- Drenkard, Karen PhD, RN, NEA-BC, FAAN
The author describes the role of the chief nurse executive in delivering a business case for the Journey to Magnet Excellence(TM). Calculating a return on investment provides clear measurement of benefits of the credential and can be used to evaluate upfront resources that result in a longer-term gain. The range of cost savings that can possibly be achieved for a typical 500-bed hospital is presented. Although not every hospital will achieve the level of performance implied by the national assumptions, securing only a modicum of the potential level of cost improvement will ensure a multifold return on the investment required.
One of the important responsibilities of a chief nurse executive (CNE) is to share information with the rest of the executive team about programs and efforts that are beneficial to the delivery of patient care. This includes securing the support of the chief executive officer and others at the executive level. When a financial investment is required, stating a strong and convincing case is a key strategy for engaging the executive decision makers, including the chief financial officer. In the case of a decision to pursue Magnet(R) status, the support of the entire executive team is a necessity. In 2008, a new Magnet model was developed based on scholarly review and statistical analysis.1
The new Magnet model offers a framework for organizing a nursing services division (Figure 1). Magnet status is not a prize or an award; it is a credential of organizational recognition of nursing excellence. The process requires organizations to develop, disseminate, and enculturate evidence-based criteria that result in a positive work environment for nurses and, by extension, all employees. It is a multiyear commitment and requires the full support of the leadership team, the hospital health care organization's administration, and the board of directors.
|Figure 1. The Magnet model.|
History of Magnet Recognition Program(R)
During the nursing shortage of the 1980s, a group of insightful nurse researchers took a unique approach to understanding the shortage of that decade. They led a nationwide research study, commissioned by the American Academy of Nursing, that investigated what was right with the hospital workplaces that had low RN vacancy and turnover rates, rather than spend time chronicling reasons why RNs left their jobs. This groundbreaking research was described in 1983 in the book, Magnet Hospitals: Attraction and Retention of Professional Nurses,2 and identified themes that were later called the forces of magnetism. This research base served as the foundation of the creation of the Magnet Recognition Program(R), a program of the American Nurses Credentialing Center. To date (2010), more than 370 domestic and international hospitals and healthcare organizations have met the sources of evidence for nursing excellence and are recognized as Magnet hospitals.
Why Consider Magnet as a Framework for Nursing Services?
The Magnet Recognition Program is used by many CNEs as a road map for excellence in nursing services and can serve as a framework for organizing a hospital nursing delivery system. This article articulates the steps for development of a business case for Magnet recognition to obtain organizational support. The article also presents the research and financial evidence to build and present the "case" for embarking on the Magnet journey.
What Is a Business Case?
The business case is a proposal that can assist an organization or executive in presenting the reasoning for beginning a change project or group of tasks. The evaluative nature of a business case assists in the decision to "go or not to go" with a specific initiative, as well as evaluation of one decision or project against others. In the case of seeking Magnet recognition, the CNE can present organizational change, business, and financial implications and benefits in a formal presentation that all members of the executive team can understand. This helps to begin the process of acquiring support and serves as a milestone in the Magnet process for approval and sponsorship of the executive team and the board of directors.
Weaver and Sorrell-Jones3 describe the business case as a strategic tool for change and encourage the development of the business case as a key tactic in determining choices among multiple options, especially in tough economic times. They describe 5 key information areas that need to be covered in the business plan including degree of strategic fit, program objectives, review of options, affordability, and achievability.3(p415) Measurements for addressing key milestones as a way to measure progress should be developed and included. In addition, the business case should answer the question: "How will this effort solve the issues we face?"
The business case includes the reason for the project, the expected business results and benefits, and the costs and the risks. The case serves as a way to capture knowledge, functions as a basis for receiving funding and approval, helps prioritize the project against other competing initiatives that might also require funding, and secures a consistent message to all key stakeholders in the process.4,5 Formal business cases can ensure that the investment has value and importance, that the project will be properly managed, that there is capability to deliver, that the program or project is adequately resourced, and that the project has the long-term support required for success.6,7
Building the Business Case for Magnet
The business case should include the purpose statement and the value added of embarking on the initiative. In this case, why would your hospital commit to the Journey to Magnet Excellence? Linking the purpose of the initiative to the mission of the organization is an effective way to align the decision to pursue Magnet with the needs of the patients and community. Within the framework of the organizations' strategic plan and the nursing services strategic plan, determining the degree of fit is critical. The CNE needs to strategically align the priorities of the organization with the framework for nursing excellence. Viewing nursing's contribution to the organization as a strategic differentiator of high-quality care is one perspective that the Magnet journey fully supports.
