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14 Mar

Benchmarking Nurse Outcomes in Australian… | Good Grade Guarantee!

Positive reports of nursing-related outcomes such as quality nursing care, nursing engagement with work and good practice environment are crucial in attaining and maintaining Magnet® designation. The majority of Magnet®-designated organisations (N = 482) are in the USA, with their aggregate nursing outcomes widely published as benchmark data. Australian Magnet® outcomes have not been aggregated or ublished to date.
Methods: The aims are to benchmark educational preparation, occupational burnout, job satisfaction, intention to leave and working environment of nurses in Australian Magnet®-designated facilities and to determine the reliability of the Practice Environment Scale-Australia. The design is a cross-sectional multisite survey set in all three Australian Magnet®-designated organisations. The demographics included age, gender, level of education, years in practice, level of seniority and position title.Two items measured job satisfaction and intent to stay in current employment. The Maslach Burnout Inventory explored the three domains of nursing engagement: depersonalisation, personal achievement and emotional exhaustion. The Australian version of the Practice Environment Scale interrogated participants’ perceptions of their work environments.
Results: 2004 nurses participated (response rate 45.9%). Respondents’ mean age was 39.2 years (range 20–72). They were predominantly female and had worked in their current facility for more than 5 years. Eighty five percent had a minimum of a Bachelor’s degree. Eighty-six percent of respondents were satisfied or very satisfied with their current position. Eighty eight percent had no intention of leaving their current employer within the next 12 months. Participants rated their hospitals highly in all domains of the practice environment. Respondents reported less burnout in the personal accomplishment and depersonalisation domains than in the emotional exhaustion domain, in which they reported average levels of burnout. The internal consistency of the Practice Environment Scale- Australia was confirmed in this sample (Cronbach α’s 0.87–0.9 for subscales and 0.89 for composite score).
Conclusion: In this paper, we present nursing outcome data from all Australian Magnet® hospitals for the first time. This provides a benchmark that facilitates comparison with nursing outcomes published by Australian non-Magnet®hospitals and with international Magnet® organisations. Keywords: Magnet®, Nursing outcomes, Job satisfaction, Burnout, Practice environment
Background:-Magnet® designation is conferred by the American Nurses’ Credentialing Centre (ANCC). Amongst other things, Magnet ® designation indicates that a health service satisfies the ANCC’s criteria for nursing outcomes. Three important nursing outcomes are the capacity to attract and retain nurses who practise to the highest standards (which includes appropriate educational preparation), a high level of nursing engagement, and nurses’ perceptions of a good practice environment [1, 2]. Positive reports of these outcomes in American Magnet® hospitals are well documented[3]. In this paper, we present nursing outcome data from all Australian Magnet® hospitals for the first time. While the critical mass of 482 [1] Magnet®-designatedfacilities is in the United States of America (US), Magnet ® recognition is also sought internationally. Eight non-US hospitals currently hold Magnet® designation, three of which are Australian. The Australian hospitals comprise two government-funded ‘public’ facilities in Brisbane and Perth, and one ‘private’, not-for-profit hospitalin Sydney.
Decades of work by the ANCC and affiliated researchers has led to considerable standardisation in how nursing outcomes are defined and assessed for designationand research purposes [3, 4]. Most research in this field assesses nurses’ educational preparation for practice, their job satisfaction and intention to remain in current employment, levels of burnout and perceptions of the quality of the nursing practice environment. This standardisation has facilitated comparison and benchmarkingof these nursing outcomes across different US Magnet® settings [3, 4].
