Abstract

Background: The Magnet Recognition Program® is considered one of the best programs around the globe that recognizes healthcare organizations for nursing excellence in providing high-quality nursing care. Purpose: the purpose of the current study was to identify nurses’ attitudes and perceptions regarding the Magnet program components as a preliminary step in the Magnet process at King Abdullah Medical City (KAMC). Methods: A descriptive, cross-sectional design employing a survey approach was utilized. A sample of 438 registered nurses employed at KAMC completed the Demographic Data Questionnaire and the Nurses’ Perceptions Regarding the Magnet Program Questionnaire that was developed for the purpose of this study. Descriptive statistics were employed to identify the percentage of participants' agreement regarding various domains related to the Magnet Recognition Program®. Results: Most respondents were females (61.2%), aged 20-30 years (82.4%), and have a Bachelor Degree in nursing. Overall, the respondents have demonstrated positive perceptions and high levels of agreement regarding the various domains of the Magnet program. Only few items had a percentage of agreement less than 80%. Conclusion: Most nurses working in KAMC support the initiation of the culture of excellence in the areas where they are working. However, nursing administrators in KAMC may want to empower their staff to assure their readiness to starting the Journey to Magnet Excellence®.

1. Introduction and Literature Review

The American Nurses Credentialing Center (ANCC) Magnet Recognition Program^® is considered one of the best programs around the globe that recognizes healthcare organizations for nursing excellence in providing high-quality nursing care ¹. In addition, it recognizes health care institutions that show innovations in professional and evidence-based nursing practice. This Magnet Recognition Program^® is considered a “Gold standard” for the health care institutions that demonstrate excellence in nursing practice and nursing care provided for patients ¹.

Recently, Magnet hospitals have shown an excellence in nursing care, nursing leadership and management style, organizational structure, autonomy, nursing image, and professional development ^{2, 3, 4}. In addition, Magnet hospitals were found to have better outcomes in various aspects than non-Magnet hospitals ^{3, 5}. Therefore, Magnet recognition is an indication that the healthcare organization strives to improve various patient outcomes such as patient satisfaction and the quality of care provided for the patient ⁶. The achievement of such outcomes can be enhanced by nursing excellence that is associated with a high quality of care and high quality nursing services ⁷.

Literature revealed that Magnet Program has positive outcomes on nurses' job satisfaction and nurses productivity in the clinical health care setting ^{8, 9, 10}. Consequently, applying the Magnet Recognition Program® will have a vital role in improving the hospital environment, enhance the productivity of nurses, and increase their job satisfaction ¹¹. In addition, it will empower autonomy in decision making at bedside by nurses, build a culture of shared governance, and enhance evidence-based practices ^{12, 13}.

Nursing excellence requires well-planned steps, strategic planning, transformational leadership, and introducing the change in an effective manner ¹⁴. Nursing excellence is usually connected with improvements in working environments and patients' outcomes ¹⁵. In order to be a Magnet hospital, various hospitals worldwide have reported journeys of success by involving health care professionals in the change and developing and applying specific standards and policies ^{14, 16, 17}.

One of the large hospitals that is going to be a Magnet recognized one is the King Abdullah Medical City (KAMC). The KAMC is located in the Western region of the Kingdome of Saudi Arabia in Mecca city. The KAMC is a tertiary and quarterly hospital that provides highly specialized services for patients in Mecca region and in Saudi Arabia as a whole. To meet the international standards, nursing administrators in KAMC work hard to improve the nursing services and to assure high quality of nursing care. In addition, nursing administrators in KAMC conduct continuous training for nurses to assure covering all specialties in the hospital with highly skilled nurses. Furthermore, the KAMC has adopted recent clinical practice guidelines and involved clinical nurses in various leadership roles that have positive influences on patients.

As a part of nursing strategic planning at KAMC to enhance the culture of patient safety and to encourage nurses to provide evidence-based practice, hospital administrators are planning to make the hospital recognized by the Magnet Recognition Program®. Recently, various evidences have shown that Magnet Recognition Program® is important for nursing administrators to achieve an excellence in nursing care ^{5, 15, 18}. Considering this, applying Magnet Recognition Program® Model at King Abdullah Medical City is important to allow nurses lead the change, enhance their leadership abilities, and involve them in shared governance. However, before applying Magnet Recognition Program® Model at King Abdullah Medical City, there is a need to identify nurses' attitudes and perceptions regarding the Magnet programs and its components. Little is known about the nursing perceptions toward magnet programs or its components in a setting that not yet introduced any structural plans for excellence program journey. The main objective of this study is to describe and investigate the nurses’ perception toward magnet program at initial and preparation phases. This is an important step in change management that emphasizes on shared governance principles. Therefore, the purpose of the current study was to identify nurses’ attitudes and perceptions regarding the Magnet program® components and to identify the aspects of the Magnet program components that nurses do not strongly agree with them. The current study is important to assess nurses' readiness to implement the Magnet program and to implement specific intervention programs based on the identified nurses’ attitudes and perceptions.

