Many countries pay much attention to the establishment of high-quality healthcare services. People want to receive professional help within a short period and be sure of its appropriateness. Thus, governments and specialized organizations spend certain costs and create funding groups to promote a solid background for medical care. Despite the intention to achieve success, population health still needs to be improved from organizational, technical, and social aspects, and the role of the medical staff is critical in this management process. Doctors with their degrees and knowledge cooperate directly with patients, diagnose, and develop treatment plans. Surgeries are used when pharmacological treatment is not enough and patient education is offered. However, successful healthcare teams consist of doctors, assistants, nurses, technicians, pharmacists, etc. Therefore, the role of each person has to be recognized while examining a work environment.
Today, there are many types of hospitals and care for ordinary people. Some citizens use free services at local facilities or address a private company for personalized care. Each country has a number of rules and standards according to which patient-doctor relationships are developed. For example, in the United States, health care is determined by such federal programs as Medicare or Medicaid. Germans have access to a universal healthcare system that includes obligatory insurance. Many European countries continue developing similar conditions for care, but not all governments are ready for unpredictable expenses and challenges. According to Alsufyani et al. (2020), the Saudi government faces multiple problems in achieving the golden standards in nursing care due to staffing shortages, poor education, and a lack of policies. Although healthcare leaders have already increased expectations for certain programs like evidence-based practice (EBP), education and research goals were not met (Wilson et al., 2015, p. 12). One of the possible explanations of why Saudi Arabia could lag behind in the healthcare system is its poor understanding of the golden nursing standard that is also known as a magnet hospital.
Not many people are aware if they are patients of magnet or non-magnet hospitals. This concept is not new in America and some European countries. At the beginning of the 2010s, several Arab countries got an invitation to obtain magnet status for their hospitals (Lovering, 2013, p. 619). The offer results in the increased investigation of the benefits and shortages of the magnet status and its worth for Arab hospitals. In the United States, this status is available for hospitals with the American Nurses Credentialing Center (ANCC) (Friese et al., 2015). In Saudi Arabia, such certification does not play a role, and the Arab healthcare system has its own specifications that depend on lifestyle, health, and other social needs. During the last several decades, the Saudi population has undergone several significant changes, and this era of progress affected its health care (Alsufyani et al., 2020). Citizens observed new services, and nurses followed a new golden standard when they were responsible not only for patient care delivery but for innovation promotion and institutional change. Magnet hospitals are now related to safe work environments that are managed and controlled by nurses.
Taking into consideration the fact that Saudi hospitals are poorly introduced to the magnet status, more research is required to examine the two types of hospitals. This research proposal aims at creating a plan to study magnet and non-magnet hospitals and the impact of the status on the work environment. First, it is necessary to gather a solid background that will help prove the importance of research and identify a research problem. The next step is the identification of research goals, questions, and hypotheses that have to be discussed in the study. Analyzing its scientific contribution and limitations allows learning the possible obstacles and thinking about how to manage them with minimal losses. Then, a theoretical framework and a literature review will be developed to demonstrate the researcher’s readiness to work on the project. A final step is the creation of a methodology section and the choice of methods to examine the workplace of magnet and non-magnet hospitals in Saudi Arabia.
The examination of the work environment is a complex task and requires the evaluation of different aspects. For example, one should identify the conditions under which the healthcare system has been existing before the intervention of the magnet status in Saudi hospitals. To understand how the magnet status affects the care environment in the country, it is not enough to learn its healthcare system or nursing practice. The country has its history, and there are certain economic and political decisions that determine nursing and medicine.
Saudi Arabia Background
Saudi Arabia is one of the largest countries in the Middle East. It takes about three-fourth of the Arabian Peninsula and consists of mostly deserts (Alsufyani et al., 2020; Walston, Al-Harbi and Al-Omar, 2008, p. 243). That is why the country’s government takes many precautionary measures not to lose its natural resources that drive an economic boom at the beginning of the 2000s, namely oil reserves. In a short period, the Kingdom of Saudi Arabia has been recognized in the world arena as a meaningful international trade partner. Oil demand and the possibility of establishing and control a pricing policy turned out to be a solid benefit for the Saudi government (Walston, Al-Harbi and Al-Omar, 2008, p. 243). The quality of life has been considerably improved, and the World Health Organization (cited in Alsufyani et al., 2020) observed a life expectancy increase from 69 years to 76. As a result, the discovery of oil and the possibility of using it to stabilize the gross domestic product created new opportunities for healthcare providers. Additional funding, international cooperation, and vision were enough to show that the Saudi healthcare system may be improved.
Every population needs a well-defined healthcare system to be confident that professional help can be adequately delivered. In Saudi Arabia, health care is a fundamental right for all citizens as per the national constitution (Ragman, 2020, p. 1). The Ministry of Health (MOH) has been responsible for establishing and controlling free health services and managing welfare policies since 1925 (Ragman, 2020, p. 1). In addition to the MOH network, two more sectors exist governed by either governmental organizations or the private sector (Walston, Al-Harbi and Al-Omar, 2008, p. 244). New funding means new annual reports and explanations through statistical calculations and investigations. During a long period, there were two major types of healthcare funding: public (about 75%) and private or out-of-pocket expenditures (about 25%) (Walston, Al-Harbi and Al-Omar, 2008, p. 244). However, today, more facilities explain the necessity of privatization for most hospitals and clinics in Saudi Arabia. This process aims at transferring ownership of the government to private-profit or non-profit organizations (Rahman, 2020, p. 1). Privatization will introduce new insurance coverage and additional opportunities for foreigners to be medically advanced.
