Certain hospitals possess organizational characteristics that allow nurses to use their expertise, knowledge, and skills to provide quality patient care. These organizations have been able to weather national nursing shortages because of their favorable reputation for attracting and retaining nurses. 1 One model that has empirically confirmed job satisfaction outcomes on numerous occasions is the "magnet hospital model."1 Magnet hospitals perform better than the average U.S. hospital, with lower reported turnover and vacancy rates and higher job satisfaction levels. 2,3
The original magnet hospital report in the early 1980s had a significant effect on the nursing profession at a time of severe nursing shortage. 4,5 The organizational characteristics of these hospitals were not in themselves novel, but acknowledged as key indicators of attracting and retaining clinical nurses. 4 These hospitals were usually led by a well-qualified nurse executive, in a decentralized structure, who was a formal member of the highest decision-making body in the hospital. This nurse leader supported 2-way communications with nurses and encompassed organizational structures that emphasized open, participatory management. These hospitals also established a system of an autonomous, self-managed, self-governed operation at the unit level. The clinical nurses managed hospital-wide governance issues (eg, decisions regarding interdepartmental patient flow, equipment expenditures). 6,7 Also, the administrative structures supported nurses' decisions about patient care. 1 In all, supportive nursing leadership and commitment to professional qualities of the clinical nurse were reported as the most important and effective traits of a magnet hospital. 1
Although magnet hospitals have been operating for nearly 20 years, comparable research on their effectiveness has been limited. Since the early 1980s, when the original magnet research was published, many significant changes have occurred in the U.S. healthcare system. Hospitals are merging with acute care sectors, the focus is on outpatient versus inpatient care, costs are escalating, and length of stay has decreased. Hospitals are changing staffing levels, treating sicker patients for a shorter time, and offering more intense services and care-overall, placing a greater demand on the clinical nurse. 4 Do these organizational characteristics still enhance nursing job satisfaction in today's healthcare setting, as they did 20 years ago?
Purpose of Study
This study began with the premise that certain key organizational characteristics provide the means for clinical nurses to use their expertise and knowledge to deliver excellence in patient care, thereby increasing job satisfaction and retention, and that these key organizational characteristics are supportive of the nurse leader. The purpose of this study was twofold. First, to examine the difference between clinical nurses employed at magnet and nonmagnet hospitals and their perceptions of job satisfaction as it relates to organizational characteristics. Second, to gain an understanding of the nurse leader's perception of the value of his/her role in today's setting. Clinical nurses at various hospitals were surveyed to determine whether there was a difference in magnet and nonmagnet hospitals at the level of job satisfaction. Dialogue with nurse executives and managers provided an in-depth perception of leadership attributes, especially those that that foster job satisfaction among clinical nurses in their practice environments. The results of the quantitative and qualitative methods were combined to achieve a more complete understanding of nursing leadership and job satisfaction.
During a major nursing shortage in the early 1980s, the American Academy of Nursing (AAN) conducted extensive research to identify hospitals that were successful in recruiting and retaining nurses. The first objective was to evaluate characteristics of hospital structures that supported and facilitated professional nursing practice. 4 The second was to demonstrate that these hospitals differed from others based on their organizational characteristics and low rates of nursing turnover, despite the nationwide shortage. 8 An aggregate scoring and ranking process yielded a total of 41 hospitals across the country that exhibited exceptional organizational characteristics supporting professional nursing. The selection method predicted that the 41 hospitals shared common organizational characteristics. 8 Thus, these hospitals became the focal point of further research-based activity, and became known as "magnet hospitals."4,8
The key characteristics of magnet hospitals identified by the AAN task force were grouped under 3 headings: administration, professional practice, and professional development. The task force recognized that the nurse executive was a formal member of the highest decision-making body at these hospitals (ie, considered a member of the executive administrative team), which signified the priority that hospital administration placed on nursing. 1 Nursing services were organized in a flat organizational structure, with minimal levels between clinical nurses and the nurse executive. 1 This allowed for a system of autonomous, self-governed operation at the unit level. For example, all staffing and scheduling was conducted at the unit level, which enabled nurses on each shift to be empowered and accountable for making staffing decisions for the next shift. Decision-making was decentralized to the unit level, utilizing a shared governance nursing model, which offered the nurses on each unit much discretion for organizing and delivering patient care. 1 The AAN task force also identified flexible staffing, adequate nursing staffing ratios, and providing clinical career opportunities as significant attributes of magnet hospitals. 4,6,7
