Spotlight on nurse staffing, autonomy, and control over practice

Magnet™ hospitals are becoming more important as research shows they consistently yield positive nurse and patient outcomes. Even during a nursing shortage, these hospitals tend to offer:

  • higher nurse-patient ratios
  • better-educated and more competent nurses
  • greater nursing autonomy and control over nursing practice
  • better nurse-patient communication and relationships
  • strong administrative and organizational support for nursing
  • a stronger focus on the patient.

These characteristics help Magnet hospitals attract and retain nurses and achieve better patient outcomes—fewer complications, lower mortality rates, and higher patient satisfaction.
In 1983, the first published study of what would come to be called Magnet hospitals identified nurse staffing, nursing autonomy, and control over nursing practice as crucial to a “magnetic” environment. Now, a quarter-century later, these are still hot-button issues.

Nurse staffing
In findings from studies of Magnet hospitals, the term staffing pertains not just to the quantity of nurses but also to their quality or competence, their educational preparation, and the nursing skill mix used on a unit. In the 1983 study, nurses at Magnet hospitals described their facilities as adequately staffed—a feature they said was critical to their job satisfaction. They believed these facilities had favorable nurse-patient and nurse-nonprofessional ratios.

In the nurses’ view, quality of the staff was just as important as the quantity. Quality of nursing staff derives from such factors as adequacy, competency, level of professionalism, and the proportion of registered nurses (RNs) and baccalaureate-prepared nurses. A 2004 report from the Institute of Medicine (IOM), “Keeping Patients Safe: Transforming the Work Environment of Nurses,” reported that Magnet hospitals have a higher percentage of baccalaureate-prepared nurses (50%) than the national average (34%).

Nurses in Magnet hospitals consistently view working with other clinically competent nurses (defined as experienced and educationally prepared colleagues) as the most essential variable in providing high-quality care. Competence enables nurses to rely on and trust each other, leverage each other’s abilities, and adapt to inadequate staffing in a constructive manner. Even in times of less favorable nurse-patient ratios, nurses at Magnet hospitals can compensate better because they know their colleagues are competent.

During the healthcare restructuring of the 1990s, many Magnet hospitals were forced to reduce the number of nursing positions. Yet Magnet facilities generally maintained a higher level of RNs than other facilities, and their nurses weathered restructuring better—thanks largely to strong nursing leaders who had the foresight to use unlicensed assistive personnel (UAP) to enhance the RN staff rather than replace it.

Over the last few decades, studies show Magnet hospitals consistently have fewer nursing vacancies and lower nurse turn­over than other hospitals. This promotes a stable environment where nurses know each other’s capabilities and have established relationships with other healthcare professionals.

Staffing levels and quality of care
Adequate nurse staffing is crucial to the delivery of high-quality care, and Magnet hospitals generally have higher nurse-patient ratios than other hospitals.

Better staffing at Magnet hospitals is linked to nurses’ higher job satisfaction and a more positive perception of the care their facilities provide. Conversely, where staffing is inadequate, nurses’ job satisfaction declines—and so does their perception of quality of care at their facility.

Fewer RNs, more illnesses and deaths
Inadequate nurse staffing hurts both nurses and patients. During the 1990s, many hospitals reduced RN positions—but this approach often backfired. With fewer nurses, patient care deteriorated and the savings gained by eliminating RN positions were offset by increased costs resulting from:

  • higher nurse turnover (at a high price per nurse)
  • increased long-term disability problems of nurses
  • more malpractice lawsuits and bad publicity resulting from increased patient morbidity and mortality linked to decreased patient surveillance and failure to rescue.

Patient surveillance (monitoring) is a primary activity of nurses; with fewer nurses on staff, patient surveillance suffers. Citing a review of 81 studies, the 2004 IOM report states that nursing surveillance is one of three organizational variables consistently related to lower patient mortality.

Enhancing the nurse-patient ratio
Strategies that Magnet hospitals have used to improve the nurse-patient ratio include:

  • extending or enhancing RN staffing rather than substituting UAP for RNs
  • planning assignments to enhance patient care, such as with homogeneous patient clinical groupings
  • developing float teams of nurses based on clinical conditions, which allows nurses to function well even during times of short-staffing
  • formulating unit-specific recommended levels of nurse-patient ratios. (However, this poses difficulties because nurse-patient ratios are complex and involve many variables.)

Nursing autonomy
Autonomy refers to individual decision making in nursing practice—the freedom to assess and provide actions appropriate for patient care and to establish standards, set goals, monitor practice, and measure outcomes. Clinical autonomy is based on the structure and philosophy of the hospital and must be accompanied by competence, professional expertise, and knowledge. Nurses in Magnet hospitals consistently cite clinical autonomy as important to delivering high-quality patient care. They see themselves as capable of making decisions about patients’ care needs—and Magnet hospitals offer the environment that makes this possible.
Nurses in the 1983 Magnet study stressed the importance of autonomy, professional recognition, and the ability to practice nursing as it should be practiced. Across various research studies done over the past few decades, nurses have continued to view autonomy as integral to job satisfaction. What’s more, autonomy is linked to positive patient outcomes. One study found that greater nursing autonomy leads to better patient outcomes and reduced mortality rates.

Strategies that Magnet hospitals use to enhance nursing autonomy include:

  • ensuring strong, visible nursing leadership to set expectations for independent actions and to support them
  • decentralizing control over patient care decisions to frontline clinicians and nurse-managers
  • initiating patient care programs at the unit level
  • implementing empowerment strategies that support auton­omy.

Control over nursing practice
Control over nursing practice refers to organizational autonomy—the freedom to take the initiative in shaping unit and hospital patient care policies and in accessing organizational resources needed to provide care. Nurses with control over their practice enjoy an increased sense of respect, status, and recognition within the hospital and a sense that they’re valued members of the healthcare team. According to one study, patients are more satisfied with their care when nurses have control over their practice.

Control over nursing practice and nursing autonomy are interactive concepts. Both are critical to empowering nurses and motivating their job satisfaction and retention. And both rely on competent nurses who can initiate therapeutic actions and patient care programs and who can be held accountable for these initiatives.

Magnetic convergence of staffing, autonomy, and control over practice
Magnet hospitals use their Magnet label to advertise and attract both nurses and patients. Their Magnet characteristics provide an atmosphere that empowers nurses to function autonomously, which contributes to job satisfaction and lower turnover. Nurses in Magnet facilities are more likely to perceive themselves as having control over their practice, being able to tailor patient care as appropriate, and having organizational support.

It has been 24 years since the first Magnet hospital study was published. Even then, nurses knew a favorable nurse-patient ratio means better patient care and more satisfied and productive nurses. They also knew autonomy can give them the tools required to best meet their patients’ needs. Research conducted since then provides more evidence to support these perceptions.

Selected references
Aiken L, Havens D, et al. The magnet nursing services recognition program: a comparison of two groups of magnet hospitals. Am J Nurs. 2000;100(3):26-36.

Aiken L, Sloane D, Lake E, et al. Organization and outcomes of inpatient AIDS care. Med Care. 1999;37(8):760-772.

Havens D. Comparing nursing infrastructure and outcomes: ANCC magnet and nonmagnet CNE’s report. Nurs Econ. 2001;19(6):258-266.

Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, D.C.: The National Academies Press; 2004. Available at: Accessed February 15, 2007.

Kramer M, Schmalenberg C. Essentials of magnetic work environment: part 1. Nursing2004. 34(6):50-54, June 2004.

McClure M, Poulin M, Sovie M, Wandelt M. Magnet Hospitals: Attraction and Retention of Professional Nurses. Washington, D.C.: American Nurses Association; 1983.

Ritter-Teitel J. The impact of restructuring on professional nursing practice. J Nurs Adm. 2002;32(1):31-41.

Silbur J, Rosenbaum P, Ross R. Comparing the contributions of groups of predictors: which outcomes vary with hospital rather than patient characteristics? J Am Stat Assoc. 1995;90(425):7-18.

Sovie M, Jawad A. Hospital restructuring and its impact on outcomes. J Nurs Adm. 2001;

For a complete list of selected references, see April 2007 references.

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