International Journal of Nursing Practice 2008; 14: 357 365 RESEARCH PAPER. Accepted for publication June 2008

International Journal of Nursing Practice 2008; 14: 357 365 RESEARCH PAPER Nurses work environment and nursing outcomes: A survey study among Finnish university hospital registered nurses Tarja Tervo-Heikkinen RN Researcher MNSc PhD(c) Researcher, Department of Research, Kuopio University Hospital, Department of Nursing Science, University of Kuopio, Finland Pirjo Partanen PhD RN Senior Lecturer, Department of Nursing Science, University of Kuopio, Finland Pirjo Aalto PhD Chief Nursing Director, Pirkanmaa Hospital District, Tampere University Hospital, Finland Katri Vehviläinen-Julkunen PhD RN Professor, Department of Nursing Science, University of Kuopio, Department of Research, Kuopio University Hospital, Finland Accepted for publication June 2008 Tervo-Heikkinen T, Partanen P, Aalto P, Vehviläinen-Julkunen K. International Journal of Nursing Practice 2008; 14: 357 365 Nurses work environment and nursing outcomes: A survey study among Finnish university hospital registered nurses The aim was to assess the interrelationships between nurses work environment and nursing outcomes. A cross-sectional survey of 664 registered nurses (RN) on 34 acute care inpatient hospital wards was used to measure nurses perceptions. Patient data (n = 4045) consisting of a total patient satisfaction indicator were collected simultaneously with the nurse data during year 2005. RN s assessments of staffing adequacy, respect and relationships were the most important factors of work environment having an influence on job-related stress, job satisfaction, patient satisfaction and adverse events to patients and nurses. Some 77% of the RN reported adverse nurse events and 96% reported adverse patient events during a 3 month retrospective period. Ensuring sufficient and suitably qualified nurses availability in delivering nursing care is an important management issue. Nurses are concerned about the quality of care, and the concerns perceived by nurses can influence their clinical work. Key words: cross-sectional studies, hospitals, nurses, nursing, questionnaire. Correspondence: Tarja Tervo-Heikkinen, Kuopio University Hospital, Department of Research, PO Box 1777, FIN-70211 Kuopio, Finland. Email: tarja.tervo-heikkinen@kuh.fi doi:10.1111/j.1440-172x.2008.00707.x INTRODUCTION Nurses work environment has been conceptualized and measured in various ways. According to Sleutel, 1 it is a set of related concepts described as organizational factors that influence nursing practice. Aiken et al. 2 have been theorizing a quality nurses work environment to a work setting that promotes nursing professional autonomy,

358 T Tervo-Heikkinen et al. greater control over practice environment and better physician nurse relationships, thus resulting in better outcomes for nurses and patients. Economic changes affecting the whole western world in the 1990s (recessionary period and health-care staffing reductions), pressures for hospital restructuring and the decrease of the working age population have had an impact on the health-care systems and registered nurses (RN) work environments. A poor organizational climate and high workloads have been associated with increased levels of needlestick injuries. 3 The importance of optimal staffing levels has been confirmed recently by Rauhala et al., 4 connecting nurses work overload to increased sick leaves. Magnet hospital characteristics, such as progressive employment policies and organizational support for nurses, have been found to be associated with better nurse job satisfaction, 5,6 a safer work environment for nurses 5 and also better patient safety outcomes 7 than in nonmagnet hospitals. Hospitals priorities and policies also influence nurses work environment, for example, in the use of nursing staff. In summary, nurses work environment and its relationship to different nursing outcomes have been studied quite widely during recent years in the USA 5,8 and Canada. 9,10 Research findings indicate a link between nurses job satisfaction and patient outcomes, such as mortality rates and patient satisfaction. 11 Also, numerous studies have linked organizational factors and factors related to work environment to nurses job satisfaction. 12 As the shortage of nurses is an international problem, it is very important to examine whether there are differences in nurses work environment across different cultures and health-care systems. To date, relatively little is known about the nurses work environment situation in European and Scandinavian hospitals. Rafferty et al. 13 studied the nurse environment situation in English hospitals, specifically the effects of staffing on patient outcomes (mortality and failure to rescue) and nurse retention outcomes, stating the same outcomes as in the USA. Also, a couple of other studies 14,15 have been describing the European nurses work environment. In measuring the nurses work environments staff nurse survey is a widely used method that has been developed and refined over the past decades. 16 In these surveys the most used instrument seems to be the Nursing Work Index (NWI) which was developed by Kramer and colleagues. 