JONA
Volume 34, Number 7/8, pp 365-378
Development and Evaluation
of Essentials of Magnetism Tool
Marlene Kramer, RN, PhD, FAAN
Claudia Schmalenberg, RN, MSN
Staff nurses in 14 magnet hospitals identified 8 at-
tributes associated with the original concept of
magnetism as essential to their ability to give qual-
ity care. The 8 Essentials of Magnetism (EOM) tool
was generated from participant observation and in-
terviews with 289 magnet hospital staff nurses. The
psychometric properties of the EOM tool were es-
tablished in a study involving 3602 staff nurses in
16 magnet and 10 nonmagnet hospitals. The au-
thors discuss the EOM tool and its use in diagnos-
ing elements needed in the environment to produce
what staff nurses say is essential for productivity of
quality patient care.
What are the essential attributes of a magnetic
work environment that attracts and retains nurses,
provides them with job satisfaction, and enables
them to give quality patient care?1 Two decades ago
to describe such an environment, the investigators
developed the Nursing Work Index,2 based on Kor-
man3 and Locke’s4 need fulfillment theory. Job satis-
faction and productivity are the products of the rel-
ative importance of an attribute to the individual’s
work-related and personal needs. The multiplica-
tive model5 was used. For an organizational at-
tribute to be a job satisfier and/or a factor enabling
quality patient care, both the valuation of the orga-
nizational attribute judged to be important for job
Authors’ affiliations: Vice President, Nursing (Dr Kramer),
Health Science Research Associates, Apache Junction, Ariz; Research
Associate and Consultant (Ms Schmalenberg), Health Science Re-
search Associates, Tahoe City, Calif.
Corresponding author: Dr Kramer, Health Science Research As-
sociates, 3285 N. Prospector Rd, Apache Junction, AZ 85219
(mcairzona@juno.com).
JONA • Vol. 34, No. 7/8 • July/August 2004
©2004, Lippincott Williams & Wilkins, Inc.
satisfaction and work productivity, and the pres-
ence of the attribute in the work environment must
be determined. Attributes present but not valued do
not contribute to job satisfaction or enable quality
care.
The Nursing Work Index
The Nursing Work Index (NWI) tool, constructed
in 1984 by the investigators on the basis of attrib-
utes and traits identified as related to a magnet
work environment, has been useful in distinguish-
ing differences in staff nurse job satisfaction and
productivity of quality care in magnet and nonmag-
net work environments.2,6-10 There is considerable
evidence that the NWI is now outdated. What was
useful, innovative, and important to magnetism, job
satisfaction, and productivity in 1984 is not neces-
sarily the same in 2004.
During the past 15 years, many of the 65 items
on the NWI have never been selected by magnet
hospital staff nurses as important to either their job
satisfaction or enabling them to give quality patient
care. The relevance and importance of these items
to magnetism, to an exciting and rewarding work
environment, one that attracts, retains, satisfies,
and enables quality patient care,1,2 is therefore in
question.
Many items on the NWI lack a commonly
shared and understood definition. Collaborative
Practice Programs (CPP), the product of the Na-
tional Joint Practice Commission (NJPC) sponsored
jointly by the American Nurses Association (ANA)
and American Medical Association (AMA), were at
the cutting edge of professional practice in the
1980s.11 With the withdrawal of AMA support,12
365
there was a dramatic and noticeable decline in all
activities related to CPP—initiation, research, pub-
lication—so that many nurses today have little or
no understanding of the NWI item “functional col-
laboration (joint practice) between nurses and
physicians” other than that “it sounds good, and I
know I should be for it” (2001 interview with mag-
net hospital staff nurse). Items containing words
such as “autonomy,” “control over practice,” and
“professional model” are vague and lack common
definition and understanding.13,14
There is also confusion and logical inconsis-
tency with regard to the validity of the subscales on
the NWI. An item such as “staff nurses actively
participate in developing their work schedules”
fits the definition and domain of control over
nursing practice as reported by magnet hospital
staff nurses14 but is not included in the control
over nursing practice subscale. Another item,
“nursing controls its own practice,” loads on the
autonomy subscale but not on the control over
nursing practice subscale.
In the factor analysis of a recent study based
on NWI data collected in 1984, Lake15 found that
the autonomy subscale identified by Aiken and Pa-
trician16 using the same 1984 NWI data had disap-
peared entirely. Finally, organizational attributes,
such as evidence-based practice and critical path-
ways, that are now at the forefront of magnet envi-
ronments are not included on either the NWI or any
of its revisions or derivations.
The revisions made in the NWI by Aiken and
Patrician16 do not solve the NWI’s problems of out-
datedness or relevance to a magnetic work environ-
ment. The revised NWI no longer measures job sat-
isfaction or productivity of quality care, although it
continues to be used by researchers for this pur-
pose. (See Upenieks.17) It now measures only pres-
ence (not relative importance) of hospital organiza-
tional traits. Addition of items such as “team
nursing as a nursing delivery system” that do not
have a particular bearing on magnetism limit the
tool’s usefulness in distinguishing magnet from non-
magnet environments. There is also no opportunity
for respondents to differentiate between “old” and
“new” team nursing.18
In 1999, the investigators eliminated items sel-
dom or never chosen by magnet hospital staff
nurses as important to their job satisfaction or pro-
ductivity of quality care, reduced the number of
items from 65 to 37 items, included only items re-
lated to and indicative of a magnetic work environ-
ment, and labeled the tool “Dimensions of Magnet-
ism.”18 We know that work productivity and job
satisfaction are related intuitively19 and empiri-
366
cally.20 In our causal model study, we found that
both attraction and retention are highly correlated
with job satisfaction and that more than 80% of
nurse job satisfaction is attributable to being able to
give quality patient care.6,7 We therefore eliminated
the nurse job satisfaction component of the tool
and focused only on quality care productivity.
When presented with the Dimensions of Mag-
netism, staff nurses in 14 magnet hospitals identified
8 of the 37 traits as essential to being able to give
quality patient care.18 These 8 Essentials of Magnet-
ism (EOM), most of which are described by staff
nurses as processes that flow from structures and
lead to desired outcomes are: building and maintain-
ing good nurse–physician (RN-MD) relationships,
autonomous nursing practice, a culture in which
concern for the patient is paramount, working with
clinically competent co-workers, controlling nursing
practice, perceived adequacy of staffing, support for
education, and nurse manager support.
Tool Development
The first step in developing the EOM tool was to
ascertain how staff nurses working in magnet hos-
pitals defined these “essentials.” What do they
mean by control over nursing practice? What con-
stitutes a “good” RN-MD relationship? What are
the dimensions of nurse manager support? We
know from the literature that 3 of these essentials of
magnetism, autonomy (AUTO), control of or over
nursing practice (CNP), and good RN-MD relation-
ships, are particularly enigmatic and bereft of a uni-
versally agreed-upon definition.13,14,18,21
Mindful of Donabedian’s caution that to pro-
ceed to measurement without a firm foundation of
prior agreement on what constitutes the definition
and substance of a care process is to court disaster,19
we chose a multimethod approach,22 conducting a
qualitative study to obtain magnet hospital staff
nurses’ definitions and dimensions of AUTO, CNP,
and RN-MD, and then a quantitative study to eval-
uate the resulting scales. From 1990 to 1992, the in-
vestigators conducted week-long participant obser-
vations studies of hospitals desiring evaluation as
magnet hospitals.23 Observations and interviews of
nurses on every unit on every shift, as well as inter-
views with patients, physicians, hospital, and nurs-
ing administration yielded a plethora of data. In
2000 to 2001, the investigators visited 14 magnet
hospitals and conducted in-depth, individual, tape
recorded, on-site interviews with 289 staff nurses,
directors of education, and chief nurse executives
(CNEs), as well as group interviews with nurse
managers and clinical directors.18 During the staff
nurse interviews, the investigators elicited defini-
JONA • Vol. 34, No. 7/8 • July/August 2004
tions, dimensions, and examples of the 8 essentials
of magnetism.
A grounded-theory approach was used to gen-
erate themes, taxonomies, typologies, and theo-
ries.22 Grounded theory is a style of qualitative
