited to, emphasizing the relevance of the survey through the director of nursing and clinical services, the nursing executive staff, and the NMs; continuing professional development sessions conducted in all clinical areas by the research assistant working on the study to stress the relevance of the research for Magnet redesignation; and negotiated work time to undertake the survey while the clinical nurse educators released staff from patient care responsibilities. The chief investigator used internal competition to generate a sense of fun and rivalry among staff, who were divided into teams of clinical units and departments, with incentives being provided on the basis of response rate attainment at 95% or above. Accordingly, 3 of the 13 grouped clinical units attained a 100% response rate. Ethics approval for the study was obtained from the hospital’s Practice Development and Research Committee, which reviewed the study for human protection because the participants were employees. This committee functions identically to an institutional review board and is responsible for the review and approval of research involving human participants. Instrument The PES-NWI was developed by Lake9 through factor analysis of data from the original Magnet hospitals research.11 The PES-AUS is a modified, 30-item version of the PES-NWI, developed by Middleton et al7 for the Australian context. Middleton removed the item referring to ‘‘use of nursing diagnosis’’ from the subscale ‘‘nursing foundations for quality care’’ because nursing diagnoses are not used in Australia and also altered the descriptions of 8 job titles from the PESNWI to suit the Australian context (Figure 1).8(p368) For each of the 30 questions, nurses were asked to rate, using a 4-point Likert scale (strongly agree to strongly disagree), whether specific organizational characteristics were present in their current job. They were also asked 6 demographic questions: sex, age, level of highest qualification, employment status (fulltime, part-time, and casual), nursing classification (NA, EN, RN, clinical nurse specialist), and length of time employed on their unit or department. Data Analysis Data were analyzed using SPSS version 19.0. (IBM, Armonk, New York). The PES-AUS instrument was scored according to directions supplied by Lake (E. Lake, unpublished data, 2004). A mean subscale score was calculated for each respondent. In compliance with the scoring instructions, responses for nurses
JONA Vol. 44, No. 12 December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 1. Practice Environment Scale, Australia. Modified from the 31-item Practice Environment Scale of the Nursing Work Index.9
who did not answer all of the items were still included in the subscale scores. The denominator for the subscale ‘‘nursing foundations for quality care’’ was adjusted to allow for the 1 item that was removed from the PES-NWI (Use of Nursing Diagnoses). The potential score range for each of the subscale means was 1 to 4. Higher scores indicated greater agreement that subscale items were present in the current job situation; specifically, values above 2.5 indicated agreement and values below 2.5 indicated disagreement. A composite score was created and comprised the mean of the 5 subscale scores (Figure 2).7 The mean of subscale scores rather than item scores was chosen
JONA Vol. 44, No. 12 December 2014
to give equal weight to each subscale. Measures of central tendency were used to describe the mean and standard deviations of the PES-AUS subscales. Mean scores were compared with 2009 data using a 2-tailed t test of significance. Mean scores were also compared with published US Magnet hospital data.9
Results A total of 492 nurses from all clinical areas in the hospital completed the survey (94%; n = 492). There were 430 (85%; n = 430) female nurses and 62 (12.3%; n = 62) male nurses. The largest represented age group was 21 to 40 years (64.2%; n = 325). Nearly
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Figure 2. The 5 subscales of the Practice Environment Scale, Australia.8