17 NWI-revised (NWI-R) instrument was further developed by Aiken and Patrician 18 from the original one. NWI-R was far lighter for the respondent than the original version, since only the presence of selected attributes was asked. After that the NWI-R has been largely used and modified. It is especially an instrument that has been used in the context of magnet hospitals as a satisfaction tool. 19,20 The NWI-R findings on nurses work environment together with different nursing outcomes, such as adverse events to RN and patients 3,7,21 and RN s assessed overall nursing care quality, 22 have been studied by different researchers. Those studies showed the relationship between nurses work environment and outcomes; a better practice work environment brings better outcomes. METHODS Aim and research questions The aim of this study was to assess the interrelationships of acute care hospital RN s evaluations on their work environment and selected nursing outcomes. Specified research questions were: what is the relationship between nurses work environment and (i) nurses job-related stress and job satisfaction; (ii) patient satisfaction; (iii) adverse events to nurses; and (iv) adverse events to patients? Design and sample To examine the relationship between the nurses work environment and nursing outcomes, a conceptual framework based on earlier studies 8,17,18 was used (Fig. 1). A cross-sectional questionnaire survey was carried out in April to May 2005 on 34 adult inpatient wards: 19 medical, 13 surgical and two joint medical-surgical wards, in four university hospitals in Finland. University hospitals are publicly funded tertiary care teaching hospitals. In Finland, altogether five university hospitals produce ª55% of tertiary medical care patient days. Four of these hospitals participating in this study offer nearly threequarters of all the university hospital beds (n ª 5540, n = 3753). 23 The design of the data collection is presented in Fig. 2. The sample consisted of altogether 664 RN of whom 451 RN returned a completed questionnaire, giving a response rate of 68%. One ward was excluded from the wardspecific analysis because of its low response rate (11%). The outcome of patient satisfaction is derived from our patient survey (n = 1730) via with a modified version (Humane Caring Scale-revised) of an earlier developed instrument 24 from the study hospital wards during the same data collection period. In this study only the total satisfaction indicator was used.

Nursing environment and outcomes 359 Figure 1. Conceptual framework of nurses work environment used in this study based on results of earlier studies. 8,17,18 RN, registered nurse; MD, doctor of medicine. RNs Evaluation of the Work Environment - Professional advancement and support of the TOP management - Support of immediate superiors - Staffing and resource adequacy - Nursing respect and RN RN/RN MD relationships - Standards of professional nursing Outcomes Job-related stress Patient satisfaction RNs job satisfaction Adverse events to patients Adverse events to RNs 34 inpatient wards in four university hospitals 664 RNs survey 4045 patients survey No respond n=213, 32 % Respond rate n=451, 68 % Respond rate n=1730, 43 % No respond n=2315, 57 % Figure 2. Design of the data collection. RN, registered nurse. Data collection The data were collected via survey instruments sent to participating wards head nurses, who distributed them to the RN with a minimum working period of 1 month in the ward and working in clinical position (inclusion criteria). Our nurse survey instrument the Registered Nurse Working Conditions Barometry Index-revised (RN-WCBI-R) included the statements of the NWI-R. The instrument was based on a previously (2004) executed national survey of RN (a nationally representative random sample of 3000 RN) in Finland by the authors, and reported in a prior article, 25 concerning RN s views on their work environment as a whole across various different working settings. For this present study focusing on acute care hospital settings, we shortened the earlier wide instrument, removing some not relevant background questions to this study. The reliability of the instrument was between 0.737 and 0.838 as measured by Cronbach alpha (Table 1). Data of this article The NWI-R in this study Our questionnaire included the NWI-R with 55 statements excluding two items from the 57 original statements by Aiken and Patrician. 18 The NWI-R scale was translated into Finnish language and independently backtranslated by bilingual translators to validate the accuracy of the translation. Of the NWI-R s statements, 41 constituted five subscales (Table 1). These subscales were constructed by Exploratory Factor Analysis using survey material collected earlier (spring 2004) from members of the Finnish Nurses Association. 25 From that sample only those (n = 162) who worked at university hospital inpatient wards were included in the factor analysis. The respondents were asked to rate items on a 4-point Likert scale (1 = strongly agree, 4 = strongly disagree) to indicate their level of agreement that the item being evaluated was present in their current work situation. The scores of all the items were reversecoded, so that higher scores indicated perception of a positive statement. Principal component analysis was used as an extraction method. All the items with lower communality than 0.300 were excluded from the final analysis. 26,27 A final description of the factors (subscales) was made from items that had higher loadings on the factor.