analysis that follows certain methodologic guide-
lines, such as the making of constant comparisons
and using a coding paradigm to ensure conceptual
development,24 and stresses understanding of many
concepts and their linkages. A grounded-theory ap-
proach is particularly appropriate when concepts
and constructs to be explicated and ultimately mea-
sured are changeable, ill defined, misunderstood,
and not grounded in reality. A primary goal of the
grounded-theory approach is to continuously gen-
erate theory, at various levels of generality.25
Constant comparative26 and thematic, categori-
cal analyses27 were used to generate grounded the-
ory and develop ranked category scales for AUTO,
CNP, and RN-MD.18 Data obtained from the inter-
views with CNEs, clinical directors, nurse man-
agers, and directors of education provided the per-
spective and variability needed to ensure that the
resultant theories would be conceptually dense.
RN-MD Relationships
Items selected for the RN-MD scale were derived
from the 5 relationships identified through analysis
of staff nurses’ descriptions, illustrations, and ex-
amples of RN-MD relationships provided during
the interviews. Power was the primary underlying
continuum for the 5 kinds of relationships de-
scribed, with quality of outcomes as a secondary
source. Collegial (equal power/positive outcomes)
was the highest, ie, the most beneficial for the pa-
tient, type of RN-MD relationship; collaborative
(mutual, ie, both have power) was second highest;
and hostile, adversarial (physician only has power;
outcomes are negative) was the lowest of the 5
types of relationships.
Social Empowerment
Kanter’s theory of social empowerment28 provides
additional theoretical and empirical support for the
use of power to describe different kinds of relation-
ships. According to Kanter, power is the ability to
mobilize resources to get things done. Differences in
power can be measured by difference in access to
the “lines of power,” one of which is access to infor-
mation. Staff nurses are the gatekeepers to patients
and are the responsible agents for ongoing surveil-
lance. They control the physicians’ access to patient
status information, both by the assessments and ob-
servations they make and by nurses’ choice of what
JONA • Vol. 34, No. 7/8 • July/August 2004
information they transmit to the physician. Another
aspect of this line of power is how and what infor-
mation nurses choose to communicate to physi-
cians. This includes information about the urgency
of the patient’s condition, signs of “need to rescue,”
persistence or amelioration of signs and symptoms
beyond which the nurse considers to be acceptable
limits, and whether the orders provided by the
physician are “right”/sufficient for this patient and
his current problem.
Theory of Autonomy
Items for the AUTO and CNP scales were derived
from the theories emanating from the qualitative
study. On the basis of data analysis, the investiga-
tors constructed a theory of autonomy, ie, the men-
tal assembling, synthesizing, and integrating of the
who, when, what, why, and where of nursing au-
tonomy, and then constructed items to measure
each dimension of the theory. The theory of auton-
omy briefly follows:
Who?
Nurses engaged in autonomous practice judge
themselves to have the necessary knowledge, often
enabled by evidence-based practice, and perceive
that there is organizational sanction and nurse
manager support to do so. The latter are communi-
cated through trust, empowerment, not having to
do something against one’s better judgment, and
being held accountable in a positive, constructive,
rather than a blaming or punitive, manner.
Why and When?
Autonomous practice is necessary because the pa-
tient needs something now (an emergent situation);
what was ordered was not in the best interest of the
patient (patient advocacy motive); nurses judge that
they do not have sufficient or the correct orders
they need for this patient and his current problem;
or there is a need to rescue.
Where?
Autonomous practice occurs at the clinical interface
between patient, nurse, physician, and family, and
occurs in both the nursing sphere of practice and in
the sphere where nursing overlaps with the practice
of other disciplines, including medicine. During the
interviews, it became apparent that this overlapping
sphere of practice was of particular importance to
staff nurses in the practice of autonomy. Many felt
compelled to clarify that autonomous practice was
not a nurse practicing medicine, but rather it was a
nurse providing care that complements and at times
367
overlaps medical therapy.29 This overlapping sphere
of practice has also been recognized by the NJPC in
its guidelines for CPP.11
What?
Autonomy is the freedom to make independent de-
cisions that exceed standard nursing practice and
are in the best interest of the patient. Freedom
means without fear, not unduly inhibited by bu-
reaucratic rules, and not having to get consent, or-
ders, or permission first. The outcomes of au-
tonomous action are being held accountable for the
quality of patient care; lowered cost and length of
patient stay; increased patient satisfaction; and a
feeling of pride, competence, satisfaction, of really
making a contribution and a difference in this pa-
tient’s care, of being appreciated for the use of one’s
intelligence and expertise.
Control Over Nursing Practice
The empirically constructed theory upon which the
CNP scale is based is
Who?
Staff nurses, not administrators and others outside
of nursing, control nursing practice and contribute
to the formulation of departmental policies and is-
sues.
What?
Control equals input plus decision making. Some
kind of organizational committee structure (fre-
quently shared governance) is needed through
which staff nurses are enabled to exert CNP.
Where?
CNP occurs at unit, departmental, and hospital lev-
els and includes clinically focused issues, as well as
personnel issues affecting nurses. Control at the
unit level “is a beginning but it’s not really CNP
until nurses participate in departmental policy and
decision making” (2001 interview with magnet hos-
pital staff nurse).
When?
CNP has been achieved when there are discernible
outcomes “owned” by staff and when there is
recognition of nursing’s CNP by other professionals
and administrators. Two factors that might make it
appear as though “control” is there when it isn’t, is
a committee structure run by a small group to
the exclusion of others, and a committee structure
that is visible but is a rubber stamp, not decision
making.
368
Why?
Practice policies and issues formulated by staff
nurses are not only more efficient and accurate,
they also result in the patient receiving better care,
more cost-effective care, and nurses feeling more
professional, valued as employees, and more satis-
fied with their job and work. Items were con-
structed to measure all dimensions of this theory.
In a recent study, Laschinger presents convinc-
ing data that collective accountability is an impor-
tant component of professional autonomy.30 There-
fore, it ought to be included on scales that measure
CNP, which magnet hospital staff nurses define as
synonymous with professional autonomy.14 In our
observations and interviews, however, collective ac-
countability was never mentioned by a staff nurse,
or by any member of nursing administration whom
we interviewed. We therefore did not include such
an item on the CNP scale.
Other Measures
Items selected to measure the other 5 EOMs—sup-
port for education, clinical competence, cultural val-
ues, nurse manager support, and adequacy of
staffing—were conceptually derived from the partici-
pant-observation study,23 from the literature, and
from the 2001 qualitative interview study.18 The con-
tent domain for these essentials was sampled31 as the
constructs are relatively unambiguous, and it is not
always necessary for a cognitive measure to address
each and every aspect of the content area to fully rep-
resent the scope of the content. For the perception of
adequacy of staffing scale, our previous work on
nurse work force extenders8,32 was used, in addition
to dimensions obtained from the 2001 study.
Tool Administration
The EOM tool was administered to 3602 staff
nurses in 26 hospitals. Principal component factor
analysis (Table 1), using Varimax rotation with
Kaiser normalization, was run to identify subscales,
ie, factors.33 Items with a loading of .31 or better
were included on the subscale. The 65-item EOM
generated 10 factors. The first 8 factors contained
the clusters of items constituting the 8 EOMs but
not completely as designed. All items on the clini-
cally competent and support for education scales
loaded together on the same factor, instead of on 2
different factors. The nurse manager support items
loaded on 2 adjacent factors, with leadership activi-
ties clustering on one subscale and managerial ac-
tivities on the other. One value item (keeping physi-
cians happy) did not load on any factor and was
JONA • Vol. 34, No. 7/8 • July/August 2004
 Table 1. Results of Factor Analysis on Essentials of Magnetism Tool

