Strategic management in the establishment of a magnet hospital: A nursing staff perspective ()
1. INTRODUCTION
Worldwide, the developing of magnet hospitals has become the trend for solving the nursing shortage, and it has been viewed as the gold standard for nursing excellence [1]. It also reflects the way that patients seek objective benchmarks that will aid them in finding a hospital with a higher level of care [2]. Considerable evidence has shown that, in magnet hospitals, patients have lower mortality and morbidity rates, shorter lengths of stay, higher patient-satisfaction, and interdisciplinary patient and family-centered care. Nurses who work in magnet hospitals have lower turnover and vacancy rates, higher job-satisfaction, autonomy in the professional practice environment, and good interdisciplinary working relationships [3,4]. Therefore, the process of achieving the magnet hospital designation becomes a roadmap for improving the quality of care and working environment in many hospitals [5].
According to the American Nurses Credentialing Center (ANCC), magnet recognition refers to meeting certain criteria by which a hospital is able to withstand nursing shortages, and attract and retain nurses [6]. The criteria include 5 magnet model components and 14 forces of magnetism: 1)Transformational Leadership (encom-passes 2 Forces: Quality of Nursing Leadership, Management Style); 2) Structural Empowerment (encompasses 5 Forces: Organizational Structure, Personnel Policies and Programs, Community and the Healthcare Organization, Image of Nursing, Professional Development); 3) Exemplary Professional Practice (encompasses 5 Forces: Professional Models of Care, Consultation and Resources, Autonomy, Nurses as Teachers, Interdisciplinary Relationships); 4) New Knowledge, Innovations and Improvements (encompasses 1 Force: Quality Improvement); 5) Empirical Outcome (encompasses 1 Force: Quality of Care). In 1993, the fourteen forces of magnetism were drafted and a credentialing service was provided by the ANCC. Today, about 7% of hospitals (nearly 400 hospitals) have achieved magnet recognition in over the United States as well as some in Lebanon, Singapore, Australia and other countries. Over the last 2 decades, strong evidence has shown that magnet hospitals have excellent nursing staff, a superior work environment, and better patient outcomes [7,8]. This integration of recognition, resources, and culture may be helpful to other hospitals in preparing for magnet recognition and encourage others to do so [9].
To date, the number of hospitals that have achieved magnet recognition is not as good as expected; not only in the United States but even Canada, England, Scotland, and Germany still face the challenge of nursing shortages [10]. Although there are differences in the health care systems, the nursing shortage issue is the same. Identifying the barriers and looking for possible solutions are important issues to deal with if the current nursing shortages are to be resolved. The role of nurses has expanded and the demands on nurses have increased [11,12], so setting priorities has become a major challenge faced worldwide by health plan decision-makers with limited resources [13]. The magnet hospital concept presents itself as a possible solution to the challenge of nursing shortages [10]; however, previous research has focused primarily on provider and patient correlations with magnet hospital characteristics, and less on the identification of an organizational social structure that would promote its development and maintenance [14]. Kanter indicated that social structures in the work-place influenced employee attitudes and behaviors to a greater extent than did natural personality predispositions [15,16]; therefore, strengthening the social structures in the hospital work environment was a precursor to magnetism. Kanter also conceptualized power as the “ability to mobilize resources to get things done” [17]. The American Hospital Association recommended that hospitals needed to redesign work processes, develop new modes of working, and increase work efficiency and effectiveness and employee satisfaction in order to make hospitals the employers of choice [18].
Magnet hospitals can create a magnetic working environment that encourages professional nursing and provides excellent nursing practices which serve as the hallmark of high performance institutions [19]. It is also critical to identify the gaps in factors that promote hospital magnetism while considering the allocation of resources and effectively creating a positive work environment that enhances these factors. A two-dimensional strategic matrix [importance-performance gap analysis (IPGA)] has been applied to health care fields [20,21] as it can quickly offer useful information to decision makers. This study used the IPGA model, from nurses’ perspectives, to investigate the key magnetic factors influencing their practice and to identify the gaps between nurses’ perceptions and hospital performance in order to provide policy makers and professionals with valuable reference information in order to develop an effective magnet hospital. The aims of this study were: 1) to investigate the key magnetic factors which influenced nursing practice; 2) to analyze the gaps between nurses’ perceptions and hospital performance; 3) to examine the relationship between nurses’ characteristics, hospital attributes and performance gaps; and 4) to provide key factors to hospital managers, when considering the allocation of resources to help set strategic management goals when establishing a magnet hospital.