three-quarters of nurses were educated to the level of bachelor degree or above (74.3%; n = 376); this accounted for a 5% increase since 2009.12 Employment status was primarily full-time (66.6%; n = 337). All respondents were employed as clinicians (100%; n = 492). The nursing classification of respondents included 384 (75.9%; n = 384) RNs, 69 (13.6%; n = 69) clinical nurse specialists, 4 (e1%) ENs, and 35 (6.9%) NAs. The median length of time employed on the study units was 4 to 8 years (Table 1). The PES Mean scores and standard deviations of the 5 PES-AUS subscale items and the composite scale from the study hospital are depicted in Table 2, where they are compared with the reported means from the 2009 baseline data10 and Magnet hospital data in the United States.9 Mean values were above 2.5 for all 5 of the subscales: nurse participation in hospital affairs (mean, 3.01), nursing foundations for quality of care (mean, = 3.18), nursing unit manager ability, leadership, and support of nurses (mean, 3.09), staffing and resource adequacy (mean, 2.88); and collegial nurse-doctor relations (mean, 3.05), as well as the composite scale (mean, 3.04). These results affirm that each of the subscale items was present in the current work environment. The mean score for ‘‘nurse participation in hospital affairs’’ (3.01) was comparable with the score at baseline (3.06) (P = .20). In addition, the mean score for ‘‘nursing foundations for quality of care’’ (3.18) was identical with baseline data (3.18) (P = .76). The mean score for ‘‘nursing unit manager ability, leadership, and support of nurses’’ (3.09) was significantly below (P = .04) the baseline (3.17). The mean score for ‘‘staffing and resource adequacy’’ (2.88) was identical with baseline (2.88) (P = .94), whereas the mean score for ‘‘collegial nurse-doctor relations’’
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(3.05) was comparable with baseline (3.01). The mean score for the composite scale (3.04) was comparable with the baseline (3.06), indicating that Magnet recognition has had a sustained positive impact on the PE. Table 1. Nurses’ Demographic Characteristics Reported in 2012 for the Total Sample (n = 492) Characteristic Sex Female Male Age e20 21-30 31-40 41-50 51-60 Q61 Level of highest qualification Certificate (hospital-trained RN) Certificate 3 Certificate 4 Diploma (Tafe/university) Advanced diploma Bachelor’s degree Graduate certificate Graduate diploma Master’s degree Employment status Full-time Part-time Casual Years employed in department e1 1-3 4-8 9-15 Q15 Nursing classification AIN EN RN Clinical nurse specialist
n
%
430 62
85 12.3
1 171 154 86 60 20
0.2 33.8 30.4 17 11.9 4
60 21 8 19 8 237 73 25 41
11.9 4.2 1.6 3.8 1.6 46.8 14.4 4.9 8.1
337 142 13
66.6 28.1 2.6
86 115 160 85 46
17 22.7 31.6 16.8 9.1
35 4 384 69
6.9 0.8 75.9 13.6
JONA Vol. 44, No. 12 December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table 2. Follow-up Subscale Scores for the PES-AUS Compared With Baseline and American Magnet Hospitals
Subscalesa (Our Subscale, N = 492) Nurse participation in hospital affairs Nursing foundations for quality of care Nursing unit manager ability, leadership, and support of nurses Staffing and resource adequacy Collegial nurse-doctor relations Composite scale
Total Sample (N = 492)
Baseline Data (2009) (N = 384)
American Magnet Hospitals (N = 1610)
Mean (SD)c
Mean (SD)
P
Mean (SD)
P
9 9b 5
3.01 (0.55) 3.18 (0.4 8) 3.09 (0.66)
3.06 (0.42) 3.18 (0.38) 3.17 (0.52)
.20 .76 .04
2.76 (0.47) 3.09 (0.39) 3.00 (0.59)
G.001 G.001 .50
4 3 5
2.88 (0.63) 3.05 (0.58) 3.04 (0.49)
2.88 (0.58) 3.01 (0.51) 3.06 (0.39)
.94 .33 .53
2.88 (0.62) 2.99 (0.52) 2.95 (0.40)
1.00 .02 G.001
No. of Items
2012 data were compared with American Magnet hospitals9 along with the 2009 baseline data.10 a Sample size (n) of subscale item varies because of missing data. b This is a 10-item scale in the original tool. One item was removed for use in the Australian context (Use of Nursing Diagnoses) as it was not relevant. c Mean sample size of subscale items. Values above 2.5 indicate agreement that the subscale items are present in the current work environment. Values below 2.5 indicate disagreement that the subscale items are not present in the current work environment.