With nursing as the primary service that is provided in hospitals, having the recognition that your hospital's nursing services is in the top 5% to 10% of the nation's hospitals is a mark of excellence that has a strong value proposition for key stakeholders, including physicians and consumers. A growing body of research indicates that Magnet hospitals have higher percentages of satisfied RNs, lower RN turnover and vacancy, improved clinical outcomes, excellent nurse autonomy and decision-making capabilities, and improved patient satisfaction.8-20
Table 1 presents evidence related to return-on-investment opportunities. It displays some literature-based quality, service, cost, and human resource measures that are worth evaluating in organizations to determine if the Journey to Magnet Excellence could be a strategic driver toward improvement. Although costs and return on investment are important, they are not the only reason for deciding to pursue Magnet recognition. Often, having the multiyear framework for quality improvement efforts and a mechanism for engaging staff in decision making is a helpful tool for a new a helpful tool for a new CNE or CNEs looking for a way to energize and motivate their team. Team building, collaborating across disciplines, and building staff engagement are harder to quantify but are often results of the Magnet journey.
|Table 1. Return-on-Investment Opportunities: The Evidence.|
When building the business case, it is important to identify critical factors that will maximize success in reaching the end goal of obtaining Magnet status. Completing a Magnet gap analysis is a helpful first step and should be completed before the business case is presented to the board. Once the gap analysis has been analyzed, the CNE is in a better position to completely identify what resources and support will be needed to meet the Magnet program sources of evidence. In addition, the gap analysis will guide the timeline for completion of any areas that need strengthening. Critical success factors also inform a discussion of strategic risks that need to be shared with the executive team.
What, if any, are the downsides of pursuing Magnet status? How can the risk of failure be minimized? These will be different for each organization but include the willingness of the organization to engage in the Magnet journey as a peer-reviewed credentialing process with some degree of risk in the event that not all of the criteria are met. The achievement of Magnet status is a high bar, and the support of the entire executive team and the board is necessary.28,29 The executive leadership has a responsibility to ensure that Magnet status can be sustained over time. The business case should also include a high-level timeline, assigned accountability for the executive ownership of the work plan, and an implementation, communication, and evaluation plan for the monitoring of the progress toward achieving Magnet recognition.
The Literature Base of Evidence for Quality, Service, and Cost
One good way to build the case for pursuing Magnet designation is to provide the evidence base to the executive leadership. This selected review of the literature pertaining to Magnet status benefits gives CNEs an array of choices that can be linked to the needs of their organization. In addition, opportunities for cost savings can be identified by understanding the basis for improvement opportunities.
Increasingly, nursing is being recognized as having a major contribution to quality and safety in patient care.50,52,54 Decreased pressure ulcers and decreased falls have been linked to Magnet hospitals.40-42 Results of a cross-sectional design of hospitalized patients with hip fractures led to conclusions that, including Medicare beneficiaries, those who had received care for a hip fracture were less likely to develop a decubitus ulcer in a Magnet hospital.43 Other studies support the advantages of Magnet hospitals compared with non-Magnet hospitals related to skin integrity and the cost-saving opportunities of $43,180 per case.42,55,56
Another nurse-sensitive indicator that has been demonstrated as having lower rates in Magnet hospitals is patient falls. Multiple studies report fall rates in Magnet hospitals being 10.3% lower than in non-Magnet hospitals.49 Compared with the reported rates in general44,46-48,57 of 3.38 to 4.44 per 1,000 patient-days, savings can be determined based on the reduced frequency of patient falls in Magnet hospitals.
Recent studies have evaluated the linkages between the work environment for nurses and the patient safety climate.50-54 In these studies, overall Magnet hospital characteristics were significantly and positively related to a patient safety climate in the work setting. The combined effect of increased access to empowerment structures and Magnet hospital characteristics was significantly related to higher perceived safety climate.
The 2 compelling studies from the original Magnet research were conducted by nurse scientist Dr Linda Aiken. For the Medicare mortality study,38,39,58-65 characteristics of a Magnet environment were measured and associated with significantly better outcomes for mortality 30 days from admission. In addition, a significantly better outcome was determined for nurse safety, job burnout, and patient satisfaction.
Nurse Satisfaction and Patient Satisfaction
Magnet hospitals have a long history of positive nurse and work satisfaction linked to increased autonomy in practice, structural empowerment, participation in decision-making opportunities, and a positive work environment.34,36,37,66-69 Ulrich et al70 evaluated areas of work and the professional practice environment in a study of 735 RNs in Magnet and non-Magnet facilities. Their findings revealed that RNs in Magnet organizations reported higher satisfaction with their present job (85% very or somewhat satisfied) than did RNs who work in non-Magnet organizations (p < 0.05).