Several reasons for promoting privatization can be mentioned in the Saudi Arabia context. First, privatization is a solution to an unstable economy and irregular funding. Economic progress occurred in the middle of the 2010s, and now, not all companies are as successful as they were several years ago. Thus, oil prices have to be reduced, some people lose their jobs, and financial challenges should be recognized (Rahman, 2020, p. 3). The government does not want to change the rules under which healthcare services are delivered, but the decision to shift some burdens to consumers was made (Rahman, 2020, p. 3). In addition, the Saudi Vision 2020 and 2030 underline the importance of improving the health delivery system, nursing practice, leadership, and self-reliance (Alsufyani et al., 2020; Ragman, 2020, p. 4). The population growth is hard to control, the public sector problems are not easy to manage, and privatization is the step that could protect citizens at the moment.
Another piece of the current research background touches upon the ways in which people receive health care. There are 13 regions in the country and 20 health directorates that organize different health affairs (Walston, Al-Harbi and Al-Omar, 2008, p. 244). The MOH offers sponsorship to more than 3300 health centers, but it is not the only facility that contributes to the healthcare budget. The Medical Services Department of the Ministry of Defense and Aviation, the National Guard Health Affairs, and the Ministry of Interior Medical Services provide services to their employees with respect to national standards and rules (Walston, Al-Harbi and Al-Omar, 2008, p. 244). All these governmental organizations sponsor different health centers and enlarge their impact on the Middle East. The progress of the private sector cannot be ignored because the number of hospitals continues to grow from 18 in 1971 to 113 in 2005 (Walston, Al-Harbi and Al-Omar, 2008, p. 244). People are free to use the services from any sector, and their personal preferences, financial status, and health-related problems define this choice.
Magnet Status Background
Safety and quality are the two core expectations of health care. People want to know how all services are managed, nurses try to get access to multiple resources, and doctors investigate new forms of treatment to help patients. Each stakeholder in the system has a particular task, and what is required to investigate the system and its main characteristics. Magnet hospitals are places where nurses gain power and knowledge to promote change. During the last 20 years, these hospitals were implemented in the system and increased the responsibility of nurse leaders and managers (Upenieks, 2002, p. 564). In the 1980s, the idea of magnet hospitals attracted many nurses, and this step was a serious response to the nursing shortage (Shao, Tang and Ye, 2017, p. 312). In 1994, the ANCC created the Magnet Recognition Program (MRP) and, in 2002, designated the magnet status and promoted good and sensitive nurse-patient outcomes (Capuano et al., 2005, p. 229; Middleton et al., 2008, p. 367). The idea of magnetism in nursing practice continues developing, and today, it is known as a strategy when nurses protect the safety of their workplace.
Magnetism in hospitals may be present and absent because of different reasons. In Saudi Arabia, the creation of such facilities is not an easy task because of additional awareness, unknown experience, and practices that require new resources. Employees of magnet hospitals follow such essentials as support for education, collaboration, control of nursing practice, and adequate staffing (Kramer, Maguire and Brewer, 2011, p. 6). In most cases, magnet hospitals are based on transformational leadership and new knowledge (Kutney-Lee et al., 2015, p. 551). Still, effectiveness may be hardly achieved if a hospital is run by nurses, and the identification of golden standards where nurses and doctors cooperate and demonstrate their skills is obligatory.
In general, the offered background shows that the theme of magnet and non-magnet hospitals is actual for the Saudi healthcare system. There are enough reasons for implementing this approach to the already existing hospitals and allowing nurses to develop their skills and encourage research. At the same time, Saudi Arabia is not ready to accept magnetism as it is in the United States because of the lack of certification and experts in the field. This background helps me get prepared for a new study and learn what sources and studies might be credible. It is possible to take a look not only at the American experience but at European and Asian examples and find out if Saudi Arabia and magnet hospitals may co-exist. Nursing practice is a burning issue in the Middle East, and if the Saudi government considers the possibility of opening new magnet hospitals, researchers should investigate the field and think about available opportunities.
The Importance of Research
People’s knowledge about the peculiarities of healthcare processes and nursing care is usually limited to what guides and policies display. Many standards and definitions determine expectations and the ways in which care is delivered and cooperation is organized. When the first magnet hospitals emerged in the United States, citizens and healthcare employees were interested in this idea as a solution to such challenges as nurse shortage, unemployment, and poor and unequal care quality (Kelly, McHugh and Aiken, 2012, p. 44). During the next several years, the same status was offered to hospitals in different American states and worldwide. European and Asian countries and Australia wanted to retain staff nurses and offer them a full expression of skills and knowledge (Desmedt et al., 2012; Middleton et al., 2008, p. 367; Shao, Tang and Ye, 2017, p. 312). When employees are motivated and supported, the level of productivity and quality increases. Thus, magnet hospitals are characterized by effectiveness and positive patient outcomes. Non-magnet hospitals have their benefits, which explains their need in today’s system. Comparing these hospital types is vital for a current research project.
