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Critical Care Nurses’ Work Environments Value of Excellence in Beacon Units and Magnet Organizations

Dana Woods is the director of marketing and strategy integration for the American Association of Critical-Care Nurses. She is the staff lead on the association’s Healthy Work Environment Initiative.

Karen Hart is a senior vice president in the Health Care Division of Bernard Hodes Group, a recruitment communications company.

Ramón Lavandero is director of development and strategic alliances for the American Association of Critical-Care Nurses. He is adjunct associate professor at Indiana University School of Nursing, where he serves on the school’s external board of advisors.

John Leggett is executive vice president for marketing, events, consulting, and research at the Gannett Healthcare Group.

Diane Taylor is research manager for Bernard Hodes Group.

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.

Financial Disclosures
This study was a joint effort of the American Association of Critical-Care Nurses, Gannett Healthcare Group (publishers of Nursing Spectrum and NurseWeek), and Bernard Hodes Group, all of which provided support for the project.

Corresponding author: Beth T. Ulrich, 3811 Abbeywood Dr, Pearland, TX 77584 (e-mail: BUlrich{at}GannettHG.com).

Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but we rather have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit.

—Aristotle

Intuitively one would expect nurses from units and hospitals nationally recognized for excellence to report healthier work environments and greater satisfaction with their work and their profession than nurses from other units and hospitals do. Is intuition supported by evidence?

In the October 2006 issue of Critical Care Nurse, we reported how 4034 critical care nurses in the United States view their work environments and nursing as a career.¹ The results of a collaborative survey by the American Association of Critical-Care Nurses (AACN), Nursing Spectrum (now the Gannett Healthcare Group), and Bernard Hodes Group (a division of Omnicom) indicated that a majority (63%) of critical care nurses are very satisfied with being a nurse. However, verbal and physical abuse, sexual harassment, and leadership issues were important problems in their work environments.

Many nurses in the survey reported working in units that participate or seek to participate in the AACN Beacon Award for Critical Care Excellence and/or the American Nurses Credentialing Center Magnet Recognition Program. This information offered us a unique opportunity to examine how nurses view their work environments and nursing as a career when working in units and hospitals that are nationally recognized for excellence or are pursuing such recognition.

Beacon Award for Critical Care Excellence

Developed in 2003 by the AACN, the Beacon Award for Critical Care Excellence recognizes individual critical care units that meet high-quality standards, providing exceptional care of patients and patients’ families while fostering and sustaining healthy work environments. To receive the Beacon Award, which may be applied for annually, a unit must meet 42 criteria in 6 categories. The categories are innovation/excellence in recruitment and retention; education, training, and mentoring; evidence-based practice and research; patients’ outcomes; creating and promoting healing environments; and leadership and organizational ethics.²

Magnet Recognition Program

The Magnet Recognition Program was developed and is administered by the American Nurses Credentialing Center, the credentialing arm of the American Nurses Association. The program recognizes healthcare organizations that demonstrate excellence in nursing care and professional nursing practice. Magnet-designated organizations must demonstrate achievement of quality indicators and standards of nursing practice as defined by the American Nursing Association and must meet criteria in 14 different areas or "forces of magnetism."^3,4 Along with providing consumers a benchmark of quality care, the Magnet Recognition Program also strives to facilitate sharing of excellent nursing practices and elevate the standing of nursing as a profession.

Study Design and Sample

The details of the study are described in an earlier article.¹ Briefly, an online questionnaire was used to elicit information. After a pilot survey was done, the request to complete the final survey was sent to AACN nurse constituents. As part of the survey, respondents were asked to indicate the Magnet and Beacon status of their work environment: whether Magnet and/or Beacon status had been achieved, whether achieving the status was in process (hereafter referred to as Magnet-pursuit organizations and Beacon-pursuit units), or whether neither was the case (no-Magnet-activity organizations and no-Beacon-activity units). Respondents could also indicate if they worked in a unit or organization that was ineligible for Magnet and/or Beacon status.

Of 4034 usable responses received, 3332 respondents indicated the Magnet status of their organizations and 2897 respondents indicated the Beacon status of their work unit (Table 1). The responses from the subset of nurses who indicated Magnet and/or Beacon status was used to answer the following question: Do nurses working in organizations that have achieved a standard of excellence (in this case, Magnet or Beacon designation), or are in the process of seeking to achieve such a standard, view their work environment and the nursing profession differently than nurses in organizations/units that neither have achieved this standard nor are actively seeking it?