Cost Opportunities for Magnet Hospitals
Early work by Kramer and Schmalenberg71-73 found that outcomes were better in 2 areas in Magnet hospitals. These were high nurse job satisfaction as measured by "being a good place to work" and high-quality care as measured by being a "good place to practice nursing." In addition, the ability of these hospitals to recruit and retain nurses led to lower vacancy and turnover rates.
The study of Lacey et al18 examined the difference between nurses' scores (n = 3,337) on organizational support, workload, satisfaction, and intent to stay among Magnet, Magnet-aspiring, and non-Magnet hospitals. Magnet hospitals had better scores than non-Magnet hospitals, with an implication that Magnet hospital nurses were more likely to be retained than nurses working in non-Magnet hospitals.
Costs and benefits of reducing nurse turnover were identified by Jones and Gates21 in an attempt to develop a business case for nurse retention. The Advisory Board74 reports turnover costs of 1 RN at $42,000 to $64,000, depending on specialty area, because of costs of orientation and lost productivity. Turnover costs have been estimated to range between 0.75 and 2.0 times the salary of the departing RN22 and generally accepted at one times the costs of an RN salary.21 Nurse retention benefits identified by Jones and Gates21 and others75,76 include reduction in recruitment costs, reduction in orientation costs, productivity gains, decreased patient errors and improved quality of care, increased levels of trust and accountability, and deep organizational knowledge.
Historically, during economic downturns, the vacancy rates for RNs have traditionally dropped, but soon return to pre-recession levels once the economy returns. This is due to a "false impression that the shortage may be over, generating complacency in the industry."77 The Magnet recognition sources of evidence and structures and processes for nursing services support a positive work environment that historically contributes to lower RN vacancy rates. The current vacancy rate at Magnet hospitals as of October 2009 is 3.64%, with reported national vacancy averages in 2007 at 8.1% to 16%, depending on the specialty and the region of the country.78
Upenieks24 identified a cost-benefit equation based on the costs of Magnet designation and the offsetting costs of decreased nursing turnover. The decrease in agency utilization was calculated on a sample cost-benefit ratio of several 300-bed acute-care hospitals. With an assumption of the reduction of a range of 5 to 20 agency shifts per day at $40 to $60 per hour differential costs per day, the potential for cost savings was calculated at several million dollars in a 300-bed hospital.
Occupational Health Injuries: Needlestick Injuries, Musculoskeletal Injuries, and Blood and Body Fluid Exposures
Multiple studies9,25,27 report up to a one-third reduction in needlestick injuries in Magnet facilities at a cost of $405 per event. In testimony to the House Subcommittee on Workforce Protections Committee on Education and the Workforce, Dr Linda Rosenstock testified that a working ratio is 30 needlestick injuries per 100 hospital beds. The CDC reports 385,000 needlestick injuries per year,79 which equals an average of 67.5 per hospital. Occupational health injuries for musculoskeletal injuries and blood and body fluid exposures are also lower in hospitals with Magnet status.80,81 Costs per musculoskeletal injury ranged from $50,000 to $100,000 per injury per nurse. By determining the needlestick injury rates and musculoskeletal injuries before or while on the Magnet journey and tracking rates, a cost-benefit can be determined for the hospital based on lower rates in Magnet hospitals.
There is growing evidence that Magnet hospitals have lower rates of patient falls than non-Magnet hospitals.44-49 Hines and Yu55 described a cost per hospitalization for patient falls of $33,894. They described the number of preventable injuries in the United States for fiscal year 2007 of 193,566 falls. Unruh82 estimates costs per fall at a range of $1,019 to $4,235 per case, with a rate of 3.73 falls per 1,000 patient-days. Magnet hospitals have a reported 10.3% lower fall rates.
Several studies have linked Magnet hospitals to decreased pressure ulcer rates.41-43 Mills83 also reported lower decubitus ulcer rates among adult, medical-surgical patients in Magnet versus non-Magnet hospitals in a 2008 study. Hines and Yu55 report that the number of cases of pressure ulcer stages 3 and 4 in the United States is at 257,412 annually. This would average 51.5 cases per hospital. Magnet hospitals have an improved rate of 5%, which would equal an average of 2.5 fewer cases. A daily cost for medical and surgical patients was estimated at $5,177.84
Marketing Return on Investment
An identified benefit of having Magnet status is the marketing opportunities that come to Magnet facilities with publications, presentations, and other opportunities for exposure at the national level. This replaces the costs of advertisements that might otherwise need to be bought at market rates. In a business case analysis completed by the James A. Haley Veteran's Hospital in 2004,85 the page rate was calculated at $10,000 per advertisement.