Subscale and Conceptual Subscale and Conceptual

Component of Items Loading Component of Items Loading

Cultural values RN–MD relationships

Values known and shared 0.734 Collaborative: willing cooperation based 0.825
Proactive, anticipating changes 0.679 on mutual power
Transmits cultural values 0.671 Collegial: physicians treat nurses as equals 0.786
Contributions of all valued 0.649 Negative: frustrating and hostile 0.654
People are enthusiastic 0.620 Student–teacher: doctors teach nurses 0.639
Concern for patient is paramount 0.619 Student–teacher: RNs teach/influence doctors 0.610
Cost is important, but the patient comes first 0.601 Friendly stranger: formal information 0.427
Swift action 0.597 exchange only
High performance and productivity are expected 0.574 Clinically competent nurse/support for education
Interdisciplinary and intradisciplinary team 0.554 National certification is evidence of competence 0.579
Try new things 0.498 Work with clinically competent nurses 0.558
Control of nursing practice High clinical competence is rewarded 0.556
Practice issues and policies 0.676 Degree education is evidence of competence 0.479
Personnel policies and issues 0.629 Support to attend continuing-education programs 0.473
Recognition by doctors, administrators, 0.722 Financial assistance or time off offered 0.348
and others Few rewards for pursuing education 0.345
Visible, viable structure 0.681 Other professionals value nurses pursuing 0.342
Input but no decision making 0.486 education
Effective outcomes 0.663 Adequate staffing
Unit level only 0.590 Experienced versus new to the unit 0.798
Others outside of nursing decide 0.548 Good ancillary and support services help 0.722
Supportive nurse manager: leadership behaviors Cohesiveness and teamwork 0.710
Empowers RN–MD relationships 0.792 Not enough; safety compromised 0.419
Facilitates staff working together 0.790 Not enough RN positions budgeted 0.579
Supports autonomous practice 0.769 Delivery systems
Provides resources 0.762 Old team nursing 0.749
Instills values 0.676 Varies day to day 0.637
Supportive nurse manager: managerial behaviors New team nursing 0.584
Day-to-day management 0.814 Differentiated practice 0.389
Makes out schedules 0.743 Delivery systems
Manages patient flow 0.720 Combination of primary and total patient care 0.728
Orients and teaches 0.591 Modified primary 0.680
Gives direct patient care 0.553 True primary (5 tenets) 0.529
Autonomy
Must get permission first 0.428
Nurses fear getting into trouble 0.678
Bureaucratic rules inhibit 0.527
Sanction and support for autonomy 0.666
Positive accountability 0.612
Combined spheres of practice 0.704
Evidence-based practice—knowledge base 0.679