The central attributes of "magnet hospitals" bear a striking resemblance to the recommendations made by the Sigma Theta Tau International Honor Society of Nursing, that nurses be recognized, supported, and involved in decision-making about patient care and hospital governance. 9 The major characteristics found in magnet hospitals that represent the suggestions of Sigma Theta Tau consist of professional autonomy of nurses, an environment that supports professional practice and development, and supportive leadership attributes by nursing administration. 3,9 These organizations enable professional nurses to use their knowledge and to do for patients what they know should be done in a manner consistent with professional standards. 10
During the follow-up study of magnet hospitals, the most essential organizational characteristic was determined to be the quality of nursing leadership. 10 Nurse leaders interviewed referred to leadership attributes they felt were crucial in achieving organizational success and improved job satisfaction among nurses: being visionary and enthusiastic; supportive and knowledgeable; able to maintain high standards and staff expectations; highly visible to clinical nurses; responsive; able to uphold open lines of communication; valuing education and professional development; able to preserve a position of power and status within the hospital; and actively involved in state and national professional organizations. 3,4
Despite previous research on organizational characteristics that enhance job satisfaction, and the recommendations stated by Sigma Theta Tau, 9 minimal comparable research exists concerning hospitals that maintain key organizational characteristics, and those not labeled as such-magnet hospitals compared to nonmagnet hospitals. Also, minimal research was found on whether these hospitals are able to provide increased job satisfaction among clinical nurses in today's healthcare setting, considering the impact of the current critical nursing shortage.
The purpose of this study was to determine whether there was a difference in the level of job satisfaction among clinical nurses employed in diverse hospital settings, and whether this was linked to leadership provided by the nurse executive. The aim of this inquiry was both explanatory and comprehension. Surveying clinical nurses at various hospitals produced differences in the level of job satisfaction and provided quantitative analysis for the study. Content analysis was employed to understand the nurse leader's perception of successful attributes in today's healthcare setting that foster job satisfaction among clinical nurses in their practice environments.
To achieve a more complete understanding of nursing job satisfaction and the impact of the nurse leader's role on this outcome, the survey component provided empirically generated constructs, and the results from the qualitative component enabled the researcher to more broadly understand the statistical results. 11,12 Through the use of triangulation, a search for logical patterns of relationship and meanings between and among significant variables was inaugurated, resulting in a more comprehensive conceptual understanding of the link between job satisfaction and leadership. 13-15
A convenience sample of 2 magnet hospitals and 2 comparable nonmagnet hospitals constituted the sampling frame for this study. A list of magnet hospitals was obtained from the American Nurses Credentialing Center for Magnet Hospitals. The 2 magnet hospitals were selected based on their willingness to participate. The first 2 magnet hospitals that were approached agreed to participate in the study. After selection of the 2 magnet hospitals, a listing of nonmagnet hospitals was obtained from the most current listing of American Hospital Association (AHA) Annual Survey of Hospitals. From this list, 2 nonmagnet hospitals who were willing to participate were selected from the same geographic location, matching as closely as possible the magnet institutions in terms of number of beds (ie, bed size) and nonprofit status (ie, a magnet and nonmagnet hospital from the same urban locality). From the 2 localities, a total of 7 nonmagnet hospitals were approached; although 5 declined, the other 2 agreed to participate in the study.
The sample population of interest consisted of a convenience sample of clinical nurses from the 4 hospitals. All medical-surgical registered nurses were invited to participate and asked to complete a questionnaire; 700 questionnaires were distributed. The return rate was 44%, with 305 nurses returning usable questionnaires.
The Revised Nursing Work Index (NWI-R) measurement tool was used for this study. 16 The NWI-R was designed by the original magnet hospital researchers through an extensive review of literature related to job satisfaction. The tool measures job satisfaction among hospital nurses and organizational attributes relevant to clinical nursing. Three subscales are measured: autonomy, nurse control over the practice setting, and relations between nurses and physicians. The higher the scores, the more satisfied nurses are considered to be, due to the presence of key organizational structures in the work setting. 16 For the purpose of this study, 3 additional subscales were designed to assess more thoroughly differences in scores related to hospital structures: self-governance, organizational structure, and educational opportunities (Table 1). Measures of central tendency were used to describe the mean and standard deviations of the survey subscales. A 2-tailed t-test of significance was employed to measure mean differences in scores between magnet and nonmagnet nurses.