2. METHODS
2.1. Study Participants
The participants were nurses who had at least 1 years experience in a hospital located in the same administrative district covered by national health insurance in Taiwan. Each of 9 district teaching hospitals recruited 50 eligible nurses during August 2012. A total of 450 selfadministered questionnaires were collected, and, of these, 436 were valid.
2.2. Research Scale Design
In order to investigate the key magnetic factors influencing nursing practice and identify the gaps between nurses’ perception and hospital performance, this study was carried out with a questionnaire using the 14 forces of magnetism drafted by the ANCC [22] and others from a nurse opinion questionnaire [23] as guides. Because it needed to account for a Taiwanese background and health system, the draft was reviewed by academic specialists and practitioners, and pre-tested and revised before the final version was distributed. The contents of the questionnaire included three dimensions: nurses’ perceptions of the importance of magnetism, nurses’ perceptions as to how the hospital performed, and nurse characteristics. The resulting 18 items were: 1) nursing leadership, 2) power-responsibility assignment, 3) management style, 4) salary structure, 5) welfare, 6) manpower deployment, 7) flexible scheduling, 8) professional care model, 9) facility and equipment, 10) quality improvement, 11) consultation and resources, 12) autonomy, 13) Nurse-patient relationships, 14) clinical teachers’ attitudes, 15) interdisciplinary relationships, 16) professional knowledge, 17) opportunity for education, 18) handling nurse-patient disputes. Each item was scored on the nurse’s perception of importance (1 = very unimportant to 5 very important) and the nurse’s perception of hospital performance (1 = very dissatisfied to 5 very satisfied).
Nurse characteristics included gender, age, education, salary, marital status, experience, work setting, clinical ladder, and work shift. Hospital attributes were public or private.
2.3. Data Analysis
Descriptive statistics, such as mean, standard deviation, frequency and rank order, were used to investigate the key magnetic factors which influenced nursing practice.
Paired sample t-tests were used to analyze the gaps between nurses’ perceptions and hospital performance. Factors with statistical significance (P < 0.05) were defined as performance gaps.
Independent samples t-tests and ANOVA were used to examine the relationships among nurses’ characteristics, hospital attributes and performance gaps.
The IPGA matrix was used to develop strategic management for magnet hospitals. The IPGA tool is a simple graphic that enables a comparison of perceived importance against performance, and is expected to help make service decisions through a simple strategic matrix. It also includes a gap theory to identify hospital failures based on nurse’s expectations vs. their perception of hospital services. Understanding nurse’s demands should help hospital managers to provide effective leadership.
The IPGA model includes the following six steps:
Step 1: Collect nurses’ perceptions of importance and hospital performance for all 18 forces of magnetism.
Step 2: Calculate the average value of importance of each item (
), the average value of performance of each item (
), the average value of importance of all items (
), and the average value of performance of all items (
).
Step 3: Use paired sample t-tests to determine whether the gap between perception and performance for each item of the 18 forces of magnetism was a positive gap (performance > importance), negative gap (performance < importance) or no gap (performance = importance).
Step 4: Compute the relative importance (RI) and relative performance (RP), RI =
. Determine if
and the t-test was significant, RP(j) =
., if 
and the t-test was significant, RP(j) =
, or if 
or 
and the t-test was non-significant, RP(j) = 0.
Step 5: Draw the IPGA strategic matrix (Figure 1), where relative importance (nurses’ perceptions of importance) is the vertical axis and relative performance (hospital service) is the horizontal axis, and the intersec-
Figure 1. Results of importance-performance gap analysis model.
tion is fixed at (0,1). The IPGA grid represents the different strategies for resource allocation and management, as illustrated below:
1) Quadrant I is composed of high relative performance and high relative importance items and corresponds to “Keep up the good work”’.