RN, registered nurse; MD, physician.

eliminated. Factors 9 and 10, related to clusters of
items relative to different kinds of nursing care de-
livery systems, will be reported elsewhere.
Tool Evaluation
Content Validity
Content validity, the determination of content rep-
resentativeness and relevance of the items of an in-
strument, was promoted by using both the tool de-
velopment and judgment processes as detailed by
Lynn.34 The developmental process is described in
the Tool Development section. In the judgment as-
pect, 23 nurses from 6 different magnet hospitals
served as judges. Nurses with at least 5 years of ex-
perience in a magnet hospital were chosen as ex-
perts in the content domains. Because of the com-
plexity and length of the scales, 5 experts each
judged the inclusiveness and content relevance of
the items on the RN-MD, CNP, and AUTO scales;
2 experts each judged the items on the support for
education, clinically competent, values, and nurse
manager support scales. Ten experts were used to
judge the adequacy of staffing scale.
Judges were presented with a specific set of
questions/instructions and were asked to identify

JONA • Vol. 34, No. 7/8 • July/August 2004 369

areas that may have been omitted from the scale.
Items were reduced and revised to improve clarity.
The content validity index for the 8 subscales,
based on the proportion of experts whose endorse-
ment is required to establish content validity be-
yond 0.05 level of significance,34 ranged from 0.88
to 1.00, with a median of 0.92. No omissions were
identified; the content validity of the EOM scales is
asserted.
Another way of examining content validity of
instruments in which data are collected at one level
for ultimate focus at a different level is to ascertain
whether item referents are at the desired focal level.
All items on the CNP and values scales are hospital
or departmentally referent. The RN-MD, nurse
manager support, and adequacy of staffing scale
items are all unit referenced. On the other 3 scales,
between 33% and 40% of the items are unit refer-
enced; the remainder are departmental or hospital
based. Because clinical unit was the minimum antic-
ipated group focal level, all scales meet the 90% cri-
terion level suggested by Verran et al.35
Validity of Assigned Ranks and Weights
Magnet hospital staff nurses made it clear when
providing examples and descriptions of RN-MD re-
lationships, autonomous practice, control over
nursing practice, and nurse manager support that
some factors and environmental features are more
important than others. For example, although still
considered positive, student–teacher RN-MD rela-
tionships are not as beneficial for quality patient
care as are collegial relationships. The investigators
ranked all items on these 4 scales based on the in-
formation provided to us during the interviews. To
determine the validity of our rankings (and corre-
sponding weights), we asked a sample of 392 nurses
working in 7 different magnet hospitals to rank
order each scale item on each of the 4 scales on the
basis of: which kind of relationship is most benefi-
cial for quality patient care? (RN-MD scale); which
factor most enables you to practice autonomously?
(AUTO scale) or control your nursing practice?
(CNP scale); which nurse manager activity indicates
to you the most support? (nurse manager support
scale). The mean rank order assigned by the 392
nurses for each scale item was then correlated with
the rank assigned to the item by the investigators on
the basis of the interviews.
Spearman rho rank order correlation coefficients
on the 4 scales ranged from 0.659 to 0.978, all sig-
nificant at the ⬎0.05 level. These very high correla-
tions indicated little difference between assigned and
observed ranks. We concluded that the weights as-
370
signed on the basis of the ranks were accurate reflec-
tions of the importance nurses attached to each item;
these weights were used to obtain a composite score
for each respondent on these 4 scales.
Representativeness
The EOM tool was developed so that magnet hos-
pitals could evaluate themselves on the effectiveness
of structures put into place to achieve a magnetic
work environment. Hospitals aspiring to magnet-
ism could assess their readiness for magnet applica-
tion and also obtain indications of where they
might improve to acquire the processes staff nurses
say they need for quality care productivity. To ac-
complish these purposes, data would need to be ac-
quired at the individual staff nurse level and aggre-
gated to the work group, clinical unit, and,
ultimately, the hospital level. Using individuals to
represent a group requires extensive examination of
the representativeness of the sample for generaliza-
tion to the department or hospital level.
The extent to which the number of informants
selected for participation in a study is sufficient to
represent the group adequately is important not
only in validity, but also in establishing the reliabil-
ity of an instrument. Both number and characteris-
tics of the individuals need to be considered. Nurses
with less than 1 year of experience were omitted be-
cause data collected during the qualitative study in-
dicated that their lack of experience and limited ex-
posure to the unit’s organizational traits made it
likely that they would operate on different defini-
tions of the EOM than would experienced nurses.
(For example: all new graduates but no experienced
nurses defined CNP as the ability to master their
own patient care assignment.)
Verran et al35 suggest that a response rate of at
least 50% is desirable before using an aggregate
score as a measure of a group. The study referenced
by Verran et al aggregates individual informants as
a measure of clinical units. In our earlier work, we
used a 20% random sample of nurses in 16 magnet
and 8 nonmagnet hospitals to assess differential
and identifying organizational traits and were able
to demonstrate adequate hospital representation, as
well as valid and reliable results.2,6,7,22,32,36 The results
of those studies also compared exceptionally well
with those reported by Aiken et al, who used a
50%⫹ individual sample for aggregation to clinical
units as the focal group.16,37
After appropriate institutional review board
(IRB) approval in those hospitals requiring it, 16
magnet and 10 magnet aspiring/nonmagnet hospi-
tals agreed to participate in the validity and reliabil-
ity testing of the EOM tool, with 3602 staff nurses
JONA • Vol. 34, No. 7/8 • July/August 2004
 Table 2. Number of Hospitals, Number of Informants, and Return Rate by Magnet Status