360 T Tervo-Heikkinen et al. Table 1 Result of Exploratory Factor Analysis (n = 162): Five-factor solution of the Nursing Work Index-revised (NWI-R) Subscales and component items Loading 1 Professional advancement (and support of the high managers) (a 0.838, mean 2.23, SD 0.51, variance explained = 43.8%) Career development/clinical ladder opportunity. 0.675 A chief nursing officer is highly visible and accessible to staff. 0.646 An administration that listens and responds to employee concerns. 0.638 Opportunity for staff nurses to participate in policy decisions. 0.620 Opportunities for advancement. 0.611 Nursing staff is supported in pursuing degrees in nursing. 0.523 Active in-service/continuing education programmes for nurses. 0.482 Freedom to make important patient care and work decisions. 0.469 An active quality-assurance programme. 0.439 2 Support of immediate superiors (a 0.765, mean 2.50, SD 0.51, variance explained = 37.3%) A nurse manager who is a good manager and leader. 0.607 A nurse manager backs up the nursing staff in decision-making. 0.599 Nurse managers consult with staff on daily problems and procedures. 0.583 Floating so that staffing is equalized among units. 0.566 The supervisory staff that are supportive of nurses. 0.511 Regular, permanently assigned staff nurses never have to float to another unit. -0.487 Flexible or modified work schedules are available. 0.479 The nursing staff participate in selecting new equipment. 0.401 Staff nurses are involved in the internal governance of the hospital. 0.354 3 Staffing (and resource) adequacy (a 0.799, mean 2.21, SD 0.61, variance explained = 58.4%) Enough registered nurses (RN) on staff to provide quality patient care. 0.800 Enough staff to get work done. 0.744 Adequate support services allow me to spend time with my patients. 0.726 Enough time and opportunity to discuss patient care problems with other nurses. 0.667 Primary nursing as the nursing delivery system. 0.522 4 Respect and relationships (Nursing respect and RN RN/RN doctor of medicine relationships) (a 0.737, mean 3.16, SD 0.36, variance explained = 33.3%) Working with nurses who are clinically competent. 0.715 Opportunity to work on a highly specialized unit. 0.680 Physicians give high-quality medical care. 0.574 The contributions that nurses make to patient care are publicly acknowledged. 0.547 Working with experienced nurses who know the hospital. 0.497 Physicians and nurses have good working relationships. 0.494 Not being placed in a position of having to do things that are against my nursing judgement. 0.492 Much teamwork between nurses and doctors. 0.491 High standards of nursing care are expected by the administration. 0.434 5 Standards of professional nursing (a 0.789, mean 2.64, SD 0.51, variance explained = 37.9%) Standardized policies, procedures and ways of doing things. 0.602 Nursing care is based on a nursing rather than a medical model. 0.600 A clear philosophy of nursing pervades the patient care environment. 0.596 A preceptor programme for newly hired RN. 0.566 A good orientation programme for newly employed nurses. 0.534 Use of nursing diagnoses. 0.531 Written up-to-date nursing care plans for all patients 0.507 Patient assignments foster continuity of care. 0.502 Total patient care as the nursing delivery system. 0.478 Extraction method: principal component analysis. Rotation method: Varimax with Kaiser Normalization. Subscales theoretical variation was 1 4. Note: This table contains the original NWI-R wording (Aiken and Patrician 2000). 18 Subscale, items, Cronbach alpha (a), mean of subscale, standard deviation (SD) and variance explained.