Results of the Analysis

AACN Healthy Work Environment Standards
A total of 16 survey items were developed from the AACN Standards for Establishing and Sustaining Healthy Work Environment.⁵ Respondents were asked to indicate their level of agreement with each statement twice, once for their organization (macrosystem) and once for their work unit (microsystem). The agreement options were strongly agree, agree, disagree, and strongly disagree. The overall results are presented in Table 2.

Communication and Collaboration
Nurses were asked to assess the quality of communication and collaboration in their organizations among registered nurses (RNs), between RNs and physicians, between RNs and frontline managers, and between RNs and administrators. Response options were excellent, good, fair, and poor.

The results are shown in Table 3. Once again the responses of nurses in Magnet and Beacon status differed, often significantly, from those of the other respondents. For all groups, the highest levels of communication and collaboration were among RNs. Communication between RNs and physicians and between RNs and frontline managers were rated lower and about the same. Communication and collaboration between RNs and administrators was rated much lower.

Respect
Respondents were asked to rate respect for RNs in their organizations shown by other RNs, physicians, frontline managers, administrators, and other healthcare colleagues. The rating options were excellent, good, fair, and poor. Table 4 shows how significant differences were related to Magnet and Beacon status. RNs’ respect of each other was rated highest by all groups; administrators’ respect of RNs was rated the lowest.

Recognition and Reasons for Staying
Regardless of Magnet or Beacon status, recognition was most meaningful when it came from patients; next was recognition received from other RNs. In addition, and again regardless of Magnet or Beacon status, the No. 1 reason for continuing to work in their current organizations was "people I work with," a response selected by more than half of the respondents in every group.

Skills of Frontline Managers and Chief Nurse Executives
Because of the influential role of nurse leaders in units and organizations, each respondent was asked to rate the skills of his or her frontline manager and chief nurse executive. Skills rated included communication; collaboration; providing staff resources; providing supplies, equipment, and other nonhuman resources; effective decision making; recognition of others’ contributions; and leadership. The rating options were excellent, good, fair, and poor.

For every skill, frontline managers in Magnet organizations were rated significantly higher than were those in Magnet-pursuit or no-Magnet-activity organizations (P<.05). The skills of frontline managers in Beacon units and in Beacon-pursuit units also were rated significantly higher than those of their counterparts in no-Beacon-activity units (P<.05). A similar pattern was found in the skill ratings of chief nurse executives (Table 5).

Regardless of Magnet or Beacon status, most organizations provided in-house CE and paid time off for CE, although differences were significant. In several instances, Magnet organizations were significantly more likely than Magnet-pursuit or no-Magnet-activity organizations to provide specific support for CE. The same difference occurred among Beacon units, Beacon-pursuit units, and no-Beacon-activity units (Figure 1).

View larger version (42K): [in this window] [in a new window]   Figure 1 Support for continuing education.

View larger version (38K): [in this window] [in a new window]   Figure 2 Support for certification.

View larger version (58K): [in this window] [in a new window]   Figure 3 Satisfaction with being a registered nurse and with current position.

Discussion

Does excellence make a difference? Indeed, it does. Nurses in this study who work in organizations and units that have met a national excellence standard—in this case, Magnet or Beacon designation—consistently reported healthier work environments and expressed higher satisfaction with their current jobs. They also gave higher ratings to the skills of their formal nurse leaders. In addition, they rated the quality of patient care as higher and more often reported that care had improved from the previous year. In many instances, nurses in organizations and units pursuing achievement of a standard of excellence (Magnet or Beacon designation) reported similar positive findings. These results support earlier findings⁶ on the views of nurses who work in Magnet organizations and organizations pursuing Magnet status.

These results also support those of previous research^4,7–14 comparing the positive outcomes of Magnet and non-Magnet organizations. In every area of a healthy work environment, the results of our survey indicate that excellence and the pursuit of excellence make a difference.

Communication and Collaboration
Nurse respondents in Magnet organizations and Beacon units consistently rated communication and collaboration higher than did respondents in other units. Communication issues continue to be the No. 1 cause of sentinel events reported to the Joint Commission.¹⁵ Collaboration has long been reported to be related to both patients’ outcomes and to higher satisfaction with the career of nursing. Further, extensive evidence^16–22 indicates that poor collaboration has an effect on outcomes for patients and their families, satisfaction among staff members, retention of nurses, and costs.