The qualitative sample population consisted of 16 nurse leaders, 3 to 5 from each of the institutions surveyed. One nurse leader was recruited at the executive level, and 2 to 3 at the director/manager level. The nurse leaders were interviewed to gain an understanding of what nursing leadership attributes foster success in today's healthcare setting. Interviews ranged from 60 to 90 minutes and were taped. While a core set of questions served as a guide, the interviews were open-ended. Additional questions were incorporated into the discussion to serve as prompts or to clarify understanding. One interview was conducted per subject.
The content analysis method, as defined by Downe-Wamboldt, 17 was used. The category and subcategory definitions that were used for the deductive analysis were derived from magnet hospital research studies. Because content analysis relies heavily on face or content validity that can be determined by the judgments of experts in the field, 17,18 2 nurse leaders, specialists in the field of nursing leadership based on years of experience, reviewed the preexisting definitions.
Triangulation: Quantitative and Qualitative Analysis
A matrix system was constructed to display nurse leaders' answers to interview questions selected in relation to the institution's survey scores. 19 Row components were drawn from quantitative results and consisted of either the overall NWI mean score or certain subscale mean scores. Cell entries were obtained from the qualitative analysis and consisted of brief summary phrases or direct quotes from the nurse leaders that reflected their perception of what increased nursing job satisfaction. Thus, the matrix system facilitated comparison of transcribed responses to interview questions and survey results, resulting in a more precise explanation of possible differences in job satisfaction scores among magnet and nonmagnet nurses.
There were some notable differences in the sample (Table 2). Magnet hospitals varied between 300 and 400 in bed size. The nonmagnet hospitals also varied between 300 and 400 in bed size. Bed occupancy was nearly at maximum level at all 4 locations. At magnet hospitals, the predominant age group of nurses was 40 to 49 years (45%) followed by 30 to 39 years, or 21%. The nonmagnet hospital age distribution described a bell curve, although the primary age group was 40 to 49 years. At magnet and nonmagnet hospitals, over 60% of the nurse respondents were age 40 or older. Thus, the age demographics reflected the supply trends of the nursing shortage: aging nursing workforce and a smaller pipeline of students entering the profession. 9 Also, 37% of the nurses at magnet hospitals had 0 to 5 years of nursing experience, whereas the majority of nurses at nonmagnet hospitals had 20 years of nursing experience.
In comparing nurses' education across the 2 settings, the percentage of nurses with baccalaureate degrees was higher at magnet hospitals. Of the nurse respondents in magnet hospitals, 52% were baccalaureate prepared, compared to 31% of those in nonmagnet hospitals. In contrast, 47% of nurse respondents at nonmagnet institutions held associate degrees.
Magnet hospital mean scores were substantially higher in all NWI-R subscales compared to nonmagnet hospital mean scores, demonstrating a higher level of job satisfaction among clinical nurses employed at magnet hospitals (Table 3). Overall, nurses in magnet hospitals demonstrated better physician relations, and greater autonomy and control over their practice environment, than did nurses employed at nonmagnet hospitals. Greater autonomy and control over their practice setting meant that nurses in magnet hospitals had sufficient autonomy to influence others and deploy needed resources for patient care delivery, and their contributions were acknowledged and appreciated. Clinical nurses in magnet hospitals also felt they were receiving considerably greater support from administration, enhanced self-governance structures, and more continuing education opportunities. Greater support from administration meant that the leadership team was responsive to concerns regarding patient care delivery and that the chief nursing executive was visible. In fact, the greatest mean difference between nurses employed at magnet hospitals versus those at nonmagnet hospitals was their rating concerning the organizational structure subscale (administrative structure), with mean scores differing by .53 (magnet M = 2.93; nonmagnet M = 2.40;t = 9.049;P < .001).
The proven prediction, that clinical nurses employed at magnet hospitals would demonstrate a greater level of job satisfaction as compared to nurses employed at nonmagnet hospitals, was supported when a 2-tailed t-test of significance was applied to compare differences in NWI-R mean scores (Table 4). Magnet hospital nurses had a total mean of 143.75, nonmagnet hospital nurses a total mean of 125.33, and the means differed significantly at the P < .001 level (t = 6.02;P < .001). Further analysis showed a difference in mean scores between magnet and nonmagnet hospitals when the 2 locations were segregated. In both locations (A & B), magnet hospital nurses scored significantly higher compared to nurses at nonmagnet hospitals (Table 5). However, a higher mean score was obtained at magnet hospital A, compared to B; while the 2 nonmagnet hospitals scored relatively the same.