Nursing environment and outcomes 361 Selected measures The parameters collected by surveying RN and patients were aggregated to unit-level data so that items were summed to obtain a score for the unit. RN s work environment was measured by NWI-R. Subscale data were used as an independent variable in relation to the different nursing outcomes. Nursing outcomes Five measures were used to quantify nursing outcomes in this study: (i) RN reported experience of job-related stress; (ii) job satisfaction; (iii) patient satisfaction with nursing care; (iv) adverse events to the RN; and (v) adverse events to the patients. RN s experience of jobrelated stress constitutes of the reported number (%) of RN who experienced work stress quite a lot or exceedingly. Job satisfaction is RN s reported experience of their satisfaction with their present job. A measure of the total patient satisfaction from the patient satisfaction survey 24 is used as patient outcome indicator in this study. The total patient satisfaction indicator was formulated from eight subscales of patient satisfaction with hospital care. Nurse-assessed adverse RN events per 1000 RN working hours (adverse RN events) and adverse patient events per 1000 incoming patients (adverse patient events) were calculated from RN s reported numbers of adverse events that occurred to the RN and patients during a 3 month retrospective period. Adverse events to RN were, respectively, proportioned to each ward s total RN hours during the first quarter of 2005. RN were asked to evaluate the number of different work-related accidents during the past 3 months, such as sharp-device injuries, slipping, injuries caused by patients and injuries caused by lifting or moving patients. The number of adverse patient events was proportioned to each study ward s incoming patients during the first quarter of 2005. Respectively, nurses were asked the number of adverse events that happened to their patients, namely patient falls, medication errors or nosocomial infection or pressure sores. Ethical considerations The study design was reviewed by the Northern Savo Ethical Committee and was given a national positive statement (number 154/2004, 9 November 2004). Permission for the RN survey was given by the Chief Director of Nursing and Director of Nursing of each participating hospital. Permission to remodel and use the RN-WCBI questionnaire was given by the Finnish Nurses Association. Questionnaires with a return envelope were sent anonymously to the head nurses of the study wards, who gave them out to the RN fulfilling the study criteria. In an information sheet the researchers emphasized the respondents freedom to answer or not. The respondents answered anonymously, and there was no information that could be used to identify the respondents. Only information about the hospital and ward could be connected to the respondents. Permission for the patient satisfaction survey and use of administrative data was given by the chief executive medical directors and ethical committees according to each hospital s standards. Data analysis All the statistical analyses (i.e. frequencies, percentages, correlations) were performed using spss version 14.0 for Windows. Principal component analysis and reliability analysis (Cronbach alpha) were used to formulate subscales from the survey data and to test the reliability of the modified version of the NWI-R scale. In the subscales a large number of statements are grouped into subareas linked by the principal component analysis on the basis of the given information. 27,28 The ward-specific values of the subscales were constructed using the means of the RN s statements on each ward. Regression analysis was used to show how the independent variables interact with the dependent variables. Since regression analysis does not give the strength of the correlations, only the trend, significance (P-value), regression coefficients (b1) and total variance explanations (R 2 ) were used. RESULTS Characteristics of RN The respondents characteristics are shown in Table 2. Respondents worked on acute medical, surgical and medical-surgical inpatient wards. Their mean age was 39.3 years. In most cases the last received degree was RN (RN diploma or bachelor degree). Most of the respondents were tenured employees and worked full-time. Almost half of the respondents last work shift before answering the questionnaire was a day shift (43.6%); for one-quarter the last shift was an evening (26.9%) or night shift (26.2%). Only 3.3% reported having worked a long shift (12 15 h). Work experience was quite long so that more than two-thirds (73%) of the respondents had over 5 years of work experience as an RN.