Return Rate, % of Informants

Type of Hospital No. of Hospitals No. of Informants Range Median Mean

Magnet 16 2355 15.0–75.4 25.35 31.76

Magnet—aspiring 6 758 15.0–38.0 25.85 25.70
Nonmagnet 4 489 22.0–28.9 26.80 26.13
Total 26 3602

in these hospitals serving as informants. Based on
prior experience, we judged that we could obtain a
more, or equally as accurate, hospital representa-
tion by securing a 25% sample of informants from
each unit/clinic for aggregation to the hospital level,
rather than a larger percentage of informants for
aggregation to the unit level, or a larger percentage
of informants without regard for clinical unit. We
reasoned that the 25% by unit/clinic procedure
would ensure more accurate representation of the
total organization, because one unit would not be
overly represented while others were underrepre-
sented. Hospitals by return rates and number of in-
formants are presented in Table 2.
A test of the representativeness of a 25% sam-
ple by clinical unit was possible because, during a 2-
month period, one of the magnet hospitals in the
study provided a sample of more than 75% of their

Table 3. Significance of Difference in EOM Scale Scores Between 25% Random Sample and
Residual Sample in One Magnet Hospital: ANOVA

EOM Scale Sum of Squares df Mean Square f Significance

Adequacy of staffing
Between groups 3.38 1 3.38 5.498 .02*
Within groups 258.25 419 0.616
Total 261.63 420
Support for education
Between groups 0.01 1 0.017 0.008 .927
Within groups 839.92 419 2.00
Total 839.93 420
RN–MD relationships
Between groups 45.70 1 45.70 0.700 .403
Within groups 27356.53 419 65.29
Total 27402.24 420
Working with clinically competent nurses
Between groups 4.96 1 4.96 0.791 .374
Within groups 2631.36 419 6.28
Total 2636.32 420
Autonomy
Between groups 174.60 1 174.60 1.292 .256
Within groups 56629.72 419 135.15
Total 56804.32 420
Control over nursing practice
Between groups 396.43 1 396.43 0.984 .322
Within groups 168889.91 419 403.07
Total 169286.34 420
Values
Between groups 16.37 1 16.37 0.549 .459
Within groups 12490.55 419 29.81
Total 12506.92 420
Nurse manager support
Between groups 0.09 1 0.096 0.040 .841
Within groups 999.70 419 2.38
Total 999.80 420

EOM, Essentials of Magnetism; ANOVA, analysis of variance; RN, registered nurse; MD, physician.
*Significant at P ⱕ .05.

JONA • Vol. 34, No. 7/8 • July/August 2004 371

total staff nurse population. Data from this hospital
were entered randomly, and then a 25% random
sample was drawn from the total sample. ANOVAs
with post hoc analysis were run comparing the
25% random sample (N ⫽ 139) and the 50.4%
residual sample (N ⫽ 282). Results are presented in
Table 3.
There were no significant differences between
the 25% random sample and the residual sample on
7 of the subscales. There was a significant differ-
ence on the adequacy of staffing scale, which is
probably explained by the lower stability of this
measure over time, as was found in the test-retest
reliability study. Except for this scale, we concluded
that a sample of 25% of the staff nurse population
drawn by clinical unit is representative when aggre-
gated to the hospital level.
In 10 of the 26 hospitals, the return rate was
less than the targeted 25%—two had 15%; one had
17%, one 19%, the remainder were between 21%
and 24%. The representativeness of the samples
from these 10 hospitals was assessed by correlating
3 characteristics of the sample—education, years of
experience, and percent who had national certifica-
tion—with data obtained directly from the CNE for
the staff nurse population in that hospital. Pearson’s
correlation coefficients among the 10 hospitals for
education and years of experience ranged from .798
to .999; levels of significance ranged from .002 to
.052. All but one correlation in one hospital were
significant at the ⬎.05 criterion level, indicating a
strong relationship between sample and population
in the 10 hospitals. In 3 instances, mainly in years
of experience, hospital-reported data were less pre-
cise than that collected from the informants. We
matched our observed groupings to that of the hos-
pital. Chi-square analysis with Yates correction for
continuity on percent having national certification
was 3.841, significant at 0.102. The investigators
concluded that the samples were sufficiently repre-
sentative of the hospital’s population of staff nurses
to aggregate to the hospital level and to include
those hospitals that did not meet the targeted 25%
sample by clinical unit level.
Criterion-related validity was evaluated
through the known-groups method. Magnet hospi-
tals ought to possess the characteristics that staff
nurses consider essential to being able to give qual-
ity patient care to a higher degree than either those
hospitals aspiring to magnet status or those hospi-
tals that were neither magnet nor magnet-aspiring
hospitals. (Magnet-aspiring hospitals were defined
as those that had appointed a magnet program co-
ordinator to spearhead the process for magnet hos-
pital evaluation.) Results of ANOVA (⬎0.05) and
372
post hoc analysis on mean hospital scores for the 26
hospitals by criterion type indicate highly signifi-
cant differences among the groups on 7 scales and
on the leadership component of the nurse manager
support scale. Magnet hospitals reported fewer
managerial activities than did nonmagnet hospitals,
which was expected, but the difference was not sig-
nificant at the criterion level of .05. We concluded
that the EOM scales are valid measures of a mag-
netic work environment (Table 4)
Using aggregated magnet hospitals as known
groups assumes that there is homogeneity among
magnet hospitals with respect to criteria used by the
American Nurses Credentialing Center (ANCC) as
the basis for the magnet award. If so, then nurses
working in magnet hospitals ought to be similar
with respect to their understandings of the defini-
tions and dimensions of the 8 essentials of a mag-
netic work environment, ie, they should define
what is meant by autonomy, CNP, and “good” RN-
MD relationships the same way and should have
similar understandings of the promoters of and bar-
riers to autonomous practice, of dimensions of
nurse manager support, and so on.
Nine of the 16 magnet hospitals that partici-
pated in the 2003 quantitative tool evaluation study
were among the 14 participants in the 2001 qualita-
tive study. Because the 2001 interviews were the pri-
mary basis for EOM tool development, this raises
the question: Do the 9 hospitals that participated in
both studies, labeled “old” magnets, score higher on
the EOM scale than do the 7 hospitals, labeled
“new” magnets, that did not participate in the study
that provided the data upon which the scales were
developed? Conversely, do the 7 new magnet hospi-
tals score lower because their informants were unfa-
miliar with or used different definitions of the EOM
that did their counterparts in the 9 old magnet hos-
pitals that participated in the qualitative study?
Analysis indicated that on all scales except
nurse manager support, the new magnet hospitals
scored higher than did the old ones. On RN-MD
and values, the difference in mean score was signifi-
cant at .05. On nurse manager support, the old
magnet hospitals scored significantly higher
(F ⫽ 73.319; significant at .05) than did the new
magnets. These findings satisfied our concern that
the new magnet hospitals would be jeopardized by
not having provided the examples and definitions
upon which the EOM was based, but it raises the
issue of whether the 2 sets of magnet hospitals pos-
sessed different characteristics that could account
for these observed differences in scores?
All of the 9 old magnets were veterans to the
magnet award process, having been among the first
JONA • Vol. 34, No. 7/8 • July/August 2004
 Table 4. Significance of Difference in EOM Scale Scores Between Nurses in Magnet and
Nonmagnet Hospitals: ANOVA