The mean scores on all subscales were significantly higher than Magnet hospitals in the United States, except for ‘‘staffing and resource adequacy,’’ which was identical with them, and ‘‘nursing unit manager ability, leadership, and support of nurses,’’ which was not statistically significant. Similarly, the mean scores on all subscales were significantly higher than Australian non-Magnet hospitals.7
Discussion Understanding the PE of nurses working in an acute care, primarily surgical hospital, 18 months after inaugural Magnet designation provides an opportunity to evaluate the effect of the program on this facility and, in particular, on clinical nurses’ perception of it. The study’s purpose was to obtain PE data for Magnet redesignation and compare results with baseline data. The mean composite scale scores for 2012, as reported above, were comparable with baseline and indicate that this recently designated Magnet facility was operating at a high level of performance before undertaking the journey. The information has provided information to support nursing leaders to set the benchmark in relation to maintaining a healthy culture after Magnet recognition even higher. Our results are by no means isolated in respect of other measures of quality. They are augmented by other tools used by the hospital over the last few years, including, but not limited to, the following internal and external measures: In 2013, the hospital was rated as having a ‘‘Culture of Success’’ by Best Practice Australia, which is a national benchmarking organization for public and private hospitals in Australia. The subsequent results, which were derived from a hospitalwide survey (75% of respondents were RN), illustrated
JONA Vol. 44, No. 12 December 2014
that staff report high levels of engagement in the organization, with 76% of respondents describing the hospital as ‘‘a truly great place to work.’’ Importantly, these results have been sustained since 2007, when the culture was 1st classified as one of ‘‘success.’’ In addition, the Staff Patient Safety Culture Survey11 was administered in May 2013. This tool enables benchmarking across all 26 facilities in our corporation of Catholic hospitals. The information provided rigorous supplementary evidence of the perceptions of all personnel (nursing and nonnursing) in relation to the systems within the organization supporting service provision and optimal patient outcomes. A healthy response rate of 87.5% was obtained, demonstrating a positive patient safety climate, with favorable scores in 4 of the 6 factor analysis. Another benchmarking exercise to which the hospital subscribes is the Press Ganey patient satisfaction surveys, which are generated on a continuous monthly cycle. At time of writing, the most recent 6 months’ scores have placed the hospital on the 99th percentile when compared with peer hospitals in Australia. The only subscale that demonstrated a significantly lower than baseline result, ‘‘Nursing Unit Manager Ability, Leadership and Support of Nurses,’’ is somewhat perplexing in light of the sustained results in each of the remaining subscales and the composite score. This may suggest that staff nurses have perhaps more heightened expectations of their managers now that Magnet recognition has been achieved. Indeed, while clearly performing well against US Magnet hospitals,10 and well above the 2.5 score, which indicates agreement with the items in the subscale, it was determined that there was no cause for concern with this result, but nursing leaders redoubled the effort on the part of all managers to ensure that staff feel well supported in their work.
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Moreover, this study provides scientific evidence that organizations post-Magnet designation can maintain high levels of staff engagement and satisfaction that are comparable with pre-Magnet recognition baseline data. The findings of this study challenge, therefore, recent research that suggests that the journey to Magnet recognition has a pronounced impact on nurse perceptions of the PE and perhaps more so at the time of designation than beyond.12 Limitations There are 2 predominant limitations of this research. First, there are limited data available for comparison within the Australian context, and 2nd, we acknowledge that the US Magnet hospital data used as a comparison in this article were obtained some years ago. However, from a comparability facet, these data remain the most relevant published data set available to the research team to fulfill the research aim of benchmarking results with data from other Magnet organizations.13 Limited comparison data available in Australia restrict the researcher’s ability to benchmark the PE against both the other 2 Magnet hospitals and all other non-Magnet hospitals in Australia. Research affirms that the PE is influenced by culture.10 The differences in cultural expectations influenced by norms in the US versus non-US Magnet hospitals have not been explored. Also, surveys of
self-reported satisfaction (both those for patients and staff) are prone to bias. Increasingly objective measures of the PE and along with the satisfaction of staff and patients have not been reported.
Conclusion Sustaining a culture of success and ensuring high levels of nursing staff engagement and empowerment are challenging. Challenges include increasing complexity of patient care14 and potential for adverse events,14 the fiscal pressures on healthcare facilities to do more with less,15 and a focus on the bottom line.15 At our hospital, we were interested in measuring whether Magnet recognition had more than a temporary effect on what was already a high-performing culture.16 We were affirmed to see positive results 3 years beyond the 1st measurement of the PE as an initial strategy to analyze gaps in preparedness to undertake the Magnet journey. As we prepare for redesignation in 2015, we are more confident that a healthy and thriving nursing culture is in place in the organization.
Acknowledgments The authors thank Associate Professor Jose Aguilera, Director of Nursing and Clinical Services and the Nursing Unit Managers of St Vincent’s Private Hospital, for the support in undertaking this research.
