Leadership & Managing People: How Great Nursing Improves Doctors Performance
Every physician can think of a time — probably many — when a nurse has saved the day. And indeed ample research shows that programs that foster a culture of excellent nursing have sweeping impacts throughout health care organizations. Hospitals participating in these initiatives see higher nurse satisfaction and retention, improved patient experience and safety, decreased mortality, increased revenues, and many other benefits. Our research adds to this body of work, showing a positive association between nursing excellence and physicians’ performance. Before we discuss these findings, let’s look at one of the most rigorous and effective of these nursing-excellence initiatives, the Magnet Recognition Program, developed by the American Nurses Credentialing Center (ANCC), a subsidiary of the American Nurses’ Association. Our research focused specifically on hospitals that have achieved “Magnet” designation.
The program grew out of a 1983 American Academy of Nursing task force study of the factors that contributed to regional nursing shortages and ways to improve nursing practice. The task force identified 14 shared characteristics that set high-performing hospitals apart and later organized these into the five-component “magnet model” framework for nursing practice and research that serves as a roadmap for organizations seeking to achieve Magnet recognition. The five components are: transformational leadership that creates a vision for the future and the systems and environment for achieving it; structural empowerment — the policies and programs that support staff as they pursue organizational goals: exemplary professional practice, innovation, and “empirical quality results” categorized in terms of clinical outcomes related to nursing, and workforce, patient, and organizational outcomes. The Magnet Recognition Program evaluates hospitals’ performance on each of these and only grants Magnet status to an elite few; fewer than 10% of US hospitals have earned this designation.
It is little wonder that relatively few hospitals achieve this. It takes hospitals an average of three to five years to attain the designation, and getting there costs an average of $500,000 annually, for a mean total investment of more than $2 million. (However, research indicates that hospitals recoup this investment within a few years through lower personnel costs and better outcomes.)
In our research, we looked at the association between superior nursing (as indicated by Magnet status) and hospital scores on the national HCAHPS patient satisfaction survey as well as within Press Ganey’s database of over 2,000 health care organizations. HCAHPS gathers patients’ feedback on many aspects of their hospital experience from the hospital environment, quality of the food, and staff responsiveness to how well doctors and nurses communicate with them (Do they listen? Are they respectful? Do they explain things well?). The survey also asks for an overall rating of the hospital. Ratings are often expressed in terms of the “top box” score — the percentage of patients who give the hospital a superior score on a given measure. We found that Magnet hospitals outperformed the non-magnet hospitals on patients’ “likelihood to recommend” top box scores (75.7 compared to 70.8) and we saw a similar spread on the “overall rating score” (76.0 vs. 72.8). We also saw a smaller but significant difference on patient assessment of physician concern about the patient’s questions or worries, which gauges courtesy and respect, listening, and explaining.
Press Ganey’s proprietary survey also revealed a meaningful association between Magnet status and higher patient ratings of physicians’ skill, response to concerns, time spent with the patient, friendliness and courtesy and other measures. Mean scores for Magnet facilities ranged from 84.6 for “time physician spent with you” to 93.2 for “skill of the physician” while mean scores for non-Magnet facilities ranged from 83.6 to 92.1 for the same questions. These may appear to be subtle differences but they are meaningful. Even a few points change in mean score has a dramatic effect on the percentile rank due the tight compression of scores nationally; for example, an increase of just two points on a mean score (from, say about 88 to 90) can mean the difference between being in the 50th percentile versus the 75th. Finally, our analysis of data from 123 Press Ganey client hospitals across the U.S. found that 45% of those in the top quartile for physician engagement were designated as Magnets; only 16% in the bottom quartile were Magnet facilities. The Magnet designation identifies an organization’s commitment to excellence. However, the journey to excellence does not require achieving Magnet status. The nursing culture of Magnet with its emphasis on quality, autonomy, relationships, and leadership emanates far beyond nursing, inspiring staff at all levels, including physicians. It requires the commitment to transformational change that drives improvement in clinical excellence, workforce engagement, safety, and the patient experience — and an appreciation of how these are intertwined.
About The Authors
Christina Dempsey, DNP, RN, is the Chief Nursing Officer of Press Ganey. She is a Fellow in the American Academy of Nursing and a board member of the American Organization for Nursing Leadership.
Thomas H. Lee, MD, is the chief medical officer of Press Ganey. He is a practicing internist and a professor (part time) of medicine at Harvard Medical School and a professor of health policy and management at the Harvard T.H. Chan School of Public Health.