2. Methods

A descriptive, cross-sectional design employing a survey approach was utilized for this study.

All nurses working in KAMC were eligible to enroll in the study. The total number of these nurses was 900 nurses. Those nurses came to Saudi Arabia from 10 countries including Egypt, Philippines, Yemen, Jordan, Pakistan, Lebanon, India, Turkistan, United States and Malaysia. Staff nurses who were on any type of leave at the time of the study and those who had less than one year experience were excluded from the study. Among the 900 nurses working in KAMC, 610 met the inclusion criteria. Hence, a convenient sample of 610 potential participants were invited to complete the study.

The Demographic Data Questionnaire was developed for the purpose of this study to identify the basic characteristics of the participants who involved in the current study. The questionnaire asks the respondents to provide data about their age, gender, education, current position at KAMC, current department where they work at KAMC, KAMC nursing experience, nursing experience outside KAMC, experience in Western hospitals, and experience in accredited hospitals.

For the purpose of the current study, a structured questionnaire was developed by the principal investigator to assess the nurses’ perceptions regarding the Magnet program at KAMC. The major purpose of this tool was to assess the perception of staff nurses towards Magnet models application at KAMC. This questionnaire was developed with reference to the Magnet Recognition Program® Manuals published in 2014 and 2019 after obtaining an official permission to do so from the ANCC. The questionnaire contains 73 items rated on a 3-point Likert scale including agree, neutral, and disagree options. It has nine subscales including professional development (9 items), shared governance (7 items), nursing recognition (7 items), patient experience (10 items), staff satisfaction (14 items), clinical practice (6 items), unit key performance indicators (7 items), administration support (9 items), and community development (4 items). The participant can rate each item based on his or her own perception. The questionnaire items were reviewed by the Director of Research at ANCC. In addition, the content validity of the questionnaire was assured by a panel of experts who assured the clarity and relevance of each item.

Before data collection taking place, the IRB approval was obtained from the responsible research committee at KAMC. Privacy and confidentially of participants' information were assured as participants were not asked to write their names or IDs. The ethical rights of all participants were assured through the course of the study. In addition, their participation in the study was voluntarily. Description of the study background, purpose, and methodology was provided for all participants. All participants signed a consent form and they were provided with an information sheet in addition to the study questionnaires. The information sheet included all the information that participants need to know about the study. Participants were provided with the contact information of the primary researcher who responded to the respondents' calls and answered all of their questions about the study. In addition, respondents were allowed to withdraw from the study at any time they want. Data were kept at a safe and locked place at the office of the primary researcher.

After the protocol of the study was approved by the IRB committee at King Abdullah Medical City, the researcher met the head nurses and nursing administrators at all the units and floors of the hospital and assured their cooperation in conducting the current study. Then, the researcher identified the participants who met the inclusion criteria and invited them to participate in the study. The author asked all participants to sign the consent form and allowed them to read a detailed description about the study before completing the study questionnaires. Data collection was performed during the first quarter of year 2017 and lasted for three consecutive months. Among the 610 nurses who met the inclusion criteria, 438 agreed to participate and returned completed questionnaires, representing a response rate of 71%

Data analysis was performed using the SPSS software version 22. Descriptive analysis including frequency and percentage was used to describe the demographic characteristics of the study participants. In addition, the descriptive statistics were used to identify the percentage of participants who responded with "agree", "neutral", and "disagree". Missing data were handled using pairwise deletion using the SPSS software.