References 1. Aiken LH. Transformative impact of Magnet designation: England case study. J Clin Nurs. 2008;17(24):3330-3337. 2. Walker K, Aguilera J. The international MagnetA journey. Nurs Manag. 2013;44(10):50-52. 3. Lake ET. The nursing practice environment: measurement and evidence. Med Care Res Rev. 2007;64:104S-122S. 4. Hinshaw AS, Atwood JR. Nursing staff turnover, stress, and satisfaction: models, measures, and management. Ann Rev Nurs Res. 1983;1:133-153. 5. Kramer M, Hafner LP. Shared values: impact on staff nurse job satisfaction and perceived productivity. Nurs Res. 1989; 38(3):172-177. 6. McClure ML, Poulin MA, Sovie MD, Wandelt MA, eds. Magnet Hospitals: Attraction and Retention of Professional Nurses. Kansas City, MO: American Academy of Nursing; 1983 No. 160. 7. Middleton S, Griffiths R, Fernandez R, Smith B. Nursing practice environment: how does one Australian hospital compare with magnet hospitals? Int J Nurs Pract. 2008;14(5): 366-372. 8. Kramer M, Schmalenberg C, Keller-Unger JL. Incentives and procedures effective in increasing survey participation of professional nurses in hospitals. Nurs Adm Q. 2009;33(2):174-187. 9. Lake ET. Development of the practice environment scale of the nursing work index. Res Nurs Health. 2002;25(3):176-188.
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10. Walker K, Middleton S, Rolley J, Duff J. Nurses report a healthy culture: results of the Practice Environment Scale (Australia) in an Australian hospital seeking Magnet recognition. Int J Nurs Pract. 2010;16(6):616-623. 11. Braithwaite J, Westbrook MT, Robinson M, Michael S, Pirone C, Robinson P. Improving patient safety: the comparative views of patient-safety specialists, workforce staff and managers. BMJ Qual Saf. 2011;20(5):424-431. 12. Hess R, DesRoches C, Donelan K, Norman L, Buerhaus PI. Perceptions of nurses in Magnet hospitals, non-Magnet hospitals, and hospitals pursuing Magnet status. J Nurs Adm. 2011; 41(7/8):315-323. 13. Witkoski-Stimpfel A, Rosen J, McHugh M. Understanding the role of the professional practice environment on quality of care in MagnetA and non-Magnet hospitals. J Nurs Adm. 2014;44(1):10-16. 14. Kramer M, Maguire P, Brewer B. Clinical nurses in Magnet hospitals confirm productive, healthy unit work environments. J Nurs Manag. 2011;19:5-17. 15. Drenkard K. The business case for MagnetA. J Nurs Adm. 2010;40(6):263-271. 16. Parker D, Tuckett A, Eley R, Hegney D. Construct validity and reliability of the Practice Environment Scale of the Nursing Work Index for Queensland nurses. Int J Nurs Pract. 2010; 16(6):616-623.
JONA Vol. 44, No. 12 December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
THE JOURNAL OF NURSING ADMINISTRATION
Supporting a Healthy Culture Results of the Practice Environment Scale, Australia in a A Magnet Designated Hospital Kim Walker, PhD, RN Katherine Fitzgerald, MPH, RN Jed Duff, PhD, RN The Magnet Recognition Program requires evidence that nursing practice environments support staff to provide optimal care, access professional development opportunities, and participate in hospital affairs. The research presented in this article aimed to assess clinical nurses’ work environment at a recently designated, private Magnet hospital in Sydney, Australia. Authors compare results with baseline data collected for a gap analysis before application for recognition. The outcomes challenge previously reported data suggesting that hospitals on the journey to Magnet recognition outperform already designated hospitals in this respect. A
A
In May 2011, a private hospital in Sydney, Australia, received Magnet designation for nursing excellence. This internationally recognized credential requires hospitals to meet strict criteria related to excellence in nursing care in 4 major domains: transformational leadership, structural empowerment, exemplary professional practice, and new knowledge, innovations, and improvements.1 Well-defined empirical outcomes in each of these domains must be demonstrated to achieve Magnet recognition. Of the more than 400 hospitals carrying the Magnet designation, at the time of this writing, only 6 are outside the United States.2 A
Author Affiliations: Professor of Healthcare Improvement (Dr Walker), St Vincent’s Private Hospital, Sydney, University of Tasmania, Darlinghurst; Research Assistant (Ms Fitzgerald), St Vincent’s Private Hospital, Sydney; Clinical Research Fellow (Dr Duff), Clinical Senior Lecturer, St Vincent’s Private Hospital, Sydney, University of Tasmania, Darlinghurst, NSW, Australia. The authors declare no conflicts of interest. Correspondence: Dr Walker, St Vincent’s Private Hospital, Sydney, University of Tasmania, 406 Victoria St, Darlinghurst, NSW 2010, Australia ([email protected]). DOI: 10.1097/NNA.0000000000000143
JONA Vol. 44, No. 12 December 2014