In addition to the research-based evidence, there are anecdotal and qualitative benefits to having Magnet status that may not be included in a cost-benefit analysis but do impact the overall health of an organization. Bond ratings and risk management assessments have included Magnet designation in their criteria, and US News and World Report added Magnet designation to its criteria for national best hospitals as a measure of quality and nursing excellence.86 There are reputational benefits of holding Magnet designation, too.
The Magnet Sources of Evidence
In addition to requirements that nurse satisfaction, patient satisfaction, and clinical outcome measures are above the midpoint of the benchmarking data points, there are Magnet sources of evidence that will capture improvements in quality and cost. There are at least 3 sources of evidence that encourage nurses to work on cost improvement. These are demonstrated in Table 2. A review of the actual examples of sources of evidence submitted to the Magnet Recognition Program from June 2009 to December 2009 reveals costs savings and improvements of $5,000 to $20,000 for each nurse-driven improvement project per year.
|Table 2. Sources of Evidence That Support Cost Improvements|
Overall Financial Return
There has been agreement in the literature that there is an overall financial return of Magnet designation.21,49,85,87-90 DeSilets and Pinkerton87 document the financial return on investment including improved retention and decreased turnover, improved satisfaction, improved quality and safety, increased customer attraction for hospital selection, and superior business results with a climb in operating margin from 4% to 16% due to investment in nursing services rather than cutting expenses of salaries and staffing levels. The ability to engage the staff in business and operational review of business outcomes resulted in the staff participating greatly in improved efficiency and effectiveness at the unit levels.91
Each project that results in cost savings, cost avoidance, or increased revenue should be well documented by the CNE and monitored and evaluated during the Magnet journey.92 The value of professional nursing was quantified by Dall et al84 and provided an economic value and monetary assessment of that value of nurse staffing that impacts patient care quality. Their evaluation concluded that adding RNs to the patient bedside would decrease hospital days and result in medical savings. The findings "strengthen the economic case for hospital investment in nursing."84(p104)
Determining the Return on Investment: Developing Your Business Case
Calculating a return on investment provides clear measurement of benefits of a program and can be used to evaluate programs that require upfront resources that result in a longer-term gain. It is an important part of a business case and can add information to the decision-making process.93 For the purposes of this exercise, a case-study approach is taken. Assumptions are made based on the evidence for quality, service, and cost returns. The case assumes a "typical" 500-bed hospital and compares average Magnet hospital characteristics and outcomes to national averages.
There are direct costs associated with the process of obtaining Magnet recognition status. For the purposes of this business case, the costs should be those that are over and above the normal costs for running a nursing care service within a hospital. These costs include Magnet application fees, appraiser fees, site visit costs, and document preparation. These direct costs range from $46,000 to $251,000, depending on bed size and resource decisions made by the organization. Each organization needs to determine what its resource needs are during the Magnet journey and determine total costs.
The Return on Investment
Table 3 provides assumptions of the difference between a 500-bed Magnet and non-Magnet hospital. Table 4 demonstrates potential capture of cost improvements in the areas of quality, service, and costs. Based on the literature of improvements in Magnet hospitals and using the data assumptions of a typical 500-bed hospital, cost opportunities and a potential return on investment can be determined for a hospital. The range of cost savings that can possibly be achieved for a typical 500-bed hospital is estimated between $2,308,350 and $2,323,350. Based on estimates of direct costs associated with achieving Magnet, which range from $46,00 to $251,000, the potential resulting return on investment is compelling. Although not every hospital will achieve the level of performance implied by the national assumptions, securing only a modicum of this level of improvement will ensure a multifold return on the investment required.
|Table 3. Assumptions About 500-Bed Magnet and Non-Magnet Hospitals|
|Table 4. Benefits of Magnet Status|
Presenting the Case: Summary
Weaver and Sorrell-Jones3 advocate preparing the business case to both present and persuade key leadership in the organization. This requires establishing the credibility of the CNE as a presenter, finding common ground about the goals that are being achieved by the organization, displaying compelling evidence, and connecting with the audience_ in this case, the executive team.3(p418)
Studies are increasingly adding to the evidence that link nursing care and nursing levels to the ability to improve patient care outcomes and decrease staff turnover.89 Understanding the data and being able to articulate the potential for a strong nursing service that results in decreased costs, improved productivity, and improved healthcare outcomes can influence the level of support for the process of participating in the Magnet Recognition Program. The CNE needs to develop and sharpen skills to speak directly to the business community and encourage its support in investing in nursing as a way to improve safety and quality in patient care.89
The CNE's responsibilities include articulating the value of nursing services within a context of excellence in patient care, safety and quality, and the professional development of staff. Magnet recognition is a framework and a model that has proven results in improving costs through increasing nursing satisfaction, patient satisfaction, and clinical outcomes.
