Do Magnet®-accredited hospitals show improvements in nurse and patient outcomes compared to non-Magnet hospitals: a systematic review

BACKGROUND: The Magnet model proposes an accreditation for hospitals having demonstrated a healthy work environment and, as a result, positive staff and patient outcomes. Yet there are conflicting findings surrounding the actual impact of Magnet's organizational model on these outcomes, as well as a wide range of designs influencing the quality of these results. OBJECTIVES: To conduct a systematic review that explores the effect of Magnet accreditation on objective nurse and patient outcomes. INCLUSION CRITERIA: TYPES OF PARTICIPANTS: Magnet and non-Magnet accredited hospitals matched according to their similarity (e.g. size, type [urban or rural], level of acuity, location, etc.). Hospitals could be either university based or non-teaching hospitals and in any geographical location. As the focus of the study was outcomes specific to Magnet accreditation, studies reporting on "reputational Magnets" (the original hospitals), Magnet-aspiring and non-Magnet hospitals alone were excluded from the review. TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST: Exposure to Magnet accreditation. A Magnet hospital is defined as a hospital with American Nursing Credentialing Center -designated Magnet status at the time of study and having received this accreditation in the last four years, as this is the length of time for which the accreditation is valid, after which the hospital must reapply for another four-year accreditation. TYPES OF STUDIES: This review considered any quantitative study comparing nurse and patient outcomes in Magnet accredited hospitals with those in non-Magnet hospitals. Controlled clinical trials, controlled before and after and interrupted time series were considered first. When these were not available, case-controlled, descriptive comparative and descriptive correlational designs were considered. All studies presenting a "case study" with no comparison and other studies reporting on interviews and other qualitative data were excluded. TYPES OF OUTCOMES: The outcomes of interest were nurse outcomes related to turnover and absenteeism, as measured by the actual turnover rate if available, or the Anticipated Turnover Scale, the Revised Nursing Work Index or the Maslach Burnout Inventory, as well as nursing-sensitive patient outcomes (such as fall rates and hospital-acquired pressure ulcers) as measured by retrospective patient records, discharge abstracts, incident reports and reimbursement forms. SEARCH STRATEGY: Both published and unpublished literature between 1994 and 2014 were searched. The electronic databases searched were the following: CINAHL, MEDLINE, EMBASE, Academic Search Complete and Web of Science. Other resources included ProQuest Dissertations & Theses Database /Dissertation Abstracts Online and OpenGrey, the American Hospital Association and the American Nurses Credentialing Center websites, and the Sigma Theta Tau International library of abstracts. In April 2015, a search update was conducted including the years 2014-2015 in the databases listed above. METHODOLOGICAL QUALITY: No cut-off point for the Joanna Briggs Institute appraisal tool criteria was selected for inclusion of studies. DATA EXTRACTION: Data from included studies were extracted using the Joanna Briggs Institute Data Extraction Form for experimental/observational studies. Two reviewers extracted the data independently and results were compared for accuracy and categorized according to nurse and patient outcomes. DATA SYNTHESIS: All the studies analyzed retrospective data obtained from either combined databases or from questionnaires. The methodological heterogeneity and poor quality of the designs did not make it possible to pool quantitative results in a statistical meta-analysis. Results are presented in descriptive narrative form. RESULTS: From the 141 screened studies, ten met the inclusion criteria. Nine of these studies were retrospective analyses of data extracted from existing databases, one study collected original data. Of the seven studies examining patient outcomes, three found clear statistically significant improvements related to lower pressure ulcers, patient falls, failure to rescue and 30-day inpatient mortality in Magnet hospitals compared to non-Magnet hospitals. In the studies examining nurse outcomes, three found statistically significant improvements related to higher job satisfaction and lower intent to leave and turnover rates in Magnet compared to non-Magnet hospitals. CONCLUSIONS: Based on the mixed results and poor quality in the research designs in the ten included studies, it was not possible to conclude that Magnet accreditation has effects on nurse and patient outcomes. There is a need for more robust designs that can confidently measure the impact of hospital accreditation on objective outcomes. The Joanna Briggs Institute.