EOM Scale Sum of Squares df Mean Square f Significance*

Adequacy of staffing
Between groups 1.025 1 1.025 4.517 .044
Within groups 5.446 24 0.479
Total 6.472 25
Support for education
Between groups 6.180 1 6.180 36.135 .000
Within groups 4.104 24 0.171
Total 10.284 25
RN–MD relationships
Between groups 10.182 1 10.182 21.279 .000
Within groups 11.484 24 0.479
Total 21.666 25
Working with clinically competent nurses
Between groups 6.221 1 6.221 27.600 .000
Within groups 5.409 24 0.225
Total 11.630 25
Autonomy
Between groups 28.605 1 28.605 46.187 .000
Within groups 14.864 24 0.619
Total 43.469 25
Control over nursing practice
Between groups 53.296 1 53.296 69.011 .000
Within groups 18.535 24 0.772
Total 71.831 25
Values
Between groups 74.989 1 74.989 29.327 .000
Within groups 88.539 24 3.689
Total 163.528 25
Nurse manager support: managerial
activities
Between groups 0.949 1 0.949 0.738 .399
Within groups 30.889 24 1.287
Total 31.838 25
Nurse manager support: leadership activities
Between groups 3.552 1 3.552 12.017 .002
Within groups 7.093 24 0.296
Total 10.644 25

Abbreviations are explained in the first footnote to Table 3.

*Significant at P ⱕ .05.

admitted to magnet status; all but one had been
through at least one re-evaluation. Five of the 7 new
magnets had been awarded magnet status only
within the last year. The average number of infor-
mants by hospital was virtually the same in both
groups: N ⫽ 149 in the old magnets; N ⫽ 143 in the
new magnets. The rate of return ranged from 15% to
47% in the old magnets and from 25% to 75% in the
new magnets. The old magnets tended to be larger
hospitals that had large numbers of respondents but a
lower rate of return. It is possible that the 7 hospitals
new to the magnet award and to the study were more
enthusiastic about participating in research than were
the old magnets. And it is possible that there were
changes in the ANCC criteria or in the evaluation
process. For our purposes, we were satisfied that the
descriptions, clarifications, and examples of the 8 at-
tributes provided by the interviewees from the 9 old
magnet hospitals in the 2001 qualitative study were at
the very least meaningful to the staff nurses in the 7
new magnet hospitals and did not place them in an
unfavorable position.
Reliability
The stability aspect of reliability (constancy of re-
sults over time) was assessed in a test-retest (2- to 3-
week interval) with a convenience sample of 42
(mostly staff) nurses working in a variety of hospi-
tals. Mean scores, alphas, and significance for each
scale are presented in Table 5.
Results indicate good stability on all scales. The
least stable scale is that of working with other
nurses who are clinically competent. Interview and
observation data indicate that this scale is affected

JONA • Vol. 34, No. 7/8 • July/August 2004 373

 Table 5. Alphas and Significance of Difference in EOM Scale Scores from T1 to T2: Test–Retest
Reliability

Mean Inter-item

EOM Scale No. of Items Time 1 Time 2 Correlation Significance Alpha

Support for education 3 8.17 8.31 0.685 .498 .813

Clinically competent 5 14.33 13.05 0.526 .021 .689
RN–MD relationships 5* 14.71 14.48 0.794 .513 .885
Autonomy 7 18.83 18.93 0.798 .788 .888
Control over practice 10 25.83 26.05 0.882 .389 .937
Adequate staffing 5 14.67 14.26 0.609 .083 .757
Cultural values 12 34.07 34.31 0.876 .695 .937
Nurse manager support 10 28.57 28.67 0.733 .813 .846
Total scale 57(58) .823 .851

Abbreviations are explained in the first footnote to Table 3.