The nursing practice environment:-The nursing practice environment in Magnet® studies is usually defined as the organisational characteristics of a work setting that facilitate or impede professional nursing practice [5]. A good practice environment is distinguished by productive relationships between nurses, doctors, allied health and ancillary staff; meaningfulnursing involvement in hospital affairs and devolved decision-making; hospital management that strives to continually improve the quality of patient care and responds to the concerns of nurses involved in that care; and investment in nursing professional development [6]. In Magnet® settings these factors are usually assessedwith the Practice Environment Scale of the Nursing Work Index (PES-NWI). The US version of the PESNWI is considered a valid and reliable instrument, with internal consistency coefficients originally reported for its five subscales as ranging from α = 0.71 (i.e., acceptable) to 0.85 (i.e., good) [5, 6] in the US. A recent study in Japan(N = 1219 PES respondents) indicates international reliability (Cronbach’s α ranging from 0.78 to 0.86 for subscales and 0.79 for the composite score) [7]. The 30-item Australian version (the PES-AUS) has one less item than the PES used in the US and elsewhere. Nursing diagnosis, which is part of the subscale ‘Nursing foundationsfor quality care’, is not included in the PES-AUS as nursing diagnoses are rarely, if ever, used in the Australian setting [8]. While the reliability coefficients of the PES-AUSwere not reported by the modifiers of the instrument [8], the reliability of the original 31-item PES in Australia was reported in a study of 1192 nurses in the state of Queensland (composite score Cronbach’s α = 0.948; domain α range 0.705 to 0.892) [9]. This is problematic, because the Queensland study included the ‘nursing diagnosis’ item that is not used in any Magnet® facility in Australia. Hence the reliability of the PES-AUS commonly used by Australian Magnet® hospitals is not known.
Nursing engagement: job satisfaction, turnover and burnout Magnet® designation also indicates that nursing staff are engaged with their work. Engagement has three aspects. First engaged nurses’ express satisfaction with what they do. According to the ANCC [10], the high satisfaction of Magnet® nurses informs the second factor: engaged nurses intend to keep working at their facility. The combined effect of job satisfaction and intention to continue working with an organisation is low nursing turnover and high nursing retention. A third factor that mediates job satisfaction and nursing retention is level of nursing burnout [2]. Occupational burnout is defined as a prolonged response to chronic work-related stressors [11]. Its three hallmarks are emotional exhaustion (feelings of being emotionally overextended and fatigued by one’s work); depersonalisation (an unfeeling and impersonal response towardsthe recipients of one’s care) and reduced personal accomplishment (the sense of competence and successful achievement) in individuals who work with other people[11]. In Magnet® studies, burnout is usually measured with the emotional exhaustion subscale of the Malachi Burnout Inventory-Human Service Survey (MBIHSS)[12]. The validity and reliability of the MBIHSS is internationally recognised [11].The use of similar methods to define and assess critical Magnet® nurse outcomes has enabled pooling and benchmarking of Magnet® data in the US [3]. For example,the most recent aggregate report (published in 2011) indicated that compared to nurses employed in non-Magnet® facilities (n = 21,714), Magnet®-employed nurses (n = 4562) reported superior practice environments (p < 0.001), were more highly educated (p < 0.001), expressed less dissatisfaction with their employment (p < 0.05) and reported less emotional exhaustion (p < 0.05) [3]. It is timely to replicate US work on nursing
outcomes. This would provide a useful internationalcomparison with previously-published US Magnet® data,as well as a benchmark for any other Australian facilitiesconsidering the Magnet® journey.Aim of the studyThe primary aim of this study was to provide a benchmarkfor educational preparation for practice, occupationalburnout, job satisfaction, intention to leave andthe hospital working environment in Magnet®-designatedfacilities in Australia. The secondary aim was to determinethe reliability of the Practice Environment Scale-Australia (PES-AUS).Research designThis was a cross-sectional study undertaken in all threeMagnet®-designated hospitals in Australia.SampleAll full-time or part-time registered nurses employed inthe three Australian Magnet®-designated hospitals wereeligible to participate. Magnet® designation is predicatedon the outcomes of registered nurses involved in patientcare and who have the security of longer-term employment.Therefore, nurses on casual contracts, Directors ofNursing and non-registered nurses (e.g., enrolled nurses,assistant nurses, and licensed vocational nurses) were excluded.There were 4368 registered nurses meeting thesecriteria when the study was undertaken. While we aimedto maximise response rates, this was an exploratory studyand as such, sample size calculations were not indicated.MeasuresDemographicsDemographics included age, gender, grade (type and