1. Wolf G, Triolo P, Ponte PR. Magnet Recognition Program: the next generation. J Nurs Adm. 2008;38(4):200-204. [Context Link]
2. McClure M, Poulin M, Sovie M, Wandell M. Magnet Hospitals: Attraction and Retention of Professional Nurses. Kansas City, MO: American Nurses Association; 1983. [Context Link]
3. Weaver DJ, Sorrell-Jones J. The business case as a strategic tool for change. J Nurs Adm. 2007;37(9):414-419. [Context Link]
4. Business Case Toolkit. Available at http://www.prosci.com/tutorial-business-case-mod/html. Accessed January 9, 2010. [Context Link]
5. Business Case. Available at http://www.prosci.com/t3-toc.htm. Accessed January 9, 2010. [Context Link]
6. The Business Case. Available at http://www.valuedeliverymanagement.com. Accessed May 25, 2009. [Context Link]
7. How to refocus your projects into value. Available at http://www.valuedeliverymanagement.net/Portals/0/download/h2_ref_proj_onvalue.pd. Accessed May 25, 2009. [Context Link]
8. Aiken L, Havens D, Sloane D. The Magnet Services Recognition program: a comparison to 2 groups of Magnet hospitals. Am J Nurs. 2000;100(3):26-35. [Context Link]
9. Havens DS, Aiken LH. Shaping systems to promote desired outcomes: the Magnet hospital model. J Nurs Adm. 1999;29(2):14-20. [Context Link]
10. Kramer M. The Magnet hospitals: excellence revisited. J Nurs Adm. 1990;20(9):35-44. [Context Link]
11. Lashinger HK, Almost L, Tuer-Hodes D. Workplace empowerment and Magnet hospital characteristics: making the link. J Nurs Adm. 2003;33(7/8):410-422. [Context Link]
12. Scott JG, Sochalski J, Aiken L. Review of Magnet hospital research: findings and implications for professional nursing practice. J Nurs Adm. 1999;29(1):9-19. [Context Link]
13. Tigert JA, Laschinger HK. Critical care nurses' perceptions of workplace empowerment, Magnet hospital traits and mental health. Dynamics. 2004;15(4):19-23. [Context Link]
14. Aiken LH, Clarke SP, Sloane M. Effects of hospital care environment on patient mortality and nurses outcomes. J Nurs Adm. 2008;38(5):223-229. [Context Link]
15. Armstrong KJ, Laschinger H. Structural empowerment, Magnet hospital characteristics, and patient safety culture: making the link. J Nurs Care Qual. 2006;21(2):124-132. [Context Link]
16. Armstrong KJ, Laschinger H, Wong C. Workplace empowerment and Magnet hospitals characteristics as predictors of patient safety climate [published online ahead of print May 30, 2008]. J Nurs Care Qual. [Context Link]
17. Brady-Schwartz DC. Further evidence on the Magnet Recognition program: implications for nursing leaders. J Nurs Adm. 2005;35(9):397-403. [Context Link]
18. Lacey SR, Cox KS, Lorfing KC, Teasley SL, Carroll CA, Sexton K. Nursing support, workload, and intent to stay in Magnet, Magnet aspiring and non-Magnet hospitals. J Nurs Adm. 2007;37(4):199-205. [Context Link]
19. Ulrich BT, Buerhaus PI, Donelan K, Norman L, Dittus R. Magnet status and registered nurse views of the work environment and nursing as a career. J Nurs Adm. 2007;37(5):212-220. [Context Link]
20. Aiken LH, Sloane D, Lake ET. Satisfaction with inpatient AIDS care: a national comparison of dedicated units and scattered beds. Med Care. 1997;36(9):948-962. [Context Link]
21. Jones CB, Gates M. The cost and benefits of nurse turnover: a business case for nurse retention. OJIN. 2007;12(3). Manuscript 4. Available at http://www.nursingworld.org/MainMenucategories/ANAMarketplace/ANAPeriodicals/OJI. Accessed December 12, 2009. [Context Link]
22. McConnell CR. Staff turnover: occasional friend, frequent foe, a frustration. Health Care Manag. 1999;8:1-13. [Context Link]
23. Upenieks VV. The interrelationship of organizational characteristics of Magnet hospitals, nursing leadership, and nursing job satisfaction. Health Care Manag. 2003;22(2):83-98.