3. Results

Table 1 presents the demographic characteristics of the study participants. Most of the respondents were females (61.2%) and have a Bachelor Degree in nursing (82.4%). In addition, the majority of respondents (64.6%) aged 20-30 years. This indicates that most nurses employed at KAMC are young. Regarding the position of participants, most of them held position of RN1 and RN2, which also emphasizes that most of them are young. Furthermore, the majority of participants (69.4%) had experience less than five years in KAMC. Only 5.3% of the respondents mentioned that they had experience in working in Western countries. However, a large percent of the respondents worked previously in other local or foreign hospitals. About 55% of the participants have an experience in accredited hospitals. Finally, most of the respondents are working in critical care units (40.4%) and in-patient settings (33.3%).

Regarding the professional development subscale, agreement was high for all items (Table 2). The item that had the highest percentage of agreement was item five. The agreement of this item was 91.34%, indicating that most participants value the role of continues education to enhance the skills and knowledge of nurses. The second highest percentage of agreement was reported for item seven, with a percentage of agreement about 89.7%. This item emphasizes on the importance of leadership development programs to advance the staff and the department performance. The item that had the lowest percentage of agreement among all the professional development items was item one, with a percentage of agreement of 83.9%. This item was concerned with applying higher nursing standards to support the professional development of nurses. The percentage of agreement for all other items regarding professional development subscale are shown in Table 2.

Regarding the shared governance subscale, agreement was high for most items (Table 3). The item that had the highest percentage of agreement was item 10. The agreement of this item was 89.23%, indicating that most participants value the importance of Shared decision making in the workplace. The second highest percentage of agreement was reported for item 14, with a percentage of agreement about 88.22%. This item emphasizes on the importance of allowing nurses to participate in decision making at the unit levels to enhance their autonomy. It is noteworthy to mention that two items related to shared governance had percentage of agreement less than 80. These items are item 15 and item 16. These items are related to allowing the respondents to speak about their rights in a hospital committee and nurses participation in councils and committees. These percentages are considered alarming signs for nursing administration who need to develop specific interventions to empower their staff in the future. The percentage of agreement for all other items regarding shared governance subscale are shown in Table 3.

Regarding the nursing recognition subscale, agreement was high for all items (Table 3). The item that had the highest percentage of agreement was item 19, which is concerned with staff satisfaction, with an agreement percentage of 93.01%, followed by item 21 regarding the importance of system recognition, with an agreement percentage of 91.42%. The item that had the lowest percentage of agreement among all the nursing recognition items was item 17(with a percentage of agreement = 83.9%), which indicates a relationship between the recognition of the good work by the unit management and staff satisfaction. The percentage of agreement for all other items regarding nursing recognition subscale are shown in Table 4.

Participants' responses regarding the patient experience are presented in Table 5. Overall, agreement was relatively high in all items of this domain. The item that had the highest percentage of agreement was item 31, which is related to training and educating patients to improve patient experiences, with an agreement percentage of 94.66%, followed by item 30, which is related to importance of effective nurse-patient communication to improve patient experiences, with an agreement percentage of 94.04. The item that had the lowest percentage of agreement was item 28 (with a percentage of agreement = 79.87%), which suggest that accreditation of the hospital will make patients and their family happy. The percentage of agreement for all other items regarding patient experience subscale are shown in Table 5.

The percentages of agreements on the items of staff satisfaction ranged from 77.88% to 94.54% (Table 6). The item that had the highest percentage of agreement (94.54%) was item 47, which is related to the importance of equality in treating nurses, followed by item 39 with an agreement percentage of 93.79%, which emphasizes that nursing satisfaction would enhance their clinical practice. The item that had the lowest percentage of agreement (77.88%) was item 32, which suggests that staff satisfaction increases if they participate in nursing councils or committees. The percentage of agreement for all other items regarding staff satisfaction subscale are shown in Table 6.

Overall, all items regarding the clinical practice domain had a high percentage of agreement, ranging from 83.58% to 91.15% (Table 7). The item that had the highest percentage of agreement was item 53, which reflects the role of hiring process in recruiting talented nurses, followed by item 48 with an agreement percentage of 90.57%, which emphasizes on the role of care delivery system in improving the clinical practice. The item that had the lowest percentage of agreement was item 52, which suggests that participating in a council or a committee has a role in enhancing the clinical practice. The percentage of agreement for all other items regarding clinical practice subscale are shown in Table 7.

Overall, all items regarding the unit key performance indicators domain had a high percentage of agreement (Table 8). The two items that had the highest percentage of agreement were item 54 and item 60, with percentages of agreement equal 87.47% and 87.78% respectively. These items were related to the role of the unit key performance indicators in enhancing the unit performance and enhancing the clinical practice. The item that had the lowest percentage of agreement was item 58, which suggests that the unit specific indicators need to be a part of nurses' performance appraisal. The percentage of agreement for all other items regarding unit key performance indicators subscale are shown in Table 8.