2) Quadrant II is composed of low relative performance and high relative importance items, and corresponds to “Concentrate here”. A point farther away from coordinate (0,1) indicates a greater need for improvement.
3) Quadrant III is composed of low relative performance and low relative importance items, and corresponds to “Low priority”.
4) Quadrant IV is composed of high relative performance and low relative importance items, and corresponds to “Possible overkill”. A point farther away from co-ordinate (0,1) indicates a greater need to re-allocate resources; and Step 6: Determine the priorities for resource allocation for the items in Quadrant II.
The distance D(j) indicates the degree of priority for improvement:
3. RESULTS
3.1. Study Participant Characteristics
Among the 436 participants, 45.2% worked in a public hospital and 54.8% in a private hospital; 98.8% were women. Those aged 25 - 34 accounted for 60.7%. Being single accounted for 51.8% and being married for 48.2%; 50.2% had Bachelor’s degrees. Salaries of 40,001 - 50,000 NTD were the majority (45%), followed by 30,001 - 40,000 NTD (40.7%). Twelve or more years of experience accounted for 30.9%, and 66.5% worked on internal and surgical wards. A rotating shift was the majority (57.3%) type of work. Clinical ladders N1 and N2 accounted for 28.5% and 38.7% respectively (Table 1).
3.2. Key Forces of Magnetism Influencing Nursing Practice
For the18 forces of magnetism perceived as important and hospital performance as seen by nurses, Cronbach’s α were all >0.9. The rankings are shown in Table 2. The mean values of the nurses’ perceptions of importance for all 18 forces of magnetism were above 4.26. These forces were critical factors influencing nursing practice, especially salary structure, welfare, and manpower deployment. They were also associated with lower hospital performance as perceived by the nurses.
3.3. Priorities Determined by the IPGA Model
The 18 forces of magnetism had a statistically significant (P < 0.05) gap (Table 3). According to the IPGA model, 8 forces of magnetism in Quadrant II needed urgent improvement (Figure 1). The first priority was salary structure, the second was welfare, and the third was manpower deployment. Other priorities in sequence were flexible scheduling, handling nurse-patient disputes, clinical teachers’ attitudes, the Nurse-patient relationships and management style.
Table 1. Nurses characteristics and hospital attributes.
| |
n |
% |
|
n |
% |
|
n |
% |
| Hospital |
|
|
Education |
|
|
Clinical ladder |
|
|
| Public |
197 |
45.2 |
|
216 |
49.8 |
N |
51 |
11.8 |
| Private |
239 |
54.8 |
≥Bachelor |
218 |
50.2 |
N1 |
123 |
28.5 |
| Gender |
|
|
Salary(NT) |
|
|
N2 |
167 |
38.7 |
| Female |
431 |
98.9 |
30,001 - 40,000 |
174 |
40.7 |
≥N3 |
91 |
21.1 |
| Male |
5 |
1.1 |
40,001 - 50,000 |
192 |
45 |
Work setting |
|
|
| Age |
|
|
50,001 - 60,000 |
47 |
11 |
Emergency |
54 |
12.4 |
| ≤24 |
48 |
11.4 |
≥60,001 |
14 |
3.3 |
ICU |
92 |
21.1 |
| 25 - 29 |
121 |
28.7 |
Experience |
|
|
Internal Medicine |
163 |
37.5 |
| 30 - 34 |
135 |
32 |
≤3 |
82 |
18.9 |
Surgery |
126 |
29 |
| 35 - 39 |
74 |
17.5 |
4 - 6 |
79 |
18.2 |
Work shift |
|
|
| ≥40 |
44 |
10.4 |
7 - 9 |
70 |
16.1 |
rotating shift |
239 |
57.3 |
| Marital |
|
|
10 - 12 |
68 |
15.7 |
Evening/ night shift |
78 |
18.7 |
| Single |
216 |
51.8 |
≥13 |
134 |
30.9 |
day shift |
100 |
24 |
| Married |
203 |
48.2 |
|
|
|
|
|
|
Table 2. Key forces of magnetism influence nursing practice.