However, the identification of positive and negative influences of magnetism on hospitals is not enough to prove the importance of this study. The researcher has to identify more reasons for showing the importance of this project. Therefore, attention will be paid to three areas, namely the quality of healthcare services through the prism of magnetism, attitudes of nurses towards magnet and non-magnet hospitals, and the geographical location of magnet hospitals, which is Saudi Arabia. In other words, the significance of research about magnet and non-magnet hospitals should be discussed from the point of view of a product (care), people (nurses), and place (Saudi Arabia).
Care issues continue bothering many patients, regardless of the type of a hospital. A high readmission rate, poorly managed pressure ulcers, medical errors, and limited electronic resources or equipment challenge the staff and reduce the number of services. However, there is an opinion that if nurse staffing is qualified and high, the context of nursing care may be improved (Capuano et al., 2005, p. 229). Lacey et al. (2007, p. 199) also admit that nurses become true partners in care in magnet hospitals. As a result, magnet hospitals have a better staff where care is delivered on time and as per patients’ needs. Decreased mortality rates, high patient satisfaction, and low falling opportunities are observed because more nurses are retained, and fewer employment questions take place. It is important to underline that an overall picture of magnet hospitals is associated with positive outcomes and emotions. This research will show the relationship between care and magnetism using the personal experiences of nurses and patients.
Still, another critical reason to support this investigation is the comparison of care on the same grounds in non-magnet hospitals. If magnetism means the involvement of nurses in various care processes, the research should clarify if non-magnet hospitals do not have similar opportunities. It is interesting to visit local non-magnet hospitals and reveal current problems, challenges, and care barriers. Magnet hospitals are not many around the globe and in the Middle East in particular. This study is significant as it will discuss several care aspects at magnet and non-magnet hospitals. There are many controversies that cannot be neglected, like if the absence of a particular status defines the quality of care and equipment in a healthcare facility. Inpatient care and the work environment are broad concepts, and it is necessary to narrow down the topic and underline the most critical fields where patients ask for help.
One of the most distinctive features of magnet hospitals is the identification of the nurse’s role in a working process. The work environment depends a lot on how nurses behave, what knowledge they use, and how they cooperate. A nurse is one of the most important figures in a hospital, either magnet or non-magnet, and the contributions made by this group of people have to be identified. It is interesting to investigate not only their interests and needs but also the areas where they can promote change and offer their unique interventions. In other words, magnet hospitals create a solid background for nurses’ development and progress. Still, researchers should think about why similar opportunities are not available in non-magnet hospitals where nurses have the same responsibilities and roles in team building. Funding of hospitals hardly depends on the number of nurses and their skills. Thus, nurses and their attitudes toward their duties may be predetermined by the status of a hospital.
The quality of work in hospitals may be assessed by multiple criteria, and the most common are job and patient satisfaction, patient and nurse outcomes, and retainment. The goal of a magnet hospital is to create a supportive professional environment where nursing care is offered (Kelly, McHugh and Aiken, 2012, p. 45). When nurses feel support, they are ready to work hard and stay devoted to their workplace for a long period. If a team consists of people who are aware of each other and the environment, they spend less time on discussions but concentrate on improvement and development of some new techniques and collaborative approaches. Nurses who have experience at magnet hospitals also report a positive perception of their competence (Cimiotti et al., 2005, p. 390). However, the importance of the future study is to identify if such competencies are lacking in non-magnet hospitals and if this status changes the quality of a work environment.
Finally, one of the causes to initiate the study and examine the work environment in magnet and non-magnet hospitals is related to the peculiarities of the chosen geographical location. In Saudi Arabia, magnet hospitals are not as common as in the United States or China. However, Saudi students continue learning nursing and achieving high scores in different programs. The importance of this research lies in explaining the role of the status in the work environment in a particular country. In 2013, the proposal to introduce MRP was made for one of the Saudi hospitals (Lovering, 2013, p. 619). Despite its partially isolated location, Saudi Arabia recognizes nursing as a global concept that promotes the provision of excellent patient care (Lovering, 2013, p. 619). There are many directions of how nursing can be improved as soon as the status is given. Still, the Saudi experience is not widely studied, and the impact of magnetism is new for the country.
In terms of future studies, it is possible to investigate the conditions under which the work environment is created and managed in Saudi hospitals. This step allows understanding if cultural or social aspects may affect care, patients, and nurses and comparing different roles. Today, Saudi Arabian nursing market is not stable and is challenged by staff accessibility (citizens are eager to join the international market and earn more) and performance levels (nurses lack skills and knowledge about high-quality care) (Alluhidan et al., 2020). The Saudi government is not always able to match skills, needs, and available resources (Alluhidan et al., 2020). Thus, the establishment of the magnet status could help expand capacities and develop competence with new simulations, teaching materials, and strategies focused on nurses’ collaboration.