Magnet-recognized hospitals are required to demonstrate a healthy nursing culture, evidenced by the ability to recruit and retain high-quality nursing staff, high levels of staff engagement and satisfaction, high levels of patient satisfaction, a strong ethos of commitment to professional development among staff, and above-benchmark outcomes for identified nursing sensitive indicators such as pressure ulcer prevention, patient falls, healthcare-acquired infections, and medication safety.3 A healthy and robust nursing practice environment (PE) enables the achievement of these laudable outcomes.1 The PE is strongly indicative of nursing culture, and it greatly affects those who work in healthcare organizations.2 Understanding the PE, however, has inherent difficulties because of it being an abstruse construct to conceptualize and measure.3 Despite this, the PEs of nurses have been explored to increase understanding and to influence nurse job satisfaction and turnover.4 The Practice Environment The PE Scale of the Nursing Work Index (PES-NWI), designed to measure characteristics in the nursing PE,3 was a modification of the original NWI developed by Kramer and Hafner in 1989.5 The NWI was based on the original Magnet hospital characteristics described by McClure et al in 1983.6 These researchers explored common attributes of hospitals that were successful in recruiting and retaining nurses during a severe nursing shortage in the 1980s. In 2002, Lake3 revised the original NWI using a 5-stage approach to shorten the scale from 66 to 31 items. The Practice Environment Scale, Australia (PES-AUS) is a modified,
653
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
30-question version of the PES-NWI, developed by Middleton et al,7 that has been adapted for the Australian context, as discussed below.
Research Aims The research aims were (1) to assess clinical nurses’ perceptions of the PE at 1 hospital, (2) to compare results with baseline data obtained in 2009, and (3) to benchmark results with data from other Magnet organizations.
Methods The PES-AUS survey was administered in September/ October 2012. The eligible sample (n = 522) comprised registered nurses (RNs), enrolled nurses (EN), and assistants in nursing (AINs). Enrolled nurses refer to those nurses who possess a Diploma of Enrolled Nursing from a registered training organization, which provides vocational education and training. Enrolled nurses are the professional equivalent of a licensed practical nurse outside the United States and most Canadian provinces. Enrolled nurses work under the supervision of an RN to provide patients with basic nursing care. Within their scope of practice, ENs are accomplished in the practical skills of nursing, with advanced ENs able to undertake more complex procedures. Assistants in nursing assist RNs and ENs in the provision of nursing care. The appropriate qualification for AINs is at Certificate III level of the Australian Qualifications Framework; these nurses are the international equivalent of nursing assistants (NA). Eligible staff members were grouped into 13 clinical units for reporting purposes, with each clinical unit working under the direction of 1 nurse manager (NM). Nurse managers (n = 17) and full-time clinical nurse educators (n = 12) were excluded from the study as many of the items pertained directly to their role and function in the PE. Data were collected via the online software program Survey Monkey. This was made available to all nurses through a specially designed portal available on the clinical workstations of the hospital’s information technology system, to which all nurses had access during their working hours. Staff could also access the survey via this portal from their home computer, and NMs were given the survey link, which could be forwarded to staff on extended leave to ensure that they had the opportunity to participate. Evidence suggests that Web-delivered surveys do not always have robust response rates when compared with paper-based surveys.8 Clinical nurses in hospitals face a unique work complexity that inhibits survey participation.8 To address this potential source of bias, a number of evidence-based strategies
654
were used to enhance response rates. Strategies were tailored around the framework of precontact, follow-up, incentives, timing, and a tailored method of implementation.9 Strategies included, but were not limited to, emphasizing the relevance of the survey through the director of nursing and clinical services, the nursing executive staff, and the NMs; continuing professional development sessions conducted in all clinical areas by the research assistant working on the study to stress the relevance of the research for Magnet redesignation; and negotiated work time to undertake the survey while the clinical nurse educators released staff from patient care responsibilities. The chief investigator used internal competition to generate a sense of fun and rivalry among staff, who were divided into teams of clinical units and departments, with incentives being provided on the basis of response rate attainment at 95% or above. Accordingly, 3 of the 13 grouped clinical units attained a 100% response rate. Ethics approval for the study was obtained from the hospital’s Practice Development and Research Committee, which reviewed the study for human protection because the participants were employees. This committee functions identically to an institutional review board and is responsible for the review and approval of research involving human participants. Instrument The PES-NWI was developed by Lake9 through factor analysis of data from the original Magnet hospitals research.11 The PES-AUS is a modified, 30-item version of the PES-NWI, developed by Middleton et al7 for the Australian