professional development. Many of the leadership and management practices cited previously (providing strong leadership, managing change, creating and sustaining trust throughout the organization, involving workers in decision making pertaining to work design and work flow, and establishing the organization as a learning organization) have been documented as present in magnet hospitals.4

In a series of six surveys between 1985 and 2001, Kramer and Schmalenberg refined the original set of magnet characteristics. Their studies included a subset of 16 of the original magnet hospitals, selected by geographic location. The surveys involved interviews of CNEs, staff nurses, nurse managers, and clinical experts (Kramer, 1990a,b; Kramer and Schmalenberg, 1988a,b, 1991, 1993; Kramer et al., 1989). In these surveys, eight essential characteristics associated with magnetism were again identified by two-thirds or more of the staff nurses interviewed. They included working with clinically competent nurses (an essential element of trust), nurse autonomy and accountability, having a supportive nurse manager/supervisor (a component of both leadership and trust), control over nursing practice, and educational support (Kramer and Schmalenberg, 2002).

Two studies have examined patient mortality rates in relation to magnet hospital status. In the late 1980s, 39 magnet hospitals were compared with 195 nonmagnet matched hospitals using Medicare mortality rates. Adjusting for differences in predicted mortality for Medicare patients, the magnet hospitals had a 4.6 percent lower mortality rate, which translates to 0.9 to 9.4 fewer deaths per 1,000 discharges (Aiken et al., 1994). In a second study, patients with AIDS in magnet hospitals and those with AIDS in nonmagnet hospitals with and without designated AIDS units were compared. Patients in the magnet hospitals had a lower chance of dying than those in the nonmagnet hospitals regardless of the existence of designated AIDS units (Aiken et al., 1999). In the early 1990s, the American Nurses’ Association, through the American Nurses’ Credentialing Center (ANCC), established a formal certification program through which hospitals and nursing homes may apply for “magnet status.” The criteria for selection are based on the characteristics originally identified, as well as on specific standards of practice and administration.


In the above studies, the major administrative determinant of magnetism was found to be the quality of leadership from the CNE (Kramer and


The studies of magnet hospitals have also identified other important practices, such as maintaining adequate staffing levels and professional nurse–physician relationships. These other characteristics of magnet hospitals are discussed in the relevant chapters of this report.

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