Magnet hospital leaders had been in a nursing leadership position from 2 to 22 years, with an average of 14 years. Nonmagnet hospital leaders had held their position between 3 and 21 years, averaging 10 years. Although there were some newcomers to the leadership teams, most magnet and nonmagnet nurse leaders had considerable longevity in their current organization, averaging 16 years (including years employed prior to leadership position). The majority of nurse leaders interviewed had been promoted within their current organization, either from clinical nurse to a manager/director or from a director/assistant administrator to an executive position.
Dialogue with the nurse leaders revealed 7 prominent categories and associated subcategories that they believed fostered and influenced their success as leaders, as well as supporting clinical nurses at the bedside. The majority (85%) related to the central characteristics of magnet institutions as key indicators for organizational success, emphasizing the importance of supportive attributes of the nurse leaders and professional attributes of the clinical nurses. In this section of the qualitative analysis, categories and subcategories were discussed using samples from the interviews to illustrate how findings link to the literature.
1. Support of NursingNurse leaders perceived that clinical nurses were the most essential component of a successful professional organization. They reported that a value-driven environment transpires if importance is placed on the delivery of patient care and professional attributes of the registered nurse. The majority of nurse leaders, particularly magnet leaders, were able to articulate the organization's commitment to nursing: "I believe nursing is powerful at our hospital, or certainly influential. I think we are fairly lucky at our facility because nursing is recognized and highly valued. We wouldn't be a magnet facility if we didn't have an appreciation for what nurses bring to the organization."
1.1 Support from Nurse Executive: The nurse executive supports nursing.The nurse executive's attitude about the value of nursing and patient care filters down through the organization and influences job satisfaction among clinical nurses. This support stems from the nurse executive's ability to shape the nursing service, and articulate the value of nursing. In this study, almost all the nurse managers praised their nurse executives for being strong nursing advocates. "I believe much of the support for nursing comes directly from my boss. She has a lot to do with making other departments and administrators understand our needs, and what we need to do to provide quality patient care." One participant commented, "Our nurse executive went to bat for us while the rest of the executive team was trying to execute nursing cutbacks. I trust she truly values nursing, it comes from within her."
2. Leadership StyleEffective nursing leadership is fundamental to the success of the organization as well as to the retention of a cohesive and efficient group of clinical nurses. The participants provided an array of traits they considered important, which were similar to the distinctive leadership attributes depicted in magnet hospital research. Those most emphasized were being passionate about nursing, supportive, loyal, highly respected throughout the organization, inspiring, knowledgeable, consistent, fair, visible, and responsive. "I would probably say that my predominant leadership traits are that I have tons of energy, I'm assertive, I have strong values and respect for nursing, and a real desire to support fairness and equity." Another leader stated, "I see myself as a nurse first, administrator second."Several nurse leaders struggled with how to be visible, particularly at nonmagnet hospitals, while others reported that they were relatively visible throughout the organization. "I meet with the nurses on their units, 3 times a year. I tell them whatever is happening in the organization, what our goals are, there's [sic] usually very few secrets. In return, they give me a list of concerns and then I have a chance to respond." Some leaders conducted open forums once a month with clinical nurses, or worked a shift on their unit or as house supervisor. "The nurses want to see me in the patient care areas so that they know I know what they have to deal with. So, I spend shifts in different areas. It's not easy to do, especially when you have the rest of the administrative piece of your job."An extremely vital feature was a passion for nursing, particularly during a time of shortage. "I believe that a passion for nursing is probably the most important trait of any nurse executive. It's the only thing that will turn around the nursing shortage and encourage nurses to feel better about their jobs-so, in turn, they have their sons and daughters consider nursing as a profession."
2.1 Central Beliefs:The core principles and value system guiding the nurse leader's style.The principal value systems guiding nurse leaders were a passion for nursing, leading to serve, providing nurses with the right tools and resources to do their job, and striving for excellence. Several of the nurse leaders commented on the importance of leading to serve. "My personal goal is to get nurses the tools they need to do their job well. I'm not taking care of patients-they are. My job is to take care of them so that they can take care of the patients" and "I have an attitude that I am here to serve. I believe you're more successful as a leader when you go into your role doing it for the reasons that you want to do something better for your staff."