24. Upenieks V. Recruitment and retention strategies: a Magnet hospital prevention model. Nurs Econ. 2003;21(1):7-13, 23. [Context Link]
25. Jagger J, Hunt EH, Peatson RD. Estimated cost of needlestick for six major needled devices. Infect Control Hosp Epidemiol. 1990;11(11):584-588. [Context Link]
26. Neisner J, Raymond B. Nurse Staffing and Care Delivery Models: A review of the Evidence. Oakland CA: Kaiser Permanente's Institue for Health Policy. 2002:1-15. Available at http://www.kpihp.org/publications/docs/nurse-staffing.pdf. Accessed May 21, 2009.
27. Clarke SP, Sloane DM, Aiken LH. Effects of hospital staffing and organizational climate on needlestick injuries to nurses. Am J Public Health. 2002;92(7):1115-1119. [Context Link]
28. Doloresco LG. Building a business case for Magnet designation in VHA. Final report 2004, James A. Haley Veteran's Hospital. Available at http://www1.va.gov/nursing/docs/FinalBusCasereport11-26.pdf. Accessed January 9, 2010. [Context Link]
29. Poduska DD. Magnet designation in a community hospital. Nurs Adm Q. 2005;29(3):223-227. [Context Link]
30. Woods DK. Realizing your marketing influence. Part I: meeting patient needs through collaboration. J Nurs Adm. 2002;32(4):189-195.
31. Woods DK, Cardin S. Realizing your marketing influence. Part 2: marketing from the inside out. J Nurs Adm. 2002;32(6):323-330.
32. Woods DK. Realizing your marketing influence. Part 3: professional certification as a marketing tool. J Nurs Adm. 2002;32(7/8):379-386.
33. Gardner JK, Fogg L, Thomas-Hawkins C, Latham CE. The relationships between nurses' perceptions of the hemodialysis work environment and nurse turnover, patient satisfaction, and hospitalizations. Nephrol Nurs J. 2007;34(3):271-281.
34. Laschinger HKS, Fingan JE, Shamian J, Wilk P. A longitudinal analysis of the impact of workplace empowerment on work satisfaction. J Organ Behav. 2004;25:527-545. [Context Link]
35. Waldman JD, Kelly F, Arora S, Smith HL. The shocking cost of turnover in healthcare. Health Care Manage Rev. 2004;29(1):2-7.
36. Cimmiotti P, Quinlan P, Larson E, Pastor D, Stone P. The nursing process and perceived work environment of nurses. Nurs Res. 2005;54(6):384-390. [Context Link]
37. Smith H, Tallman R, Kelley K. Magnet hospital characteristics and northern Canadian nurses' job satisfaction. Can J Nurs Leadersh. 2006;19(3):73-86. [Context Link]
38. Aiken LH, Smith HL, Lake ET. Lower Medicare mortality rates among a set of hospitals known for good nursing care. Med Care. 1994;32(8):771-787. [Context Link]
39. Aiken LH, Sochalski J, Lake ET. Studying outcomes of organizational change in health services. Med Care. 1997;35(suppl):NS6-N18. [Context Link]
40. Aiken LH, Sloane DM, Lake ET, et al. Organization and outcomes of inpatient AIDS care. Med Care. 1999;37:760-772. [Context Link]
41. Berquist-Beringer S, Davidson J, Agosto C, et al. Evaluation of the National Database of Nursing Quality Indicators (NDNQI) training program on pressure ulcers. J Contin Educ Nurs. 2009;40(6):252-260. [Context Link]
42. Goode C, Blegen M. The link between nurse staffing and patient outcomes, 2009. National Magnet Conference abstract and presentation at October 1-3, 2009 Magnet conference; Louisville, KY. [Context Link]
43. Rosenberg MC. Do Magnet recognized hospitals provide better care? Presented at the October 1-3, 2009 Magnet National Conference; Louisville, KY. [Context Link]
44. Bates DW, Pruess K, Platt R. Serious falls in hospitalized patients: correlates and resource ulitilzation. Am J Med. 1995;99(2):137-143. [Context Link]
45. Nurmi I, Luthje P. Incidence and costs of falls and fall injuries among elderly in institutional care. Scand J Prim Health Care. 2002;20(2):118-122. [Context Link]
46. Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls in hospital setting: a prospective analysis. J Gen Intern Med. 2004;19(7):732-739. [Context Link]