seniority)of position held, highest nursing qualificationobtained and years of employment in the current facility.Nursing practice environmentThe PES-AUS consists of 30 items that assess five domains.Each item asks participants to rate whether certainorganisational characteristics are present using a 4-pointLikert scale (1 = strongly disagree, 2 = somewhat disagree,3 = somewhat agree, 4 = strongly agree). The ‘Nurse participationin hospital affairs’ subscale of nine items interrogatesperceptions of nurses’ involvement in policydecisions, the access and visibility of senior nurses andcareer opportunities in the organisation. The nine items inthe ‘Nursing foundations for quality of care’ subscale examinesparticipants’ opportunities for continuing educationand whether the organisation’s nursing standards arebased on a defined model of care. The ‘Nursing unit managerability, leadership and support of nurses’ subscale(five items) explores the degree to which senior nursesprovide good leadership and a supportive work environmentand recognise the achievements of their nurses. Thefourth subscale (‘staffing resources adequacy’) elicits viewsof nurse-patient ratios, and time allocation for patient careand peer communication. The fifth subscale (‘collegialnurse-doctor relations’) seeks participants’ perceptions ofthe quality of nursing-medical teamwork in the organisation.Subscale scores are calculated by averaging individualresponses to each item, while the overall score is calculatedby averaging the five subscales.Occupational burnoutOccupational burnout was measured with the 22 itemMBIHSS. Respondents indicated on a 7-point Likert scale(0 = never, 1 = a few times a year, 2 = once a month or less,3 = a few times a month, 4 = once a week, 5 = a few timesa week, 6 = every day) the frequency with which they experiencedcertain feelings. The subscales of emotional exhaustion(nine items), depersonalisation (five items) andpersonal accomplishment (eight items) are not combinedto report a composite score; rather, burnout is conceptualisedas a continuous variable ranging from low to moderatedegrees of the reported feeling. A high degree ofburnout is reflected in higher scores on the emotional exhaustionand depersonalisation subscales, and low scoreson the personal accomplishment scale [12]. An averagedegree of burnout is mirrored in average scores in all threesubscales, while a low degree of burnout is reflected inlow scores for the emotional exhaustion and depersonalisationsubscales and high scores on the personal accomplishmentsubscale [11].Job satisfaction and intention to leaveFollowing common practice in Magnet® studies [2], and tofacilitate potential later pooling of data, job satisfactionwas measured with one item. This asked participants toindicate how satisfied they were with their job on a 4-point Likert scale (very dissatisfied, somewhat dissatisfied,somewhat satisfied and very satisfied). Similarly, the finalitem (‘do you plan to leave your current employer in thenext 12 months) offered two choices: ‘Yes, within the nextyear’ and ‘No plans within the next year’.ProcedurePrior to undertaking the study, the Executive Directorsof Nursing (EDNS) of the three hospitals agreed thattheir staff could be approached to participate in thestudy. Human research ethics approval was obtainedfrom each study site and the project team’s university.The study leads and project officer regularly discussedstudy progress with the Magnet® managers and researchproject staff at each site, to ensure consistency of studyprocedures and governance.Stone et al. BMC Nursing (2019) 18:62 Page 3 of 11The Magnet® manager or research staff at each of thethree sites sent an email to all eligible registered nursesthrough their human resource management system. Theemail contained a link to the online survey that invitedeligible nurses to participate, described the purpose ofthe research and the requirements involved in completingthe survey. Survey administration, which was undertakenelectronically through Survey Monkey Inc., wasstaggered between July and November 2016, with eachsite undertaking data collection for 6 weeks. Due to differenthuman resource management systems, each sitemanaged their own recruitment and administered thesurvey through separate Survey Monkey Inc. platforms.Completion of the survey implied consent. To enablefollow up of participants, all potential participants wereassigned a unique identifier code, the coding key forwhich was kept by the site-specific project officer in asecure location.A reasonable window of opportunity enabled the participantsto complete the survey, after which reminderemails were sent at regular intervals to improve responserates [13]. To maximise response rates and encourage asense of competition, each site collated their unitspecificaggregate response rates each week and filteredthem down to staff through hospital-appropriate channelsfor encouragement. All respondents were enteredinto a ‘lucky draw’, with 5 respondents from each hospital(N = 15) winning two movie vouchers.Data analysisData from each site were cleaned and harmonised by twoproject staff. The disparate nursing position titles fromeach State were harmonised into the four Queenslandbands of Grade 5 (base grade registered nurse), Grade 6(nurse recognised for more advanced specialty