The identification of a research problem in a proposal is an important step as it aims at explaining why the chosen topic matters and how it may be examined. Magnet and non-magnet hospitals are characterized by different work environments, mainly because nurses have to perform their roles in different ways. As a rule, in non-magnet hospitals, nurses report a low level of EBP culture (Melnyk et al., 2020, p. 342). The problem is that the status is not as critical for nursing as the skills and knowledge students obtain during their education. In this study, the problem should be revealed from the examination of the work environments at different hospitals, depending on their magnetism status. The researcher will focus on this particular factor to prove that differences may emerge not because of the status but because of other personal or organizational issues. There are other reasons for nurses to be or not to be involved in research processes and participate in interventions when care or collaboration should be changed and improved.
A healthy work environment is necessary for hospitals as it promotes employee engagement, decreased burnout, and better care. The magnet status is associated with excellence and support for nurses and better patient outcomes and satisfaction (Lacey et al., 2007, p. 203). When nurses feel satisfied, they do not try to find new places of work and feel inspired to improve their current workplace. The problem is that not all hospitals have many resources to meet all nurses’ needs and demands. In some facilities, the staff is not knowledgeable enough to apply their skills and change something at the moment. Many students choose nursing as their career path and develop good qualities but change their decisions if they find a better income source. Some students leave education during the first year because they are not satisfied with the offered practice and employment. The main outcome of any of these scenarios is missed nursing care and poor patient outcomes. Thus, the success of future nursing is related to the staff and services that patients need.
In Saudi Arabia, nursing practice is not new, but the development of international relationships and the possibility of studying abroad allows improving students’ knowledge and experiences. It has become easy for students to exchange their thoughts and ask questions distantly. Saudi hospitals have also become better because patients could address professional help online and obtain the necessary information in a short period. However, in all these cases, the quality of care in hospitals is not easy to change and improve. Nurses and doctors need more time and resources, and the problem of limited knowledge about golden standards of nursing and health care exists. Magnet hospitals prove their quality and professionalism in the United States, Europe, and Asia, but the Middle World is not aware of all its benefits and shortages. Therefore, the comparison of the work environments in different hospitals is a challenge. Nurses are not able to compare their opportunities in various hospitals, and they have to read journals and reports to understand if magnet safety can be advantageous for them.
There are two well-known Saudi hospitals that have already gained a magnet organization status – the King Faisal Specialist Hospital & Research Centre, located in Riyadh, and the King Fahad Specialist Hospital-Dammam, located in Dammam. Non-magnet facilities like Riyadh Military Hospital, Magrabi Hospitals & Centers, Security Forces Hospital, or Green Crescent Hospital are located in different regions of the country. Some employees are eager to cooperate and share their opinions about the work environment, professional achievements, and patient outcomes. Still, many hospitals keep their information private and do not want to ask questions and participate in research studies. As a result, it is difficult to compare the work environments of local hospitals, focusing on their statuses. Recent studies prove that nurses from magnet and non-magnet hospitals could have different EBP knowledge, leading to more positive nursing and patient outcomes in magnet organizations (Melnyk et al., 2020, p. 345). Kelly, McHugh and Aiken (2012, p. 48) conclude superior nurse work environments in magnet hospitals due to low burnout and job dissatisfaction. Similar results were observed in many studies, where nurses demonstrated optimistic perceptions of their work.
Despite a common awareness of magnet status and its advantages, not many hospitals could easily obtain it. In American facilities, the examination of the work environment reveals a number of positive aspects for nurses in magnet hospitals. Still, there are also many non-magnet hospitals in Saudi Arabia, and the problem is to identify the reasons for lagging behind magnet hospitals. A healthy work environment is highly appreciated by nurses: high retention rates, low burnout, fewer nurse shortage problems, and increased job satisfaction. The differences between hospitals based on obtaining a magnet status affect the work environment and the nurses’ attitudes toward their duties. There is a need to understand why Saudi hospitals, with or without a particular status, cannot create similar conditions and support nurses.
This research proposal aims to identify a topic and a scope of practice, define the main research objectives, pose the right questions, and formulate a hypothesis that has to be proved or disproved. There will be one goal in the study and several supplementary objectives to define a list of steps to be taken during research. Several questions will be created to make sure that a topic is adequately discussed, with all issues being properly explored. Finally, a hypothesis is an idea that should be proved by future research. In other words, a hypothesis will be the main statement of the study and a prediction about the expected results.
The analysis of the work environment where nurses spend much of their time is a significant part of this project. Some nurses are satisfied with the offered conditions, and some employees expect several changes to be made. The main goal of a future study is to examine the work environment in magnet and non-magnet hospitals in Saudi Arabia. However, this purpose is general, and it is necessary to understand how to achieve it by meeting supplementary purposes. There are two main directions in the study: gather information from the review of the literature and conduct an original quantitative questionnaire. The following objectives are set as a part of the literature review:
- To describe the main characteristics of magnet and non-magnet hospitals.
- To explain how the work environment is predetermined by the magnetism status.