context. Middleton removed the item referring to ‘‘use of nursing diagnosis’’ from the subscale ‘‘nursing foundations for quality care’’ because nursing diagnoses are not used in Australia and also altered the descriptions of 8 job titles from the PESNWI to suit the Australian context (Figure 1).8(p368) For each of the 30 questions, nurses were asked to rate, using a 4-point Likert scale (strongly agree to strongly disagree), whether specific organizational characteristics were present in their current job. They were also asked 6 demographic questions: sex, age, level of highest qualification, employment status (fulltime, part-time, and casual), nursing classification (NA, EN, RN, clinical nurse specialist), and length of time employed on their unit or department. Data Analysis Data were analyzed using SPSS version 19.0. (IBM, Armonk, New York). The PES-AUS instrument was scored according to directions supplied by Lake (E. Lake, unpublished data, 2004). A mean subscale score was calculated for each respondent. In compliance with the scoring instructions, responses for nurses
JONA Vol. 44, No. 12 December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 1. Practice Environment Scale, Australia. Modified from the 31-item Practice Environment Scale of the Nursing Work Index.9
who did not answer all of the items were still included in the subscale scores. The denominator for the subscale ‘‘nursing foundations for quality care’’ was adjusted to allow for the 1 item that was removed from the PES-NWI (Use of Nursing Diagnoses). The potential score range for each of the subscale means was 1 to 4. Higher scores indicated greater agreement that subscale items were present in the current job situation; specifically, values above 2.5 indicated agreement and values below 2.5 indicated disagreement. A composite score was created and comprised the mean of the 5 subscale scores (Figure 2).7 The mean of subscale scores rather than item scores was chosen
JONA Vol. 44, No. 12 December 2014
to give equal weight to each subscale. Measures of central tendency were used to describe the mean and standard deviations of the PES-AUS subscales. Mean scores were compared with 2009 data using a 2-tailed t test of significance. Mean scores were also compared with published US Magnet hospital data.9
Results A total of 492 nurses from all clinical areas in the hospital completed the survey (94%; n = 492). There were 430 (85%; n = 430) female nurses and 62 (12.3%; n = 62) male nurses. The largest represented age group was 21 to 40 years (64.2%; n = 325). Nearly
655
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Figure 2. The 5 subscales of the Practice Environment Scale, Australia.8
three-quarters of nurses were educated to the level of bachelor degree or above (74.3%; n = 376); this accounted for a 5% increase since 2009.12 Employment status was primarily full-time (66.6%; n = 337). All respondents were employed as clinicians (100%; n = 492). The nursing classification of respondents included 384 (75.9%; n = 384) RNs, 69 (13.6%; n = 69) clinical nurse specialists, 4 (e1%) ENs, and 35 (6.9%) NAs. The median length of time employed on the study units was 4 to 8 years (Table 1). The PES Mean scores and standard deviations of the 5 PES-AUS subscale items and the composite scale from the study hospital are depicted in Table 2, where they are compared with the reported means from the 2009 baseline data10 and Magnet hospital data in the United States.9 Mean values were above 2.5 for all 5 of the subscales: nurse participation in hospital affairs (mean, 3.01), nursing foundations for quality of care (mean, = 3.18), nursing unit manager ability, leadership, and support of nurses (mean, 3.09), staffing and resource adequacy (mean, 2.88); and collegial nurse-doctor relations (mean, 3.05), as well as the composite scale (mean, 3.04). These results affirm that each of the subscale items was present in the current work environment. The mean score for ‘‘nurse participation in hospital affairs’’ (3.01) was comparable with the score at baseline (3.06) (P = .20). In addition, the mean score for ‘‘nursing foundations for quality of care’’ (3.18) was identical with baseline data (3.18) (P = .76). The mean score for ‘‘nursing unit manager ability, leadership, and support of nurses’’ (3.09) was significantly below (P = .04) the baseline (3.17). The mean score for ‘‘staffing and resource adequacy’’ (2.88) was identical with baseline (2.88) (P = .94), whereas the mean score for ‘‘collegial nurse-doctor relations’’
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(3.05) was comparable with baseline (3.01). The mean score for the composite scale (3.04) was comparable with the baseline (3.06), indicating that Magnet recognition has had a sustained positive impact on the PE. Table 1. Nurses’ Demographic Characteristics Reported in 2012 for the Total Sample (n = 492) Characteristic Sex Female Male Age e20 21-30 31-40 41-50 51-60 Q61 Level of highest qualification Certificate (hospital-trained RN) Certificate 3 Certificate 4 Diploma (Tafe/university) Advanced diploma Bachelor’s degree Graduate certificate Graduate diploma Master’s degree Employment status Full-time Part-time Casual Years employed in department e1 1-3 4-8 9-15 Q15 Nursing classification AIN EN RN Clinical nurse specialist