Regarding the administration support subscale, agreement was high for all items (Table 9). Nursing who participated in the survey had the highest agreement regarding the item 61, reflecting their interest in having a voice in top hospital committee (with percentage of agreement = 92.40%). The item with the second highest agreement was item 66, regarding the importance of the unit management support to achieve nursing excellence (with percentage of agreement = 90.55%). The item that had the lowest percentage of agreement was item 67, which suggests that specific accreditation for nurses will increase nurses power (with a percentage of agreement = 85.20%). The percentage of agreement for all other items regarding administration support subscale are shown in Table 9.

Among the four items included in the community development subscale, the item that had the highest percentage of agreement was item 73, with an agreement percentage of 85.85%, which emphasizes on the role of nurses in increasing the awareness of the community outside the health care organization. However, item 71 had the lowest mean score, as only 76.95% of the participants think that they have a role to support their patients or the family members of the patient outside the hospital settings. The percentage of agreement for all other items regarding community development subscale are shown in Table 10.

4. Discussion

The purpose of the current study was to identify nurses’ attitudes and perceptions regarding the Magnet program components among staff nurses employed in KAMC. In the current study, most participants were young. This could be related to the attitude of nursing administrators who might prefer hiring young staff nurses who are active and motivated at work. Furthermore, the majority of participants (69.4%) had an experience of less than five years in KAMC, which could indicate a high turnover rate for nurses. About 5% of the respondents had an experience in Western hospitals. This could be due to the fact that there is a difficulty of recruiting non-Muslim nurses related to the Islamic regulations that allow only Muslims to enter the Holly Capital of Mecca where the hospital is located. More than half of the respondents have an experience in accredited hospitals. This might increase their awareness regarding the Magnet program components. The high percentage of respondents who are employed in critical care units could be due to the fact that KAMC has various critical care units and services as it is the only governmental tertiary hospital in Mecca Region.

Overall, the respondents have demonstrated positive perceptions and high levels of agreement regarding the various domains of the Magnet program and its components. As shown by the study results, most of the 73 items included in the questionnaire had an agreement percentage of more than 80%. These outcomes suggest a consensus among the study participants regarding the importance of applying the Magnet Recognition Program® to achieve an excellence regarding various domains in KAMC. These outcomes are expected for various reasons. In fact, nurses are the cornerstone of any health care system and recognizing their excellence in providing high quality of care for their patients is important. The Magnet Recognition Program has devoted more emphasis on excellence in nursing practice through the improvement of professional practices that enhance patient outcomes ⁸, which is a preferable outcome for nurses. In addition, this program provides valuable standards for all nursing administrators working in the health care institutions. Besides that, it applies international standards to improve and maintain high quality nursing clinical practice and using of nursing research to produce evidence-based knowledge that guides the clinical practice.

It is noteworthy to indicate that a few items received an agreement percentage between 72.22% and 79.87%, which have important recommendations for nursing administrators working in KAMC. Nursing administrators in KAMC my want to empower nurses regarding the aspects included in these items by developing specific intervention programs to make nursing workforce better prepared for accepting the standards identified by the Magnet program. These intervention programs need to focus on providing nurses with a chance to speak up for their rights in unit committee and increasing the role of unit committee in advancing leadership skills as a reflection of shared governance domain. In addition, the intervention programs need to increase the role of nursing committee in responding to nurse's needs to improve staff satisfaction. Furthermore, patients and their family members need to be provided with some information regarding the positive consequences of hospital accreditation to be supportive of Magnet accreditation at KAMC and improve patient experience domain. Finally, there is a need to recruit Magnet Recognition Program® Related researches who are able to assess the needs of nurses during their journey for excellence.

5. Conclusion

The current study concluded that most of the nurses working in KAMC demonstrated positive perceptions regarding the components of Magnet Recognition Program®. Therefore, nurses working in KAMC support the initiation of the culture of excellence in the areas where they are working. However, nursing administrators in KAMC my want to empower nurses regarding some aspects by developing specific intervention programs to make nursing workforce better prepared for accepting the standards identified by the Magnet program. Finally, policymakers should carefully consider the importance of Magnet recognition and initiate specific steps to facilitate the Magnet accreditation of KAMC by the ANCC in the future.

References