- To investigate the work environment of hospitals within the Saudi context.
- To focus on the development of nursing practice in Saudi Arabia.
- To explore magnet and non-magnet hospitals in Saudi Arabia.
- To evaluate the perceptions of Saudi nurses about magnet and non-magnet hospital environments.
These purposes are clear and definite, and the researcher will be able to achieve each task by completing the previous one properly. There are three phases in the literature review: attention to the magnetism status in general, the nursing work environment in general, and the Saudi perspective on nursing practice in magnet and non-magnet hospitals. This approach allows understanding of the conditions under which nurses work, their roles, and their responsibilities. The opinions and findings of scholars create a solid background for future study and original research.
The following objectives will be achieved during an original part of the research when nurses participate in a questionnaire:
- To identify the criteria for analyzing the work environment.
- To prepare a questionnaire for nurses.
- To contact potential participants and obtain their consent.
- To gather the opinions of nurses about their work at magnet and non-magnet hospitals.
- To examine the characteristics of a work environment.
- To detect the type of a hospital with a more positive work environment.
These steps need additional preparation and the evaluation of the offered theoretical background. The perceptions of people are usually subjective, but, in this case, subjectivity can be a benefit because real situations and expectations will be offered. During this stage of research, it is vital to provide participants with guarantees and not to break the rules of confidentiality and anonymity. The researcher will investigate the work environment at different hospitals and use the opinions of nurses to develop a further discussion.
Regardless of the type of work or the sources of information, there is a list of questions that should be answered. Some explanations need additional evidence from scholarly resources, and some answers can be based on the findings from a questionnaire. Several questions will be close-ended to get a specific answer and use it as a reason for following discussions, but most questions will be open-ended to gather enough qualitative information.
- What is a magnet hospital?
- What is the difference between a magnet and non-magnet hospital?
- How does the work environment look like in a magnet hospital?
- What are the characteristics of the work environment in a non-magnet hospital?
- Does a work environment matter for nurses?
- What contributes to a positive work environment for nurses?
- How does nursing develop in Saudi Arabia?
- Is there access to nursing education in Saudi Arabia?
- What are nursing standards in Saudi hospitals?
- Are nurses satisfied with their work environment?
- What ways of knowledge exchange are available for Saudi nurses?
- Do nurses have enough support at their workplace?
- Does a work environment differ between the magnet and non-magnet hospitals in Saudi Arabia?
The offered questions are planned to be answered in a future project, but the researcher should understand that additional questions may emerge during an investigation. Therefore, it is obligatory to leave some space for several new queries or clarifications. In addition, the already developed questions may be removed from the list in case the literature review proves their inappropriateness in terms of the chosen topic. At this moment, three main criteria are identified for analysis, namely job satisfaction, knowledge exchange, and support.
The work environment in a Saudi magnet hospital is more positive and supportive for nurses compared with a Saudi non-magnet hospital.
The creation of an original topic is usually associated with a scientific or theoretical contribution. In this study, the examination of the work environment includes not only an evaluation process but a discussion of specific characteristics. Magnet and non-magnet hospitals continue emerging in different parts of the world. Many American and European scholars introduce their studies and compare the differences between the two types of hospitals. Currently, only two Saudi hospitals have gained this status, which could be used to compare the workplaces for nurses. Hickson (2013, p. 300) focuses on such factors as nurses’ perceptions of hostility, job satisfaction, and the level of comfort, support, and confidence. Job dissatisfaction and burnout are more evident in non-magnet hospitals by Kelly, McHugh and Aiken (2012, p. 45). Leadership skills and patient outcomes are the factors for analysis in the study by Fischer and Nichols (2019, p. 31), who prove that transformational leadership in magnet hospitals results in organizational improvement. Thus, many topics and aspects have already been analyzed to prove the differences between the magnet and non-magnet hospitals.
However, the Saudi context was neglected in most of these studies, which raises the scientific contribution of a future project. The already explained and proven significant nursing concepts will be examined from the point of view of Saudi hospitals. Every country has its regulations and standards for nursing and health care, and the Saudi government and the Ministry of Health, in particular, do as much as possible to provide care free of charge to all citizens (Walston, Al-Harbi and Al-Omar, 2008, p, 243). This research proposal will demonstrate why it is necessary to investigate the concept of magnetism in Saudi hospitals and its impact on the work environment. There are three main areas where contributions should be analyzed: Saudi nursing, Saudi work environment, and the worth of magnet hospitals for Saudi Arabia.
Today, Saudi Arabia is interested in developing the best conditions for nurses and healthcare workers. The government decides multiple challenges like poor education, paucity of international evidence, and the absence of a clear nursing practice scope (Alsufyani et al., 2020). Still, it is hard to come to one effective conclusion, and the examination of nursing interventions and strategies is required. Therefore, the idea to use the already mentioned problems and solutions and ask what real nurses think about the situation is a serious scientific contribution to the field of nursing. Nurses will be able to share their knowledge and opinions, the researcher will identify applicable theories and research problems, and the reader will expand awareness about the topic. Many studies are based on questionnaires, which proves the effectiveness of the methods. Its statistical significance is high for further implementation in the field. However, improved research methods (with respect to the literature review) will demonstrate the intention to continue the investigation in the context.