n
%
430 62
85 12.3
1 171 154 86 60 20
0.2 33.8 30.4 17 11.9 4
60 21 8 19 8 237 73 25 41
11.9 4.2 1.6 3.8 1.6 46.8 14.4 4.9 8.1
337 142 13
66.6 28.1 2.6
86 115 160 85 46
17 22.7 31.6 16.8 9.1
35 4 384 69
6.9 0.8 75.9 13.6
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Table 2. Follow-up Subscale Scores for the PES-AUS Compared With Baseline and American Magnet Hospitals
Subscalesa (Our Subscale, N = 492) Nurse participation in hospital affairs Nursing foundations for quality of care Nursing unit manager ability, leadership, and support of nurses Staffing and resource adequacy Collegial nurse-doctor relations Composite scale
Total Sample (N = 492)
Baseline Data (2009) (N = 384)
American Magnet Hospitals (N = 1610)
Mean (SD)c
Mean (SD)
P
Mean (SD)
P
9 9b 5
3.01 (0.55) 3.18 (0.4 8) 3.09 (0.66)
3.06 (0.42) 3.18 (0.38) 3.17 (0.52)
.20 .76 .04
2.76 (0.47) 3.09 (0.39) 3.00 (0.59)
G.001 G.001 .50
4 3 5
2.88 (0.63) 3.05 (0.58) 3.04 (0.49)
2.88 (0.58) 3.01 (0.51) 3.06 (0.39)
.94 .33 .53
2.88 (0.62) 2.99 (0.52) 2.95 (0.40)
1.00 .02 G.001
No. of Items
2012 data were compared with American Magnet hospitals9 along with the 2009 baseline data.10 a Sample size (n) of subscale item varies because of missing data. b This is a 10-item scale in the original tool. One item was removed for use in the Australian context (Use of Nursing Diagnoses) as it was not relevant. c Mean sample size of subscale items. Values above 2.5 indicate agreement that the subscale items are present in the current work environment. Values below 2.5 indicate disagreement that the subscale items are not present in the current work environment.
The mean scores on all subscales were significantly higher than Magnet hospitals in the United States, except for ‘‘staffing and resource adequacy,’’ which was identical with them, and ‘‘nursing unit manager ability, leadership, and support of nurses,’’ which was not statistically significant. Similarly, the mean scores on all subscales were significantly higher than Australian non-Magnet hospitals.7
Discussion Understanding the PE of nurses working in an acute care, primarily surgical hospital, 18 months after inaugural Magnet designation provides an opportunity to evaluate the effect of the program on this facility and, in particular, on clinical nurses’ perception of it. The study’s purpose was to obtain PE data for Magnet redesignation and compare results with baseline data. The mean composite scale scores for 2012, as reported above, were comparable with baseline and indicate that this recently designated Magnet facility was operating at a high level of performance before undertaking the journey. The information has provided information to support nursing leaders to set the benchmark in relation to maintaining a healthy culture after Magnet recognition even higher. Our results are by no means isolated in respect of other measures of quality. They are augmented by other tools used by the hospital over the last few years, including, but not limited to, the following internal and external measures: In 2013, the hospital was rated as having a ‘‘Culture of Success’’ by Best Practice Australia, which is a national benchmarking organization for public and private hospitals in Australia. The subsequent results, which were derived from a hospitalwide survey (75% of respondents were RN), illustrated
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that staff report high levels of engagement in the organization, with 76% of respondents describing the hospital as ‘‘a truly great place to work.’’ Importantly, these results have been sustained since 2007, when the culture was 1st classified as one of ‘‘success.’’ In addition, the Staff Patient Safety Culture Survey11 was administered in May 2013. This tool enables benchmarking across all 26 facilities in our corporation of Catholic hospitals. The information provided rigorous supplementary evidence of the perceptions of all personnel (nursing and nonnursing) in relation to the systems within the organization supporting service provision and optimal patient outcomes. A healthy response rate of 87.5% was obtained, demonstrating a positive patient safety climate, with favorable scores in 4 of the 6 factor analysis. Another benchmarking exercise to which the hospital subscribes is the Press Ganey patient satisfaction surveys, which are generated on a continuous monthly cycle. At time of writing, the most recent 6 months’ scores have placed the hospital on the 99th percentile when compared with peer hospitals in Australia. The only subscale that demonstrated a significantly lower than baseline result, ‘‘Nursing Unit Manager Ability, Leadership and Support of Nurses,’’ is somewhat perplexing in light of the sustained results in each of the remaining subscales and the composite score. This may suggest that staff nurses have perhaps more heightened expectations of their managers now that Magnet recognition has been achieved. Indeed, while clearly performing well against US Magnet hospitals,10 and well above the 2.5 score, which indicates agreement with the items in the subscale, it was determined that there was no cause for concern with this result, but nursing leaders redoubled the effort on the part of all managers to ensure that staff feel well supported in their work.