47. Dunton N, Gajewski B, Taunton RL, Moore J. Nursing staffing and patient falls in acute care hospital units. Nursing Outlook. 2004;52(1):53-59. [Context Link]
48. Hook ML, Winchel S. Fall related injuries in acute care: reducing the risk of harm. Med Surg Nurs. 2006;15(6):370-381. [Context Link]
49. Dunton N, Gajewski B, Klaus S, Pierson P. The relationship of nursing workforce characteristics to patient outcomes: a study to assess the economic value of nursing staff and registered nurses. MedScape Today. Available at http://www.medscape.com/viewarticle/569394_4. Accessed May 21, 2009. [Context Link]
50. Stone PW, Mooney-Kane K, Larson EL, et al. Nurse working conditions and patient safety outcomes. Med Care. 2007;45(6):571-578. [Context Link]
51. Armstrong K, Lachinger H, Wong C. Workplace empowerment and Magnet hospital characteristics as predictors of patient safety climate [published online ahead of print May 30, 2008]. J Nurs Care Qual. [Context Link]
52. Hughes L, Chang Y, Mark B. Quality and strength of patient safety climate on medical surgical units. Health Care Manage Rev. 2009;34(1):19-28. [Context Link]
53. Armstrong KJ, Laschinger H. Structural empowerment: Magnet hospital characteristics and patient safety culture: making the link. J Nurs Care Qual. 2006;21(2):124-132. [Context Link]
54. Laschinger HKS, Leiter MP. The impact of nursing work environments on patient safety outcomes: the mediating role of burnout/engagement. J Nurs Adm. 2006;36(5):259-267. [Context Link]
55. Hines PA, Yu KM. The changing reimbursement landscape: nurses' role in quality and operational excellence. Nurs Econ. 2009;27(1):1-7. [Context Link]
56. Beckrich K, Aronovitch SA. Hospital acquired pressure ulcers: a comparison of costs of medical and surgical patients. Nurs Econ. 1999;17(5):263-271. [Context Link]
57. Shorr RI, Mion LC, Chandler MA, Rosenblatt LC, et al. Improving the capture of fall events in hospitals: combining a service for evaluating patient falls with an incident reporting system. J Am Geriatr Soc. 2008;56(4):701-704. [Context Link]
58. Potter P, Barr N, McSweeney M, Sledge J. Identifying nurse staffing and patient outcome relationships: a guide for change in care delivery. Nurs Econ. 2003;21(4):158-166. [Context Link]
59. Aiken LH, Sloane DM. Effects of organizational innovations in AIDS care on burnout among urban hospital nurses. Work Occup. 1997;24:453-477. [Context Link]
60. Aiken LH, Sloane DM. Effects of specialization and client differentiation on the status of nurses: the case of AIDS. J Health Soc Behav. 1997;38:203-222. [Context Link]
61. Aiken LH, Sloane DM, Lake ET. Satisfaction with inpatient AIDS care: a national comparison of dedicated and scattered bed units. Med Care. 1997;35:948-962. [Context Link]
62. Aiken LH, Lake ET, Sochalski J, et al. Design of an outcomes study of the organization of hospital AIDS care. Res Sociol Health Care. 1997;14:3-26. [Context Link]
63. Aiken LH, Sloane DM, Klocinski JL. Hospital nurses' occupational exposure to blood: prospective, retrospective, and institutional reports. Am J Public Health. 1997;87(1):103-107. [Context Link]
64. Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. JAMA. 2000;288(16):1987-1993. [Context Link]
65. Aiken LH, Clarke SP, Cheung RB, et al. Education levels of hospital nurses and patient mortality. JAMA. 2003;290(12):1-8. [Context Link]
66. Laschinger H, Shamian J, Thomson D. Impact of Magnet hospital characteristics on nurses' perceptions of trust, burnout, quality of care, and work satisfaction. Nurs Econ. 2001;19(5):209-219. [Context Link]
67. Rondeau KV, Wagar TH. Nurse and resident satisfaction in Magnet long-term care organizations: do high involvement approaches matter? J Nurs Manag. 2006;14(3):244-250. [Context Link]
68. Schmalengerg C, Kramer M. Essentials of a productive nurse work environment. Nurs Res. 2008;57(1):2-13. [Context Link]