Saudi Work Environment
Today, much attention is paid to the conditions under which regular employees have to work. Depending on cultural and religious backgrounds, some organizations establish their own rules. In many companies, no distinctions on various grounds are observed, which shows the worth of equality and respect. In health care, the work environment is critical because it affects not only the staff but also consumers or patients. This study focuses on the evaluation of the work environment in two types of hospitals – magnet and non-magnet. Although nurses reported more positive attitudes and perceptions toward magnet facilities, there are many benefits at non-magnet hospitals (Tominaga, Tsuchiya and Sato, 2012). Some nurses need to understand if the achievement of a particular status (in this case, the status of magnetism) can change their workplace and introduce more opportunities. Magnet hospitals have a more supportive environment, and the scientific contribution of this study will be the identification of the reasons for organizational diversity. The answers of nurses who work in Saudi hospitals will help explain their positions and steps that are taken to be heard and respected by other representatives of a healthcare facility.
Magnet Hospitals in Saudi Arabia
Finally, not all Saudi hospitals may be called magnet, and the differences between non-magnet and magnet organizations continue to become more evident. Some nurses are ready to leave ordinary hospitals and try themselves at places where support and cooperation are high. The privatization of hospitals allows non-governmental stakeholders to be involved in the health sector and provide health care through their finances and leadership (Rahman, 2020, p. 1). This process leads to an increase in the private health insurance market but questions the protection of the population who cannot afford services in the country (Walston, Al-Harbi and Al-Omar, 2008, p. 249). As such, the contribution of this research will be to analyze how magnet hospitals can help the Saudis without challenging the existing healthcare system. Patients want to obtain high-quality services, and nurses need to have a good work environment, and the Saudi government should protect the interests of consumers and employees. Therefore, it is required to find a balance between the expectations of the three parties and use magnet hospitals as a solution.
Organizing a research proposal requires the implementation of critical thinking, problem-solving, time management, and reasonableness skills. However, even if all these recommendations are followed, there are certain limitations that a researcher cannot control. These conditions are unpredictable or predictable influences and shortcomings that may affect the choice of a method, results, and discussion. Sometimes, the researcher faces restrictions that make it impossible to continue an investigation in the chosen direction. In some cases, limitations may be insignificant characteristics that instigate the validity and credibility of the research. Therefore, in a research proposal, it is always necessary to identify several limitations and evaluate their potential impact on the work. It is not enough to provide a list of shortcomings but explain how they affect research findings and what steps to take and reduce deviations. At this moment, the following limitations have to be discussed: sample size, lack of previous studies in a particular context, the scope of discussions, and the choice of a methodology.
In most cases, sample size depends on the chosen research problem and the goals to be achieved. In addition, not all researchers are able to identify the required number of participants beforehand and give approximate numbers, which challenges a future research process in many ways. For example, real-life communication with participants could reduce or, vice versa, increase the number of people who could contribute to the study. According to the existing ethical standards and rules, all participants are free to leave the project any time they find it necessary. Thus, sample size is a common limitation of many studies, regardless of the field or topic. To predict complications and deviate from the challenges, researchers are proposed to establish a larger sample size for the further generation of more accurate results. Small sample size is usually a problem for quantitative studies because of the necessity to conduct tests and check validity. In this study, the limitation of sample size is evident because it is impossible to predict how many nurses are willing to participate and will participate at the end.
Lack of Previous Studies
The choice of sources for a study is an important step for any researcher. The way of how a literature review is organized defines the scope of the problem and the areas of investigation. Nursing is one of the largest healthcare professions, and many people work in this field and regularly introduce new issues for discussions. Many studies use the review of the literature as a solid background for original projects. In this proposal, the review is defined as a limitation because not many authors investigate the peculiarities of magnet hospitals in Saudi Arabia. During the last two decades, the concept of magnetism in health care has been properly explained and examined. The findings reveal that nurses are satisfied with their jobs and work environments in magnet hospitals (Upenieks, 2002, p. 541). Gu and Zhang (2014, p. 440) underline the benefits of autonomy and involvement for nurses in their work environments. However, only a few sources about magnet hospitals in Saudi Arabia can be found online, which could limit this project.
Scope of Discussions
Despite the research area chosen for this project, the scope of discussions may create a specific limitation because of several reasons. First, the outcomes depend on the experience of the researcher. It is not easy to conduct research, create an academic paper, and cooperate with different people if no similar steps have been taken before. The researcher may not understand how deep a particular discussion should be, decreasing the quality of information. Secondly, the number of sources and their evaluation affect the possibility of diversifying findings and use different variables. For example, Kalisch and Lee (2012, p. 35) worked with 124 care units from 11 hospitals in the United States, and Park, Gass and Boyle (2016, p. 285) used the information from 497 hospitals for their correlational data analysis. In this study, it is planned to work with at least 20 scholarly articles published within the last two decades and use communication with nurses as a primary data source. The scope of discussions has to be adequately defined when creating a research problem statement, goals, and methods.