3. Adequate StaffingThe majority of nurse leaders reported their goal was to increase the amount of professional nursing care available to each patient. These leaders perceived that with patient acuity on the rise, the only way to assure excellence is to confirm professional nursing in the care delivery system. Only one magnet hospital reported using an all-RN staff, while the other 3 hospitals used aides, technicians, and licensed practical nurses, although staffing levels were higher at magnet versus nonmagnet hospitals. "We have an all-RN staff, every patient is assigned an RN. It's not necessarily the magnet status that affects the all-RN staff, for I believe that we've always maintained this type of nursing care delivery. An all-RN staff has been implemented for the reasons that nurses bring value to the organization; nurses are the ones who provide quality care to patients and they have an impact on outcomes." Although an all-RN staff was not identified as a norm in this study, the nurse leaders reported that maintaining adequate staffing ratios with professional staff was essential in retaining nurses. As a result, the majority of nurse leaders, predominantly at the executive level, strove to maintain acceptable staffing levels. "Staffing ratios, the ability to deliver quality work, is very important to nurses. Nurses value that above dollars. You can't take care of 9 patients as well as you take care of 4 patients. Sure, they are able to get all the basics done and not make mistakes-but I would describe it as the smooth finish on patient care that is not being rewarded, and the PR aspect of nursing care."
4. Autonomous ClimateAutonomy has been described as one of the most significant features explaining job satisfaction and retention among nurses. All of the nurse leaders were able to define the meaning of autonomy as well as relate various autonomous experiences in their careers. "I equate autonomy, and responsibility and independence. Those 3 concepts are closely related. I don't believe you can have autonomy until you take responsibility, and nurses will not be autonomous until you give them the independence to do that." For the most part, the nurse leaders supported the concept of an autonomous climate and stated that nurses prefer control over their practice environment and accountability for decision-making. "Nurses choose to be fully responsible, to make proactive decisions and problem-solve. What may get in their way is lack of infrastructure and resources for them to be able to get the job done." However, there were mixed responses from nonmagnet leaders whether clinical nurses in medical-surgical settings truly desired an autonomous climate.
5. Participatory ManagementAnalysis revealed that the majority of nurse leaders supported the notion of participatory management, that it was a vital strategy in cultivating an autonomous practice environment. They perceived that decision-making should be decentralized to the unit level, allowing clinical nurses to be involved with patient care delivery, scheduling, planning innovative services, and assisting in cost-control measures. They reported that organizational structures encouraging empowerment consist of decentralized and participatory management models. "When nurses have an idea, we don't shut them out; rather, let them show us why and how. I believe that fosters the feeling they are important to the organization, that what they say counts. They have a voice and they are heard." Another nurse leader asserted, "Nurses need the opportunity to participate-it helps them feel as though they are part of the larger system, part of the solution. In return, they feel empowered and are more satisfied."
6. Collaborative TeamworkIn today's fast-paced and complex healthcare setting, team building and collaboration translates into better care management. The leaders acknowledged that team building increased efficiency and productivity, and that when nurses, physicians, and other healthcare providers work together to provide better management of complex patient problems and enhance staff and patient satisfaction, then a synergistic healthcare environment is created. "I believe, for the most part, we do have an efficient provider team; nurses, physicians, and ancillary staff truly work together to optimize patient care. The clinicians recognize the value of working together as an effective team, and significance of each team member's contribution to patient care. It makes a difference, not only for patient and staff satisfaction, but creates a more effective and positive patient flow through the system." Another leader expressed, "I try to keep the team piece together, it's the only way patients are going to receive optimal care. I create an environment where everyone's strengths are jointly tied together. As a result of this synergistic effort, everyone wins-patients are much more satisfied, physicians are happier and more cooperative, nurses feel strong partnerships with physicians and other department employees, and the care is better."
6.1. Management Support GroupHigh performance in the healthcare setting involves not only the synergistic effort of nurses, physicians, and other ancillary providers, but also a collaborative management team working with providers to attain organizational goals. The nurse leaders interviewed perceived that the best group of nurse leaders are dedicated to the organization and to each other, pool their resources, have a high degree of interdependence and interaction, are trustworthy, and are committed to achieving excellence in patient care. As with collaboration, most of the leaders agreed their management group was a solid team. However, some leaders reported that team building was a result of the leadership style provided by the nurse executive. "I feel we work very well together as a group of nurse leaders, and much of this is attributed to my boss who brings us together to think like a team. At times, when you listen to our discussions you would wonder, as people say what's on their mind and it's an open forum. There is a fair amount of disagreement, but it is done professionally and respectfully. We try as a group, with my boss guiding us towards a common purpose, to come up with the best solution."