Shared governance is one way in which communication and collaboration are enhanced. The Institute of Medicine has identified the involvement of RNs in decision-making processes as an important strategy for improving patients’ safety.²³ Data from our survey indicate that most Magnet organizations and Beacon units have formal shared governance programs in place, but only a relative few no-Magnet-activity organizations and no-Beacon-activity units have such programs.

Respect also contributes to effective communication and collaboration. Respect for RNs from every professional group investigated in our survey was higher in Magnet organizations and Beacon units than in the other units.

Support for Professional Growth and Development
Both CE and specialty nursing certification improve outcomes for patients and satisfaction among nurses.^24,25 Across the board, Magnet organizations and Beacon units as well as those pursuing these excellence designations were more supportive of CE and certification than were no-Magnet-activity and no-Beacon-activity organizations. In many instances, organizations and units in pursuit of excellence were more supportive than those that have already obtained the designations. This difference indicates the need for sustainable efforts that continue after excellence designations are achieved.

Satisfaction
Our results support those of other researchers^7,10,11 who found a positive relationship between working in a Magnet organization and satisfaction with the career of nursing. Nurses in our survey who worked in Magnet organizations, Beacon units, or units pursuing such designations were more satisfied with nursing as a career and with their current nursing positions than were nurses in non-Magnet and non-Beacon units.

Leadership
Implementing the AACN standards for establishing and sustaining healthy work environments⁵ requires authentic leadership, a characteristic that has been described as the "glue that holds together a healthy work environment."^26(p2) Authentic leadership is critical at every level of nursing. Successful chief nurse executives work from a broad base to create a vision for nursing in their organizations and provide resources and inspiration to transform the vision into reality. Effective frontline managers are vital to the success of every organization because they understand both the organization’s vision and its social structure, enabling them to serve as interpreters across organizational levels and interdisciplinary groups.^27–29 Frontline managers are influential in nurses’ decisions to remain in or leave an organization.^30,31

Our findings show higher perceived skill levels of frontline managers in organizations and units that have achieved or are pursuing Magnet or Beacon designation. Although we cannot determine if this finding represents excellence attracting excellence, excellence developing excellence, or something else entirely, logically excellence among frontline managers in organizations and units that have achieved or are pursuing Magnet or Beacon designation is not a random occurrence.

Patients’ Outcomes
Evidence^{15,22,32–34} continues to mount that meeting healthy work environment standards (especially communication, collaboration, and staffing) is related to increased safety and improved outcomes for patients. At both the unit and organization level, nurses in our study rated the current quality of care as significantly lower in organizations and units that had not achieved and were not pursuing excellence designation.

Future Research
The increased number of Magnet-designated organizations allowed us to study the views of a national sample of nurses instead of a sample of nurses working in a selection of Magnet and non-Magnet organizations. As the number of Magnet organizations continues to grow, with more than 225 organizations so designated and more than 250 others reported to be in the pipeline,³ it will be increasingly possible to use Magnet status as a variable in large studies. The AACN Beacon Award for Critical Care Excellence is much newer, so fewer nurses are working in Beacon units. As of March 2007, 78 Beacon units had been designated in the United States and more than 200 units were in the application process. As the Beacon designation becomes more well-known, those numbers will also increase, allowing Beacon status also be to used more routinely as a variable.

Summary
This study offers compelling evidence to support what we have intuitively believed: the pursuit and achievement of excellence does make a difference in how nurses perceive the health of their work environments and nurses’ satisfaction with their profession and work compared with other nurses. Nurses in units and organizations nationally designated or pursuing designation for excellence, whether through the AACN Beacon Award for Critical Care Excellence and/or the American Nurses Credentialing Center Magnet Recognition Program, report healthier work environments and higher job satisfaction, both of which have been previously reported as contributing to better outcomes for patients.

The pursuit and achievement of excellence can no longer be viewed as merely a value-added benefit to safe and effective care of patients and satisfaction among nurses. It now must become a core strategy.

Acknowledgments

We are grateful for the help of Linda Bell, RN, MSN, practice specialist at the American Association of Critical-Care Nurses, in obtaining and verifying program data for this manuscript.

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