*The RN–MD subscale has 2 items for the student-teacher relationship, each half scored, for a total of 58 items.

by the number of new graduates on a unit, so tim- Results

ing of administration of the retest could readily af-
fect stability.
Another aspect of reliability is internal consis-
tency. Verran et al35 recommend that with group-
level data, aggregate scores should be used to calcu-
late the internal consistency reliability coefficients.
After aggregation of individual nurses’ scores, al-
phas demonstrated good internal consistency relia-
bility of .80 to .90 for all scales. The combined clin-
ically competent/support for education scale had an
alpha of .78. Number of items, alphas, means, and
standard deviation for hospitals by subscale are
presented in Table 6.
The content validity of the EOM subscales has been
satisfactorily demonstrated because the proportion
of judges meeting the content validity index was
well beyond the criterion cutoff, and no omissions
were identified. Stability over time of the EOM
scales was acceptable on all scales, but timing of ad-
ministration needs to take into account the presence
of large numbers of inexperienced nurses. Repre-
sentativeness of the sample for aggregation to
group level was examined from several perspec-
tives. The 25% by clinical unit sampling method
was determined to be both valid and reliable for ag-

Table 6. Alpha, Means, and SDs by Magnet Status on EOM Scales

Mean (SD) of Nurses

No. of Cronbach’s Magnet Hospitals Nonmagnet Hospitals

EOM Scale Items* Alpha (n ⫽ 2355) (n ⫽ 1247)

Clinically competent 5 .80 14.188 (0.4725) 13.182 (0.4785)

Support for education 3 .82 8.586 (0.4517) 7.584 (0.3405)
RN–MD relationships 5 (6) .88 14.559 (0.4348) 13.274 (0.9803)
Autonomy 7 .90 18.873 (0.6381) 16.717 (0.9864)
Control of nursing practice 8 .89 26.430 (0.6915) 23.487 (1.124)
Nurse manager support
Managerial activities 5 .80 13.214 (1.231) 12.821 (0.9519)
Leadership activities 5 .89 16.231 (0.3911) 15.471 (0.7302)
Cultural values 11 .90 35.008 (1.436) 31.517 (2.530)
Adequacy of staffing 5 .81 14.182 (0.5273) 13.774 (0.3766)
Total 54 (55)

Abbreviations are explained in the first footnote to Table 3.

*One cultural values item was removed because it did not load on the factor analysis; two CNP items were omitted because analysis indicated re-
dundancy.