362 T Tervo-Heikkinen et al. Table 2 Respondent (n = 451) characteristics Characteristics n % Age (mean 39.3 years) (SD 22 63 years) Gender Women 98 Men 2 Highest nursing degree Registered nurses (RN) 10 RN (diploma or bachelor) 88 RN (+master degree) 2 Working situation Worked as a nurse (mean 11.8 years) (SD 0 37 years) Full-time workers 93 Tenured employees 70 Work setting 451 Medical wards 228 51 Surgical wards 200 44 Medical-surgical wards 23 5 RN education (2.5 years) which ended in 1980s. RN (diploma or bachelor) education (3.5 4.5 years) commenced in 1980s (diploma) and in 1990s. Nurses job-related stress and job satisfaction Only 7% of the respondents answered that they did not feel any job-related stress. More than one-fifth parts (21%) of the respondents felt stress quite a lot or exceedingly (Table 3). Those who felt that respect and relationships were lower (P = 0.013, b1 = 4.329, R 2 = 18.2%) and they also felt job-related stress rather much or exceedingly. The other subscales had the same direction, although those results were not statistically significant. Every third RN was not satisfied with her present job. When the possibilities to professional advancement were evaluated to be better (P = 0.009, b1 = 3.598, R 2 = 20%), staffing adequacy was satisfactory (P = 0.001, b1 = 9.558, R 2 = 28.9%), RN felt that nursing had respect and good working relationships (P = 0.002, b1 = 7.376, R 2 = 27.6%), and also RN s job satisfaction was better. The other subscales had the same direction although not statistically significant. Patient satisfaction All subscales (Table 3) and the patient satisfaction indicator correlated positively although not statistically significantly. When RN evaluations on standards of professional nursing increased (P = 0.015, b1 =-0.117, R 2 = 17.5%), staffing adequacy was also evaluated to be in good level (P = 0.018, b1 =-0.047, R 2 = 16.7%), nursing respect and relationships were felt well (P = 0.039, b1 =-0.053, R 2 = 13.0%), and patients level of satisfaction also increased. Adverse events to nurses Almost every fifth respondent (16%) reported of an accident at work during the last 3 month period. The mean was 1.7 accidents, with the total number fluctuating 1 6. Adverse events to all RN on the ward were also asked (Table 3). More than three-quarters (77%) of the respondents reported that accidents had happened to RN colleagues during the 3 month period. The regression analysis indicated a negative linear connection between all the subscales and adverse RN events; when the subscales positive effects increased, the rate of adverse RN events decreased linearly. However, the connection was statistically significant only for standards of professional nursing (P = 0.032, b1 = 0.270, R 2 = 14.4%) and staffing adequacy (P = 0.004, b1 = 0.870, R 2 = 24.6%). Adverse events to patients The RN were also asked to estimate adverse patient events (Table 3). Only 4% answered that there were no any kind of adverse patient events during the 3 month period. The adverse patient events and subscales were analysed as above. There were also a negative linear connection between all the subscales and adverse patient events. The connection was statistically significant for respect and relationships (P = 0.007, b1 = 2.793, R 2 = 21.3%) and staffing adequacy (P = 0.025, b1 = 2.994, R 2 = 15.2%). DISCUSSION Limitations of the study There are some limitations in this study. First, our indicators of frequency of adverse events are subjective and may be biased, for example, by recall. This kind of inquiry had to be used since in Finland we do not have a nationally uniform system of reporting adverse events, but we wanted to calculate it. Because the number of adverse

Nursing environment and outcomes 363 Table 3 Outcome measures of study wards in March 2005 (mean, SD, range) Characteristics Mean SD Range of the measure Registered nurses (RN) feeling job-related stress 21 12.76 0.0 43.8 quite a lot or exceedingly (%) RN with good job satisfaction (%) 65.9 17.65 25.0 100.0 Patients with good satisfaction (%) 69 9.51 44.45 84.91 Adverse RN events (number) 0.4 0.18 0.03 0.76 Adverse patient events (number) 11.3 7.61 1.4 43.3 The ward-specific number of RN estimating adverse events happened in the unit during the last 3 months. The ward-specific number of RN estimating adverse events happened to the patients in the unit during the last 3 months. Table 4 Subscales and direction ( or ) of chosen surveyed figures when subscales increased ( ) by regression analysis and scatter plot figures. Statistically significant findings are marked (P-value) When the subscale increased ( ) the direction where figures moved Direction of move and statistically significance (P-value) Job-related stress RN job satisfaction Patient satisfaction Adverse RN events Adverse patient events Professional advancement 0.009** Support of immediate superiors Staffing adequacy 0.001** 0.018* 0.004** 0.025* Respect and relationships 0.013* 0.002** 0.039* 0.007** Standards of professional nursing 0.015* 0.032* *P < 0.05; **P < 0.01. Finding was not statistically significant (P < 0.050); Regression analysis as independent variable; regression analysis as dependent variable. RN, registered nurses. events is based on the RN survey, its reliability was improved by calculating unit-level figures from each ward s RN data to minimize overlapping of adverse event figures in the survey. The second limitation is the varying response rate across different wards (33 100%). Although the overall response rate (68%) was good, it fluctuated 11 100%, depending on the ward, being not very representative of all the wards. That s why we decided to exclude one ward (response rate 11%) from the analysis due to scarce respondents. Discussion of the results It is already known that nurses work environment is a major determinant of patient and nurse welfare. In our study we used the NWI-R scale to measure the attributes of the professional nursing environment. The five attributes we found were compared with different nursing outcomes to identify interrelationships summarized in Table 4. All the statistics were aggregated to the unitlevel data and the items were summed to obtain a score for each ward. It is notable that most of the RN reported themselves to be more or less stressed and every fifth RN even reported feeling stress quite a lot or exceedingly. However, when the professional nursing environment was reported to be better, nurses stress level decreased clearly. When comparing the results obtained in this study, it seems that the level of satisfaction among Finnish RN is in many ways comparable to the results of the previous research 22 containing RN surveys from the USA, Canada, England, Scotland and Germany, and reporting that 17.4 41%

364 T Tervo-Heikkinen et al. of the study respondents were dissatisfied with their present job. 22 In our study every third RN (33%) was dissatisfied. Our study confirmed that RN s satisfaction with their present job was positively related to RN s work environment. All five nursing work environment variables that we studied (i) professional advancement (and support of the top management), (ii) support of immediate superiors, (iii) staffing (and resource) adequacy, (iv) nursing respect and (RN RN/RN doctor of medicine) relationships and (v) standards of professional nursing were found to be important predictors of the nursing outcomes explored in our study (Table 4). When professional environment attributes were evaluated to be better, also nurses work stress degreased and nurses satisfaction indicators increased linearly. Even the number of reported adverse events to RN and patients degreased. So, we can fairly claim that nurses professional environment influences the nursing outcomes positively. In this study the support given by managers at different levels did not make a major issue for a positive professional environment. It seemed that more important was nurses perceptions of staffing adequacy, felt respect and good relationships and the standards of professional nursing. This finding differs from the Laschinger and Leiter 7 and Gunnarsdottir et al. 15 studies, for example, where they found that leadership played a fundamental role in the quality of work life environment. This might be a reflection of a cultural difference in Finnish health care, showing also RN s worry about staffing adequacy in the future. These findings suggest that nurses are concerned about the quality of care they provide, and also that the concerns perceived by nurses can influence their clinical work and thereby their experience of the work environment. CONCLUSION In summary, the results of this study confirm earlier research on the importance of RN s work environment to nursing outcomes and thus to health-care management and leadership. Additional longitudinal studies are needed to further clarify pathways linking organizational work environment issues and patient and staff outcomes. Staffing and other resources, like adequacy of support services, together with different nursing care quality indicators also need more studying. In this study the staffing, nursing respect and relationships and also standards of professional nursing indicators were strongly related to nurses job-related stress, job satisfaction, patient satisfaction and both RN and patient safety outcomes. The findings of this study provide useful information for health-care leaders and managers at different levels and also for policymakers to be used in decision-making on human resources planning in health care. Employing professional work environment for RN with adequate staffing levels is beneficial to RN s health and satisfaction increasing also patient satisfaction and safety. ACKNOWLEDGEMENTS Financial support for this study was provided by the Kuopio University Hospital (EVO), the Kuopio University Hospital Research Foundation, the Finnish Cultural Foundation (North Savo Foundation) and the Finnish Association of Nursing Research. We would also like to thank the Finnish Nurses Association for the opportunity to use and revise the questionnaire. We want to thank statistician LicPhil Vesa Kiviniemi from Kuopio University Information Technology Centre for his abundant statistical and mathematical help. We are also most grateful to all the RN and head nurses who took part in this study by giving their time willingly in answering our survey. REFERENCES 1 Sleutel MR. Climate, culture, context, or work environment? Organizational factors that influence nursing practice. The Journal of Nursing Administration 2000; 30: 53 58. 2 Aiken LH, Smith HL, Lake ET. Lower medicare mortality among a set of hospitals known for good nursing care. Medical Care 1994; 32: 771 787. 3 Clarke SP, Rockett JL, Sloane DM, Aiken LH. Organizational climate, staffing, and safety equipment as predictors of needlestick injuries and near-misses in hospital nurses. American Journal of Infection Control 2002; 30: 207 216. 4 Rauhala A, Kivimäki M, Fagerström L et al. What degree of work overload is likely to cause increased sickness absenteeism among nurses? Evidence from the RAFAELA patient classification system. Journal of Advanced Nursing 2007; 57: 286 295. 5 Aiken LH. Superior outcomes for magnet hospitals: The evidence base. In: McClure ML, Hinshaw AS (eds). Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses. Silver Spring, MA, USA: American Nurses Association, 2006; 61 82. 6 Laschinger HKS, Almost J, Tuer-Hodes D. Workplace empowerment and magnet hospital characteristics. The Journal of Nursing Administration 2003; 33: 410 422.

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