Primary data collection is usually a challenge for many inexperienced researchers. One of the first decisions to make is the choice between qualitative and quantitative studies. The next step is to define an instrument that helps gather enough information. Finally, it is necessary to think about how to analyze the offered data and prove its credibility. In this research project, a quantitative questionnaire will be conducted. There will be several objective questions for nurses to gain their insights about the work environment, magnet and non-magnet hospitals, and the quality of care they offer to patients. The limitation is related to the impossibility of predicting if participants can answer all questions within the offered deadline. The answers have to be generated into numerical data for statistical analysis. However, not all researchers have enough experience in this practice, and they address experts for help.
In research, theories play an important role as they aim to formulate a background or a framework for new thoughts and discoveries. The researcher has to understand a phenomenon, relying on the already offered material. However, a theoretical framework is not a literature review by a structure according to which a theory is supported and explains a research problem. There are several critical definitions and concepts that are relevant to the area of investigation. A theory is used to combine all the necessary aspects and represent a plan according to which researchers identify what has already been discovered and what needs to be done.
This framework should include the already made attempts to study the healthcare work environment, nurses’ perceptions, and performance outcomes. To examine the work environment, Hickson (2013, p. 294) offers the Oppression Theory by Paulo Freire, when nurses were labeled as an oppressed group and expected to find support in a new work environment at magnet hospitals. Still, an understanding of nurse perceptions of the work environment was better demonstrated in Lacey et al. (2007, p. 201), where Maslow’s Hierarchy of Needs was implemented. Regardless of their geographical location, education, and available resources, nurses have a number of needs.
The work environment has to be created in order to meet at least some of these needs, and magnet hospitals are more successful compared to non-magnet hospitals. In the middle of the 1900s, Alfred Maslow tried to comprehend what could motivate people to improve the quality of their work and introduced five levels of needs, namely physiological, safety, belonging, esteem, and self-actualization (Aruma and Hanachor, 2017, p. 15). Years later, scholars and researchers developed new perspectives of motivation to satisfy basic needs in the healthcare sector (Ștefan, Popa and Albu, 2020, p. 125). Therefore, the choice of Maslow’s Hierarchy of Needs Theory is explained by the intention to combine personal issues (nurses’ demands), organizational concerns (workplace at magnet and non-magnet hospitals), and expected outcomes (care quality changes).
All people should be properly motivated to satisfy their needs, and Maslow shows how to arrange needs in the correct order. From the lowest level of needs (physiology) to the highest level of self-actualizations, individuals take specific steps in their development. Almost all healthcare facilities, either with a magnet status or not, help nurses meet physiological needs like food, water, shelter, and comfort. Basic needs create a vital development indicator in the work environment (Aruma and Hanachor, 2017, p. 20). If nurses cannot eat or drink, their productivity decreases and care quality gets lower. The work environment must create equal opportunities for all nurses of both genders and different ages in terms of their needs at the physiological level.
The next stage in the hierarchy of needs is safety. According to Maslow, security is an integral element of life or the workplace because people manage chaotic situations, deal with social disorder, and predict or solve physical dangers (cited in Aruma and Hanachor, 2017, p. 20). Safety needs cannot be ignored in nursing practice, and all employees want to feel protected against any harm. Effective leadership, cooperation, and management result in increased motivation, high-quality performance, and job satisfaction (Ștefan, Popa and Albu, 2020, p. 135). These elements can be observed in magnet and non-magnet hospitals, depending on people and available resources. Compared to the previous level of needs, where all of them are usually biological, and individuals hardly control them, safety needs are determined by nurses’ awareness and readiness to work.
Social needs are usually represented by the love and belonging needs of people. When people feel safe physically, they experience the need to belong to a particular organization (Aruma and Hanachor, 2017, p. 22). The work environment in magnet and non-magnet hospitals is an achievement of individuals who are confident in their abilities and contributions. At the organizational level, belonging gains a variety of forms in nursing. Employees are able to develop relationships within a single group, with a leader or manager, with a patient, or with a hospital, in general. In any case, when a nurse feels connected with a team, performance and quality raise.
During the next stage, known as esteem needs, nurses demonstrate their achievements, professionalism, status, and mastery. In other words, Maslow recognizes the importance of ego in the human or work environment (cited in Aruma and Hanachor, 2017, p. 22). A good nurse should have a purpose to be achieved in different periods. When there is no goal in their work, nurses experience difficulties in understanding their worth at the workplace. Regrading this perspective, it seems that magnet hospitals create more opportunities for nurses for their development compared to non-magnet hospitals. Still, Saudi nurses respect each other, as well as their leaders, patients, and families, which questions the superiority of one type of a hospital over another.
Finally, the fifth level of needs in Maslow’s hierarchy is based on self-actualization. As well as esteem, self-actualization is a motivational factor for nurses that positively affects satisfaction and performance (Ștefan, Popa and Albu, 2020, p. 136). On the one hand, nurses have a number of rules and responsibilities, making them grow and improve their experience at different levels. On the other hand, the work environment has to promote success and offer enough opportunities for self-fulfillment and realizing personal potential (Aruma and Hanachor, 2017, p. 22). Many modern nurses continue advancing their knowledge and exchange experiences nationally or even globally. The hospital environment should not restrict such attempts but encourage nurses to do something new and unusual.