374 JONA • Vol. 34, No. 7/8 • July/August 2004

gregation to the hospital level. Evidence was pre-
sented that a less than 25% by clinical unit sample
was also representative, providing care is taken to
obtain a satisfactory clinical unit distribution.
The EOM tool is unique in that it does not sim-
ply ask if a respondent can or cannot practice au-
tonomously, or whether RN-MD relationships are
good. It was constructed based on grounded theory
derived from staff nurse interviews and was designed
to ferret out the promoters of and barriers to auton-
omy and CNP, the different kinds of RN-MD rela-
tions, and what constitutes nurse manager support.
Analysis indicates that the tool accurately measures
these concepts as they are understood and described
by staff nurses in magnet hospitals. Mean scale scores
on the EOM clearly differentiate between known
groups, such as magnet and nonmagnet hospitals.
Discussion
The NWI, the only scale designed to measure the
importance and presence of factors related to staff
nurses’ perception of a magnetic work environment
conducive to quality patient care, is now outdated.
On the basis of data obtained from more than 10
years of participant observation and an intensive
qualitative 2001 interview study, a tool was devel-
oped to measure what staff nurses identify as essen-
tial to magnetism. Sixteen magnet and 10 magnet-
aspiring and nonmagnet hospitals participated in a
study to establish the psychometrics of the EOM
scales. In each hospital, a 20% to 25% sample by
clinical unit of staff nurse informants provided data
that were aggregated to the hospital level. Evalua-
tion indicated that the EOM tool is a valid and reli-
able measure of those aspects of a magnetic work
environment that staff nurses consider essential for
productivity of quality care.
Perception of Attributes
Nowhere is identifying the eye of the beholder more
essential than in looking at what attracts and re-
tains nurses, provides satisfaction, or enables deliv-
ery of quality care. From our 1986 research, we
know that the perception of organizational attrib-
utes related to magnetism differs by the position of
the beholder.2 The 8 Essentials of Magnetism identi-
fied by staff nurses in 2001 are markedly different
from those identified by CNEs21,38,39 or those used by
the ANCC to designate the Magnet Award.40 In
2002, CNEs identified the “quality of nursing lead-
ership” as the most essential organizational charac-
teristic of magnetism,17 whereas staff nurses during
a 20-year period consistently identified clinically
JONA • Vol. 34, No. 7/8 • July/August 2004
competent co-workers as the factor of most impor-
tance.2,6,7,23,32 The other attributes identified by CNEs
as essential to magnetism include: a leader who is
supportive, maintains high standards, is visionary
and enthusiastic, highly visible and responsive,
maintains open lines of communication, values edu-
cation and career development, preserves a position
of power and status in the organization, and is ac-
tively involved in professional organizations.
The “14 Forces of Magnetism gleaned from the
original magnet hospital report”40(p106) and used by
the ANCC are closer to those considered essential
by the CNE than to those considered essential by
the magnet hospital staff nurse, although there is
agreement between staff nurses and CNEs on the
support and value of education. The forces are
quality of nursing leadership, image of nursing,
community and the hospital, personnel policies and
programs, autonomy, consultation and resources,
organizational structure, management style,
nurse–physician relationships, quality of care, pro-
fessional models of care, quality improvement,
nurses as teachers, and professional development.40
There is agreement between the essentials and the
forces on 2 factors: autonomy and RN-MD rela-
tionship, although it is not known how these fac-
tors are defined or measured in the forces.
Structure, Process, and Outcomes
One of the major reasons for these differences is that
people approach the task of identifying and evaluat-
ing an exciting and rewarding, ie, a magnetic, work
environment from different perspectives. Donabe-
dian’s structure-process-outcome (SPO) paradigm is a
useful blueprint for viewing the endeavor of assessing
a magnetic work environment. Structure, the physical
and organizational properties of the setting, consists
of the more or less stable aspects of the environment
and also includes the attributes of human resources,
such as the qualifications of staff and nurse adminis-
trators. Process, a series of operations or actions con-
ducing to an end, includes the actual interpersonal
and technical care, as well as the actions and opera-
tions producing that care, such as autonomy and con-
trolling practice.19,41 Outcomes are what is accom-
plished, the effect of processes rendered by the care
staff on workers or patients, including both patient
and nurse satisfaction. Outcomes are the results or
consequences of process actions. Together, structure
and process influence outcomes. Structure-process-
outcomes are causally related.41 Structure leads to
process and process to outcome.
Viewed from the perspective of Donabedian’s
SPO paradigm, the Magnet Nursing Services Recog-
375
nition Program designates the structure. According to
the ANA website, the program uses the Scope and
Standards for Nurse Administrators42 to provide a
framework to recognize excellence in management
philosophy and practices of nursing services, adher-
ence to standards for improving quality of patient
care, leadership of the CNE, and attention to the cul-
tural and ethnic diversity of patients. It is logical that
the focus of the Forces of Magnetism would be struc-
tural properties under the control of, guided by, and
dependent upon the leadership practice and qualifica-
tions of the CNE. Outcomes are of concern as they
relate to adherence to standards for improving the
quality of patient care. Most of the essentials identi-
fied by magnet hospital staff nurses are processes
through which the goal of quality patient care is
achieved. The outcomes in this SPO paradigm are the
4 original magnet hospital criteria: namely, attrac-
tion, retention, nurse job satisfaction, and quality pa-
tient care. The last outcome is a very large category
and includes a host of factors, such as absence of
medication errors, nosocomial infections, falls, mor-
tality, and quality-of-life indicators, as well as nurse
and patient satisfaction. There is a fair amount of
magnet hospital organizational research connecting
structure and outcome, such as the relationships be-
tween dedicated and scattered-bed acquired immun-
odeficiency syndrome units and patient mortality,37
leader behavior on job and work effectiveness,43 and
empowerment structure and personality characteris-
tics on job satisfaction.44 Studies that compare magnet
and nonmagnet hospital structures on variables such
as mortality45 are also examples of the structure-out-
come aspect of the SPO paradigm. Little attention in
nursing has been given to study of the impact struc-
ture has on care processes or of processes on out-
comes, although copious study has been done of
physician processes and their relationship to the out-
come of quality care.46
Relationships to Study
Correlation is not causation. Donabedian cautions
that there must be pre-existing knowledge of the
linkage and kind of linkages between structure and
process and between process and outcome if an
evaluation program is to be successful.46 Not only
must all linkages be studied, we must aim for causa-
tion. The EOM will enable us to answer questions
such as: Do certain kinds of RN-MD relationships
cause nurses to leave nursing or to stay? Rosenstein
and colleagues47,48 have studied the associative ef-
fects of an adversarial RN-MD relationship on
nurse retention but have not looked at other rela-
tionships or combination of relationships. Weiss
376
and Davis49 published a tool to measure collabora-
tive conflict resolution with physicians. Other than
that, we found no other delineation of types of RN-
MD relationships or tools to measure possible cau-
sation of desired outcomes.
The EOM tool should also be useful as a self-
evaluation guide for hospitals aspiring to magnet-
ism. Subscale scores will enable hospitals to com-
pare their results with a nationwide sample of
magnet and magnet-aspiring profiles. Nurses’ per-
formance on individual items should be useful in as-
certaining what, if any, corrective action is needed,
and what supportive action is validated.
Another question that can be studied with the
EOM tool is: Do the processes affirm the structure
prescribed by the ANCC? Does the structure enable
or cause the process? For example, one structural cri-
terion of magnetism is a decentralized organizational
structure. In our work, we found movement away
from the flat organizational structures (CNE-nurse
manager-staff nurse) of the 1980s and early 1990s
that was supposed to be related to staff nurse auton-
omy. Increasingly, we have found that additional lay-
ers are being added, whether they are termed super-
visors, clinical directors, assistant nurse managers, or
permanent charge nurses on each shift.50 This raises
the question as to what impact these additional lay-
ers have on staff nurses being able to practice au-
tonomously. Does the flatness of the structure pro-
mote autonomous practice? Is autonomy decreased
with increased bureaucratic layers?
A growing body of literature suggests that some
structures specified by the ANCC in the Forces of
Magnetism may be window dressing, ie, more struc-
ture than substance and not effective in enabling
processes leading to desired outcomes.51 “Mere im-
plementation of the structural aspects of shared gov-
ernance in the form of councils and committees,
without the authority to have control over profes-
sional practice on a day-to-day basis, will result in
cynicism and unwillingness to assume accountability
for client outcomes by staff nurses.”30, p. 315 Havens52
found in a nationwide survey of staff nurses that the
degree of perceived involvement in practice decisions
was very low, despite the claim that shared gover-
nance systems were in place. Structural characteris-
tics are conducive to quality care and are more easily
measured than process or outcomes, but their pres-
ence alone does not assure quality care.46 With the
EOM, affirmation by staff nurses that the structures
deemed essential for magnetism are not only in place
but do, in fact, enable the processes needed for de-
sired outcomes, is now possible.
Trying to establish or dictate organizational
structure and design in the absence of clear infor-
JONA • Vol. 34, No. 7/8 • July/August 2004
mation on just how structures affect caregiver
processes, which in turn affect outcomes, may re-
sult in pristine structures that have little or negative
effects on the caregivers who are most instrumental
in providing effective and satisfying patient care
outcomes. Quality nursing and hospital leadership,
proactive programs, and a facilitating structure lead
to dynamic patient-centered cultures and environ-
ments in which staff nurses are supported in acquir-
ing and maintaining the knowledge and skills neces-
sary for autonomous practice and collegial RN-MD
relationships, an environment in which nurse man-
agers not only empower staff nurses to effect con-
trol over their practice, but also provide cost-effi-
cient and outcome-effective staffing levels perceived
by staff to be adequate to accomplish the goals of
job satisfaction, quality patient care outcomes, and
attraction and retention of professional staff .
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