Lower mortality in magnet hospitals.

TLDR: The lower mortality found in Magnet hospitals is largely attributable to measured nursing characteristics but there is a mortality advantage above and beyond what the study could measure.

Abstract: Nurses are key players in the effective functioning of complex hospital organizations and their ability to provide good patient care is influenced by the context in which they practice. Hallmarks of successful organizations include flat organizational structure with accessible and informed managers, decentralized decision-making, and the empowerment of front line workers to make decisions.1-2 Managerial strategies that reduce the negative effects of organizational complexity on employee productivity, work quality, and retention have emerged in a variety of industries and settings. The concept of Magnet hospitals—hospitals identified by their reputations for being good places for nurses to work—evolved from observations that hospitals that were successful in attracting and retaining qualified nurses resembled the most highly ranked U.S. corporations.3 In 1994, Medical Care published the first paper on patient outcomes in Magnet hospitals, documenting lower risk-adjusted mortality among Medicare patients in the original Magnet hospitals.4 Magnet hospital designation was formalized with the American Nurses Credentialing Center’s (ANCC) Magnet Recognition Program® in the 1990s.5 The voluntary process was subsequently shown to identify hospitals that were as good as the original “reputational” Magnet hospitals of the 1980s in terms of having excellent work environments and nurse outcomes such as lower levels of burnout and higher job satisfaction.6 With few exceptions,7 studies since have shown that care environments in Magnet recognized hospitals are different from non-Magnet hospitals.8-10 These differences are associated with higher levels of nurse satisfaction, less nurse burnout,11-12 lower patient fall rates,13 and lower mortality among very low birth weight infants.14 The number of Magnet recognized hospitals has grown to nearly 400— about 8% of hospitals nationally. The Magnet Recognition Program® has also achieved status and visibility; Magnet recognition is now an indicator for national hospital ranking and quality benchmarking programs like U.S. News and World Report Best Hospitals rankings and the Leapfrog Group hospital ratings.15-17 During the period of evolution and replication of Magnet hospitals, research emerged documenting associations between hospitals with exemplary nurse practice environments and patient outcomes. Lower risk-adjusted mortality and death following complication among surgical patients have been associated with lower patient-to-nurse ratios,18-20 a more educated nurse workforce,21 more specialty-certified nurses,22 and better nurse work environments.12, 23-24 The Magnet Recognition Program® does not specify nurse staffing levels or educational or specialty certification requirements for bedside nurses. Instead, the program requires evidence-based processes aimed at organizational reform of nurses’ work environment in relation to desired patient outcomes. Hospitals are evaluated for evidence of achieving goals in five areas: transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovations, and improvements; and empirical outcomes. Thus, a follow-up to the 1994 paper must go beyond determining whether a mortality advantage can be documented for formally designated Magnet hospitals. Our inquiry must delve into the possible explanations for such an advantage, if found, because there is now a substantial scientific base documenting the association between nursing and patient outcomes. In the 1994 paper, Magnet designation was used as a proxy for good nursing because details of nurse staffing, education, qualifications, and work environments could not be measured with available data. That is no longer the case. A multi-state survey of nurses in California, Pennsylvania, New Jersey, and Florida provides direct measures of key elements of nursing organization and practice across all general, acute care hospitals in these four large states.23 Additionally, Magnet designation is now a formal process involving evidence-based criteria, on-site evaluations, and re-designation every four years with higher standards required the longer the designation is held.25 We use the data from the four states to examine this new environment and to determine whether Magnet hospitals continue to evince organizational characteristics that differentiate them from other hospitals, and if so, the extent to which these characteristics are associated with lower risk-adjusted mortality and failure-to-rescue. Our hypothesis is that Magnet hospitals should “out-perform” non-Magnet hospitals. Differences in patient outcomes should be associated with the organizational features of nursing that can be measured. However, there may be a Magnet effect above and beyond the effect attributable to the measured nursing features alone.