The work environment of magnet and non-magnet hospitals has to contain different characteristics, and the idea of comparing them through the prism of Maslow’s hierarchy of needs has several strong arguments. Its implementation helps determine what motivates employees, what makes them change workplaces, and who is responsible for meeting their needs. As soon as a person understands that all needs are met, it is possible to continue discussing this theme with colleagues, leaders, and other meaningful stakeholders. When all five levels of needs are identified, explained, and discussed in the workplace context, it is clear what should be improved. Sometimes, an employee might need attention and support from a community or colleagues. In some cases, people expect to have more space for their work and ideas to be well-organized and supported. There are also workers who could neglect their basic needs and focus on self-actualization to feel empowerment and trust. Each level of needs makes an employee close to new areas of professional development, and it is necessary to clarify if the identification of needs is better at magnet or non-magnet hospitals.
The goal of this literature review is to show what has already been discussed on the topic, what gaps and recommendations can be identified, and what background might be used for a future project. It is not enough to find several sources about the work environment in hospitals and the opportunities of nurses in magnet and non-magnet hospitals. The choice of keywords is a vital step that allows access to the necessary sources. As the first MRP was introduced in the middle of the 1990s, and positive results were reported at the beginning of the 2000s, it is reasonable to use the articles published since the 2000s. The Saudi context is not commonly used in the magnet discussion; thus, it is expected to work with the sources where Saudi nursing practice and work environments are identified and explained. There will be four main thematic sections in this literature review to concentrate on the magnet and non-magnet hospitals, nursing practice expectations, work environments, and current Saudi care systems. Each topic should have several sub-topics to organize the flow of thoughts and clearly explain each concept.
One of the steps in developing a literature review is to identify the criteria according to which all articles and studies will be selected. As it has already been said, the theme of magnet hospitals is relatively new, and the use of sources published since 2000 is reasonable. In addition, the choice of keywords is necessary to define future projects. The field of nursing is broad, and the task is to narrow the topic as per the offered theme. Thus, such word combinations as “magnet hospitals,” “non-magnet hospitals,” “nursing,” “work environment,” and “Saudi Arabia” were chosen. Google Scholar, CINAHL, MEDLINE, and Cochrane Library were the main databases where information was checked. Another significant aspect is to use full-text articles but not their summaries or abstracts only. Authors from various countries identified their goals, created hypotheses used different methods to gather information and attract the required number of participants, and analyzed the results to develop informative discussions and conclusions. Although the chosen sources should not be critical in the examination of the work environment, they play a role in understanding the topic and formulating a solid background for new discussions.
Nursing Practice in Health Care
Modern health care is a complex system that includes a number of people, organizational issues, behavioral changes, and multiple tasks. Its performance depends on various factors and individual components, one of which is the quality of nursing care. The government of each country establishes certain expectations for the nursing profession, but regardless of geographic location, a nurse plays a critical role in a constantly changing healthcare system (Shao, Tang and Ye, 2017, p. 311). The main idea of nursing is to provide individuals and their families with care to recover from illnesses, get an education, and develop skills that maximize physical health and emotional wellness (Salmond and Echevarria, 2017, p. 21). Nurses also become good care coordinators who enhance collaboration between medical workers and patients or between the same team members. According to Upenieks (2002, p. 571), today’s settings are based on team building that can be translated into professional care management and increase productivity. Nurses have to recognize their roles for treating diseases, educating patients, supporting families, and cooperating with other employees to manage services as per the already established standards.
Talking about nursing, people want to have a qualified team of employees who know what to do and how to improve human health. Modern students and future nurses pay much attention to the promotion of EBP knowledge when the integration of research evidence, clinical expertise, and patient values is possible (Melnyk et al., 2020, p. 338; Wilson et al., 2015, p. 12). Similar practices are effective in decision-making and problem-solving, and nurses are able to develop the necessary skills at anytime. The quality of care in nursing also depends on how well nurses demonstrate their attitudes toward patients, their roles, and their obligations. A confident nurse supports patients’ ability to manage care and choose the most effective way of treatment (Kutney-Lee et al., 2015, p. 556). In most cases, any treatment process consists of checking vital signs, monitoring intake and output, emotional support, and medication control (Kalisch and Lee, 2012, p. 36). Nurses do not set preferences but follow the same order and make sure their patients receive care, attention, and explanation when they need it.
Education and support are two more aspects of nursing care in any hospital. In addition to the necessity to promote care and health in any facility, nurses become responsible for multiple education processes for patients and their families. It is not enough to follow the chosen line of treatment and follow the recommendations of a doctor. The Institute of Medicine states that health and nursing care aims at establishing a partnership between a patient, a family, and a practitioner to make decisions only if patients have the education (cited in Salmond and Echevarria, 2017, p. 21). In neonatal care, parents need additional support and explanations from nurses to make sure their children obtain all services and avoid threats that could have an adverse effect on health (Tubbs-Cooley et al., 2017, p. 8). