NUR 8320 Module 3 Work Environment Paper: The Practice Environment Scale, Magnet Outcomes and an Improvement Plan Example

Fourteen Percent Lower Odds of Death: Measuring and Improving the Nursing Work Environment at a Somerville Hospital

Student Name

Doctor of Nursing Practice, Thomas Edison State University

NUR-8320: Organizational and Systems Leadership I

Mentor Name

Month Day, Year

Fourteen Percent Lower Odds of Death: Measuring and Improving the Nursing Work Environment at a Somerville Hospital

The Starting Point

The Somerville hospital here is fictional, a 290-bed community hospital that has never pursued Magnet recognition. Its nurses describe good teamwork on most units but say they have little voice in decisions, too few nurses on some shifts and managers who are stretched thin. The board has asked the DNP-prepared chief nursing officer whether pursuing Magnet recognition is worth the cost and effort, and how to improve the work environment either way.

Some data already point to the problem. Last year 19 percent of registered nurses left, and exit interviews mention lack of voice and short staffing more than pay. The hospital has no shared governance structure; nursing policy is written by the education department and approved by directors. Only 41 percent of the nurses hold a bachelor's degree, and 12 percent hold a specialty certification. The chief nursing officer sees these facts as connected, because the research on Magnet hospitals links outcomes to education, certification and nurses' voice as well as to staffing.

Measuring the Environment

Lake (2002) built her practice environment scale, drawn from the older Nursing Work Index, out of items that describe how the first Magnet hospitals were organized. Using data from nurses in 16 Magnet hospitals in the mid-1980s, she identified five subscales: nurse participation in hospital affairs, the foundations nursing lays for quality care, the ability of nurse managers, leadership that supports nurses, enough staff and resources, and good working relations between nurses and physicians. All were highly reliable at the nurse and hospital level, and its validity was backed by higher scores from nurses working in Magnet hospitals. Later analyses of contemporary data confirmed the structure.

The hospital surveys its 820 registered nurses with the scale; 61 percent respond. Scores are favorable for nurse-physician relations and nursing foundations for quality but unfavorable for participation in hospital affairs and staffing and resource adequacy, and mixed for manager ability, with large differences between units.

Do Magnet Hospitals Have Better Outcomes?

McHugh et al. (2013) joined three kinds of records (patients, nurses and hospitals) for 56 hospitals with Magnet status and 508 without it. The Magnet group offered better work environments and employed more nurses holding a bachelor's degree or specialty certification, and much of the gap in outcomes traced back to those nursing differences. Even after accounting for nursing factors and hospital and patient differences, surgical patients treated at Magnet hospitals had odds of death 14 percent lower and 12 percent lower odds of failure to rescue, though the latter difference was of borderline significance.

Kutney-Lee et al. (2015) used a panel design to follow 136 Pennsylvania hospitals over time, 11 of which gained Magnet recognition during the study. The hospitals gaining recognition improved their work environments more than others, and their 30-day surgical mortality improved by an extra 2.4 per 1,000 patients, with failure to rescue improving by an extra 6.1 per 1,000. Nurse-reported quality and nurse outcomes improved more as well. Because it followed changes within hospitals, this study provides stronger evidence than a single snapshot, though it is still observational.

Magnet or Not?

The paper presents the board with two paths. The Magnet journey requires an application fee, data collection, a nurse-sensitive indicator benchmarking program, a coordinator and several years of work. Its value lies less in the designation than in the improvements it requires. The alternative is to adopt the same improvements without seeking recognition, using the Practice Environment Scale to track progress. The paper recommends beginning the improvements now and deciding on formal recognition in two years, once progress is visible.

The Improvement Plan

The plan targets the weakest subscales. To raise participation, a shared governance structure is created, with unit practice councils and a hospital nursing practice council whose chair sits on the hospital's quality committee and whose recommendations receive a written response from leaders. To improve staffing and resources, the paper links to the hospital's staffing budget work and adds a float pool to cover call-outs. To strengthen manager ability, managers with low unit scores receive coaching, and span of control is reviewed so that no manager oversees more than about 70 staff. To build on strengths, the hospital supports bachelor's degree completion and specialty certification with tuition support and paid exam fees, factors linked with Magnet outcomes.

The plan also sets a timeline the board can follow. In the first six months, unit practice councils start on four pilot units and the float pool is funded. By the end of the first year, every unit has a council, the nursing practice council meets monthly, and manager spans are adjusted on the three largest units. In the second year, tuition support and certification incentives reach their full scale, and the Practice Environment Scale is repeated. The board will then have two years of data to decide whether to pursue formal Magnet recognition.

Costs are presented plainly. Shared governance requires paid time for council members, about $180,000 a year, and tuition support and certification incentives add about $250,000. These are set against turnover costs, which ran above $2 million last year.

Recognition itself would add an application fee and a coordinator's salary.

Measures

The Practice Environment Scale will be repeated every two years, with unit-level results shared with managers and councils. The hospital will also track nurse turnover, the share of nurses with bachelor's degrees and certification, surgical mortality and failure to rescue, falls and pressure injuries.

Conclusion

The Practice Environment Scale shows that this hospital's nurses value their relationships with physicians and the foundations of quality but lack a voice in decisions and adequate staffing. Studies of Magnet hospitals and of hospitals gaining recognition link better work environments with lower surgical mortality. The plan begins improvements now, through shared governance, staffing, manager support and education, and leaves the decision on formal recognition for two years, when progress can be judged.

References

Kutney-Lee, A., Stimpfel, A. W., Sloane, D. M., Cimiotti, J. P., Quinn, L. W., & Aiken, L. H. (2015). Changes in patient and nurse outcomes associated with magnet hospital recognition. Medical Care, 53(6), 550-557. https://doi.org/10.1097/MLR.0000000000000355

Lake, E. T. (2002). Development of the practice environment scale of the Nursing Work Index. Research in Nursing & Health, 25(3), 176-188. https://doi.org/10.1002/nur.10032

McHugh, M. D., Kelly, L. A., Smith, H. L., Wu, E. S., Vanak, J. M., & Aiken, L. H. (2013). Lower mortality in magnet hospitals. Medical Care, 51(5), 382-388. https://doi.org/10.1097/MLR.0b013e3182726cc5