skills),Grade 7 (an advanced practice nurse such as a clinicalnurse consultant, nurse researcher, nurse educator ornurse unit manager) and Grade 8 (nurse practitioner).Analysis was performed using Stata v.15. For descriptivestatistics, categorical variables are presented as counts andpercentages and continuous variables are presented usingmeans and standard deviation. Logistic regression examinedpotential associations of age (continuous), genderand nursing classification with job dissatisfaction (very/somewhat dissatisfied versus somewhat/very satisfied), intentto leave in the next 12 months and high levels ofburnout. High burnout was defined according to MBIHSSdomains as high (vs. low/moderate) emotional exhaustionor depersonalisation, and low (vs. moderate/high) personalachievement. Models were adjusted for age, gender, nursingclassification and each site in order to take account ofhospital-level differences. The internal validity of PESAUSscores was assessed using Cronbach’s α, where values0.7 are taken as acceptable indicators of scale reliability.Logistic regression examined associations between thePES-AUS scores and job dissatisfaction, intention to leaveand high levels of nurse burnout, with models adjusted forhospital site, age, gender and nursing grade. Completecase analysis was used throughout, such that the numbersincluded differ in each analysis. Results are presented asodds ratios (ORs) and 95% confidence intervals (95% CIs)in table or figure format.
ResultsMost questions were optional; hence the data representthose nurses who chose to respond to a particular question.A total of 2004 nurses meeting the inclusion criteriaresponded to the survey request, equating to aresponse rate of 45.9%. Table 1, which profiles thedemographic characteristics of respondents, indicates amean age of 39.2 years (range 20–72). The sample compriseda predominantly female workforce who hadworked in their current facility for more than 5 years.Most (85.2%) had a minimum of a Bachelor’s degree.The demographics of this sample were consistent withthose of the national nursing workforce [14], except forage. The mean age of the Australian nurse was 44.5 yearswhile the mean age of the Magnet sample was 39.2 years(range 20–72) [14].
Job satisfaction and intent to leaveMost respondents (n = 1621, 80.9%) to the item concerningjob satisfaction were satisfied with their current position(4.8% very dissatisfied, 9.4% somewhat dissatisfied,48.4% satisfied and 37.4% very satisfied). However, 383(19.1%) nurses did not respond to the question around jobdissatisfaction, and these nurses were 3 years older onaverage (mean difference = 2.9 years, 95% CI 1.6 to 4.2, ttestp-value< 0.001). In addition, a significantly higherproportion of female (19.9% vs. 13.8% vs of male nurses,p = 0.04) and grade 7–8 (33.3% vs. 16.5% of grade 5–6nurses, p < 0.001) nurses did not respond to questionsaround job satisfaction. Of the 1983 participants (98.9%)who responded to the item asking whether they plannedto leave their current employer in the next 12 months,11.8% responded ‘yes’ compared to 88.2% responded ‘no’.
Nursing burnoutAs all questions in this survey were optional, the totalnumber of respondents for each of the MBIHSS domainswas not the same. At least one of the three MBIHSS subscaleswas available for 260 nurses (13.0%), with 1525nurses (76.1%) answering all MBIHSS questions. Therewere no age or gender differences in those not respondingto questions relating to MBIHSS. Figure 1 indicates respondentsreported approximately equal perceptions oflow (34.7%), moderate (30.0%) and high (35.4%) levels ofemotional exhaustion; the majority reported low (68.3%)Stone et al. BMC Nursing (2019) 18:62 Page 4 of 11levels of depersonalisation, and the majority reported high(44.3%) levels of personal accomplishment.Association of demographic factors with jobdissatisfaction, intent to stay and nursing burnoutTable 2 presents results from the logistic regressionmodels that explored the potential associations betweenrespondents’ age, gender and grade with job dissatisfaction,intent to leave and levels of job-related burnout.For each 10-year increase in age, respondents were 16%more likely to report job dissatisfaction, but were 21%less likely to express an intention to leave within 12months. A 10-year increase in age was also associatedwith a 23% decrease in the odds of having reported highlevels of emotional exhaustion and a 32% decrease in theodds of reporting high levels of depersonalisation. Therewas no association between respondents’ age and theirreported levels of personal accomplishment. Gender wasnot associated with job dissatisfaction or intention toleave, although male nurses were 67% more likely to reporthigh levels of emotional exhaustion and had aroundtwice the odds of high levels of depersonalisation andlow levels of personal achievement. Grade 7–8 nurseswere less likely to express an intention to leave and reported lower levels of burnout (for all three domains)compared to Grade 5–6 nurses. However, after additionallyadjusting for age and gender, associations betweennursing grade and intention to leave, emotional exhaustionand depersonalisation were not statistically significant.Grade 7–8 nurses were 48% less likely to reportlow levels of personal accomplishment than lower gradenurses.
The nursing practice environmentAs indicated in Table 3, respondents rated their hospitalshighly in all domains of the practice environmentand overall. The composite PES-AUS scale was calculatedfor the 1761 nurses (91.8%) who responded to allPES-AUS-related questions. The internal consistency ofthe PES-AUS was confirmed in this sample, with highCronbach α’s, in the range 0.87–0.9 for all subscales and0.89 for the composite score.Figure 2 indicates that higher scores on the five PESAUSsubscales and the composite scale were consistentlyand strongly associated with lower levels of job dissatisfaction,less intention to leave and less job-related burnout(p < 0.001 for all models). Odds ratios for theseassociations ranged from 0.2 to 0.6, representing 40–80% lower odds of job dissatisfaction, intention to leaveand burnout for each one-unit increase in the mean forthe PES scale included in that model.
DiscussionMagnet® hospital recognition is often (but not always)associated in the literature with lower nurse turnover,less nurse burnout, greater job satisfaction, more advancedpreparation for practice and a better working environmentthan non-Magnet® facilities [2, 3]. The resultsof this study provide a benchmark for these outcomes inthe Australian Magnet® setting. The results also confirmthat the PES-AUS measures those aspects of the practicesetting that it purports to measure.
Educational preparation for practiceMagnet® status indicates that the organisation encouragesand enables its nurses to undertake education anddevelopment through every stage of their career. Tomeet the Magnet® standards, this means that nurses areeducationally-prepared to practise. The standards stipulatethat 100% of unit-based nurse managers and thehospital-wide nursing executive must have a minimumof a Bachelor’s degree; that the Executive Director ofNursing has a minimum of a Master’s degree; and thatthe credentialing rate of nurses working in advanced orspecialty roles increases annually. The majority (85%) ofrespondents, including the large proportion of basegraderegistered nurses, held a minimum of a Bachelor’sdegree. This result was anticipated. Hospital-based educationwas phased out in Australia 30 years ago, withuniversity education the only mechanism leading toregistration since the early 1990s. Given the mean age ofthe Australian Magnet cohort (39.18 years) it would beexpected that most participants would hold a minimumof a baccalaureate degree. Nearly a third (32.3%) of respondentsheld a postgraduate qualification, but thesedata are more difficult to interpret. They cannot be comparedto international Magnet® data, or to non-Magnethospital data in Australia, for two reasons.First, the educational preparation of its registrants isnot recorded by the Australian national nurse registeringbody; hence it is impossible to estimate how many practisingnurses in Australia possess post-basic qualificationsfor comparison. Second, even when it is attainable,it is difficult to compare Australian post-basic data withdata from international Magnet® hospitals, the majorityof which are in the US. The Australian QualificationsFramework differs markedly from the US postregistrationstructure, which inhibits the ability to compareperformance in postgraduate qualifications. Forexample, specialty ‘credentialing’ is largely an Americanconcept. It is not a term widely-used in Australia, it isnot a requirement for career advancement nor is it regulatedby a professional nursing organisation. The exceptionsare nurse practitioners and mental health nurses,whose post-registration education is regulated and whoare ‘endorsed’ rather than credentialed. In essence, it isAustralian universities (not professional or nursing regulatorybodies) that confer specialty qualifications in areaslike intensive care and oncology nursing and unlike theUS, these qualifications do not require annual updating.Comparing postgraduate qualifications and credentials istherefore not possible.

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