7. CompensationParticipants naturally noted that nurses value adequate pay, autonomy, and flexibility, and supportive organizational/professional features as significant factors in their work setting. However, pay is becoming a large issue, if not the most crucial factor. The nurse leaders expressed the importance of rewarding nurses monetarily for their commitment given the labor shortage, working conditions, patient loads, and acutely ill patients. The nurse leaders related numerous mechanisms that were either in effect or being implemented to retain a professional staff at their hospital. "For the past several years we have provided a supplemental bonus program where the nurses get paid an additional $200 to work an extra shift, anything above their FTE level. It's worked like a miracle. We are rewarding our own nurses with the money that would otherwise go to agencies, and we have our own staff providing quality patient care."
The qualitative analysis revealed that the nurse leaders related to the central characteristics of magnet institutions as key indicators for leadership worth. Factors consistent with magnet hospital features that influenced nurse leader effectiveness in his or her role included: (1) an organization committed to the professional qualities of the nurses; (2) support of nursing received from the nurse administrator; (3) distinctive leadership attributes of nursing administration, including visibility, responsiveness, and a passion for nursing; and (4) an autonomous climate and participatory management style of nurse leaders. The analysis also demonstrated that nurse leaders cited several additional key organizational structures they believed were essential in producing leadership worth. One of the principal factors that influenced nurse leader effectiveness was teamwork, which entailed a collaborative approach to patient care through shared expertise of physicians, nurses, ancillary personnel, and management team. Adequate compensation of clinical nurses was considered a quotient of respect in any professional climate.
Specified interview questions were selected for completeness, and a matrix system was used to display each answer to the selected questions. 19 The matrix system facilitated comparison of transcribed leader responses to selected interview questions and institutional survey results providing a more precise explanation of nursing leadership and job satisfaction (Table 6, Matrix Display Question 1).
1. What leadership traits are valued in today's healthcare setting?The NWI-R organizational structure subscale was used to compare clinical nurse survey scores with nurse leader responses related to leadership traits valued in today's hospital environment. The organizational structure subscale determined administrative factors present in the nursing care environment as nursing leadership visibility and responsiveness. The highest mean organizational structure subscale scores were reported for magnet hospitals and the lowest mean scores at nonmagnet hospitals. Significant differences in scores were obtained for the questions relating to leadership traits: "an administrative team who listens and responds to employee concerns" (t = 8.197;P < .001), and "a nurse leader who is highly visible and accessible to staff" (t = 6.404;P < .001).When asked about leadership traits, most nurse leaders cited the importance of leadership visibility. Clinical nurses perceive that visible and accessible leaders understand their practice environment, and thus are more responsive and proactive regarding their concerns. The difference in job satisfaction scores may be explained by the nurse leader's actual visibility within the organization, compared to merely stating the importance of this trait. Managers reported that the nurse executives were less visible at nonmagnet hospitals compared to magnet hospitals. Furthermore, differences in job satisfaction scores between magnet and nonmagnet hospitals may be derived from a less supportive or committed administrative team.
2. Describe your meaning of autonomy. Do nurses prefer autonomy?Magnet and nonmagnet nurse leaders defined autonomy as an environment where nurses have full command of expert knowledge and control over decision-making. They professed that an autonomous climate lends itself to a professional practice setting and enhances job satisfaction of nurses. A percentage of nonmagnet leaders (33%) reported they were uncertain whether medical-surgical nurses truly desired such an autonomous climate.The NWI-R autonomy subscale was used to compare clinical nurse survey scores with nurse leader responses related to the meaning of autonomy, and whether nurses preferred an autonomous clinical environment. The NWI-R mean autonomy scores were higher at magnet hospitals compared to nonmagnet hospitals. Significant differences in mean scores between magnet and nonmagnet hospitals were obtained for the 2 questions related to management support in decision making: "a supervisory staff that is supportive of the nurses" (t = 6.746;P < .001), and "a head nurse who backs up the nursing staff in decision-making" (t = 5.765;P < .001).Differences in job satisfaction scores may be explained by the extent of support received by the nurse managers and/or supervisors in making autonomous patient care decisions. With encouragement from the management team, nurses in magnet environments may be more inclined to risk assuming responsibility for their professional practice, and therefore become more supportive of autonomy, whereas nonmagnet managers may tend to employ a top-down style of management, leading to a less autonomous climate.
3. Describe an environment that fosters nursing satisfaction and retention.The majority of nurse leaders offered a combination of organizational features they perceived as essential in fostering job satisfaction and retention among clinical nurses: resources and supplies, new equipment, adequate staffing, leadership visibility, recognition and rewards, continuing education, support services, clinical ladders, and better compensation. Nonmagnet leaders expressed the importance of adequate staffing, whereas magnet leaders focused on additional educational services as a retention strategy.Overall NWI-R scores were used to compare clinical nurse survey scores with nurse leader responses regarding the perfect environment for nursing job satisfaction. At magnet hospitals, high mean scores were associated with good educational programs, supportive management staff, autonomy, and high standards of care. High mean scores at nonmagnet hospitals reflected orientation and preceptor programs for nurses and high standards of care maintained in the clinical setting. On one end of the spectrum, low mean scores (2.29) at magnet hospitals were attributed to inadequate support services. For nonmagnet hospitals, the low scores (1.76) were associated with not having enough registered nurses to provide quality patient care.The magnet nurse leaders stressed the importance of providing clinical nurses with education opportunities to foster job satisfaction. Yet the nurses perceived that educational opportunities were optimally present in their organizational setting, while additional support services were a more vital concern. The leader responses may be associated with the fundamental nature of a magnet hospital setting, which stresses the importance of teaching, information sharing, and educational opportunities for all staff members. In stressing adequate staffing as one of the most crucial strategies in retaining nurses, nurse leaders from nonmagnet hospitals may have perceived there was insufficient staffing throughout their organizational setting. This awareness matched the low mean scores obtained from the clinical nurses at nonmagnet hospitals. Overall, staffing was a foremost concern for both magnet and nonmagnet clinical nurses.
Although the findings of this study are compelling, several limitations must be considered. First, the hospitals involved were selected based on their willingness to participate and therefore may not be representative of all magnet and nonmagnet hospitals. Because sensitive information pertaining to job satisfaction of clinical nurses and perceptions of leadership effectiveness was disclosed, these nurse executives had demonstrated they were already secure and confident in their roles. Consequently, both the quantitative and qualitative results may be skewed more favorably compared to the population norm of clinical nurses and leaders in the healthcare industry.
Also, a relatively low response rate of participants yielded only 44% response rate of the population base surveyed. This was explained by the fact that clinical nurses lacked time, energy, and interest to respond due to prohibitive schedules and patient assignments. Many nurses may have perceived that the administrative team would not respond to their concerns. Lastly, nurses at magnet hospitals were relatively new to the profession, compared to nurses at nonmagnet hospitals. This may have contributed to the higher scores received at magnet hospitals, as novice nurses tend to be more excited about the profession of nursing.
Results of this study suggested that clinical nurses at magnet hospitals had more autonomy and control over their practice setting compared to nonmagnet nurses. This meant that nurses at magnet hospitals had independence to deploy needed resources for patient care delivery, were accountable for patient care issues, and had relative freedom to make patient care decisions. Magnet hospital nurses characterized their work environment as one of support from administration more often than nurses in nonmagnet settings. Factors that influenced nurse leader effectiveness included a strong commitment to nursing, recognition of professional nursing practice, leadership visibility, and support of an autonomous climate.
Triangulation was applied to achieve a more complete understanding of the inclusive concept of nursing job satisfaction and the impact of the nurse leader's role on this perception, and more precise explanation of differences in job satisfaction scores among clinical nurses at magnet and nonmagnet hospitals was obtained. The differences in scores related to greater visibility and responsiveness by magnet nurse leaders; better support of clinical nurse autonomous decision-making by magnet nurse leaders; and greater support of a professional nursing climate at magnet hospitals as presented by adequate staffing in the workforce.
The presence of certain organizational characteristics in a hospital environment enhance nurse leader effectiveness as well as support clinical nurses at the bedside in providing superlative patient care. Whether or not these organizations represent magnet hospitals, certainly magnet hospitals have many of the right ingredients in place (Table 7). Attention to these structures may result in the greater retention of nurses in a hospital environment.
Support for this study was provided by the Hester McLaws Nursing Scholarship Award.