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Moreover, this study provides scientific evidence that organizations post-Magnet designation can maintain high levels of staff engagement and satisfaction that are comparable with pre-Magnet recognition baseline data. The findings of this study challenge, therefore, recent research that suggests that the journey to Magnet recognition has a pronounced impact on nurse perceptions of the PE and perhaps more so at the time of designation than beyond.12 Limitations There are 2 predominant limitations of this research. First, there are limited data available for comparison within the Australian context, and 2nd, we acknowledge that the US Magnet hospital data used as a comparison in this article were obtained some years ago. However, from a comparability facet, these data remain the most relevant published data set available to the research team to fulfill the research aim of benchmarking results with data from other Magnet organizations.13 Limited comparison data available in Australia restrict the researcher’s ability to benchmark the PE against both the other 2 Magnet hospitals and all other non-Magnet hospitals in Australia. Research affirms that the PE is influenced by culture.10 The differences in cultural expectations influenced by norms in the US versus non-US Magnet hospitals have not been explored. Also, surveys of
self-reported satisfaction (both those for patients and staff) are prone to bias. Increasingly objective measures of the PE and along with the satisfaction of staff and patients have not been reported.
Conclusion Sustaining a culture of success and ensuring high levels of nursing staff engagement and empowerment are challenging. Challenges include increasing complexity of patient care14 and potential for adverse events,14 the fiscal pressures on healthcare facilities to do more with less,15 and a focus on the bottom line.15 At our hospital, we were interested in measuring whether Magnet recognition had more than a temporary effect on what was already a high-performing culture.16 We were affirmed to see positive results 3 years beyond the 1st measurement of the PE as an initial strategy to analyze gaps in preparedness to undertake the Magnet journey. As we prepare for redesignation in 2015, we are more confident that a healthy and thriving nursing culture is in place in the organization.
Acknowledgments The authors thank Associate Professor Jose Aguilera, Director of Nursing and Clinical Services and the Nursing Unit Managers of St Vincent’s Private Hospital, for the support in undertaking this research.
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10. Walker K, Middleton S, Rolley J, Duff J. Nurses report a healthy culture: results of the Practice Environment Scale (Australia) in an Australian hospital seeking Magnet recognition. Int J Nurs Pract. 2010;16(6):616-623. 11. Braithwaite J, Westbrook MT, Robinson M, Michael S, Pirone C, Robinson P. Improving patient safety: the comparative views of patient-safety specialists, workforce staff and managers. BMJ Qual Saf. 2011;20(5):424-431. 12. Hess R, DesRoches C, Donelan K, Norman L, Buerhaus PI. Perceptions of nurses in Magnet hospitals, non-Magnet hospitals, and hospitals pursuing Magnet status. J Nurs Adm. 2011; 41(7/8):315-323. 13. Witkoski-Stimpfel A, Rosen J, McHugh M. Understanding the role of the professional practice environment on quality of care in MagnetA and non-Magnet hospitals. J Nurs Adm. 2014;44(1):10-16. 14. Kramer M, Maguire P, Brewer B. Clinical nurses in Magnet hospitals confirm productive, healthy unit work environments. J Nurs Manag. 2011;19:5-17. 15. Drenkard K. The business case for MagnetA. J Nurs Adm. 2010;40(6):263-271. 16. Parker D, Tuckett A, Eley R, Hegney D. Construct validity and reliability of the Practice Environment Scale of the Nursing Work Index for Queensland nurses. Int J Nurs Pract. 2010; 16(6):616-623.
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