69. Ulrich BT, Buerhaus PI, Donelan K, Norman L, Dittus R. Magnet status and RN views of the work environment and nursing as a career. J Nurs Adm. 2007;37(5):212-220. [Context Link]
70. Kramer M, Schmalenberg CE. Best quality patient care: a historical perspective on Magnet hospitals. Nurse Adm Q. 2005;29(3):275-287. [Context Link]
71. Kramer M, Schmelenberg CE. Magnet hospitals I: institutions of excellence. J Nurs Adm. 1988;8(1):13-24. [Context Link]
72. Kramer M, Schmelenberg CE. Magnet hospitals II: institutions of excellence. J Nurs Adm. 1988;18(2):11-19. [Context Link]
73. The Advisory Board Company. Reversing the Flight of Talent: Nursing Retention in an Era of Gathering Shortage. Washington DC: Advisory Board Company; 2000. [Context Link]
74. VHA, Inc. 2002. The business case for workforce stability. Available at http://www.healthleadersmedia.com/pdf/white_papers/wp_vha_120103.pdf. Accessed May 21, 2009. [Context Link]
75. Upenieks VV. What constitutes effective leadership? Perceptions of Magnet and non-Magnet nurse leaders. JONA. 2003;33(9):456-467. [Context Link]
76. Lavizzo-Mourey R, Verplanck J. Recession is making nursing shortage worse. The Philadelphia Inquirer. July 2, 2009. [Context Link]
77. American Hospital Association. The 2007 State of America's Hospitals-Taking the Pulse. Washington, DC: American Hospital Association; 2007. [Context Link]
78. Magnet Recognition Program data display. Magnet Recognition Program site. November 2009. Available at http://www.nursecredentialing.org. Accessed November 1, 2009. [Context Link]
79. Wilburn SQ. Needlestick and sharps injury prevention. Online J Nurs. 2004;9(3). [Context Link]
80. Stone PW, Gershon RRM. Nurse work environments and occupational safety in intensive care units. Policy Polit Nurs Pract. 2006;7:240. [Context Link]
81. Nelson A, Matz M, Chen F, Siddharthan K, Lloyd J, Fragala G. Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks. Int J Nurs Stud. 2006;43:717-733. [Context Link]
82. Unruh L. Nursing staffing and patient, nurse and financial outcomes. Am J Nurs. 2008;108(1):62-72. [Context Link]
83. Mills A. Effect of magnet hospital recognition on patient outcomes, 2008. National Magnet Conference abstract and presentation at October 15-17, Magnet conference; Salt Lake City, UT. [Context Link]
84. Dall TM, Chen YJ, Seifert RF, Maddox PJ, Hogan PF. The economic value of professional nursing. Med Care. 2009;47(1):97-104. [Context Link]
85. Doloresco MN. Building a business case for Magnet designation in VHA. James A Haley Veterans's Hospital, Tampa, FL. 2004. Available at http://www.1.va.gov/nursing/docs/FinalBusCasereport11-26.pdf. Accessed January 22, 2010. [Context Link]
86. Tuazon N. Is Magnet a money-maker? Nurs Manag. 2007;38(6):24-31. [Context Link]
87. DeSilets L, Pinkerton SE. Administrative angles: the financial return on Magnet Recognition. J Contin Educ Nurs. 2005;36(2):51-52. [Context Link]
88. Robert Wood Johnson Foundation. Charting Nursing's Future. Nursing Prescription for a Reformed Health System: Use Exemplary Nursing Initiatives to Expand Access, Improve Quality, Reduce Costs, and Promote Prevention. 2009. [Context Link]
89. Hassmiller SB, Christopher MA. Making the business case for nursing to the business community and to CEOs. Nurse Lead. 2009;7(2):48-52. [Context Link]
90. Havens DS. Comparing nursing infrastructure and outcomes: ANCC Magnet and non-Magnet CNE's report. Nurs Econ. 2001;19(6):258-266. [Context Link]
91. Havens DS, Johnston MA. Achieving Magnet recognition: chief nurse executives and Magnet coordinators tell their stories. J Nurs Adm. 2004;34:579-588. [Context Link]
92. Gelinas L, Bohlen, C. Tomorrow's work force: a strategic approach. VHA Inc; May 2002. Available at https://www.vha.com/research/public_tomorrowsworkforce_meth.asp. Accessed January 10, 2010. [Context Link]
93. Sandhusen A, Rusynko B, Wethington N. Return on investment for a peri-operative nurse fellowship. AORN J. 2004;80(1):73-81. [Context Link]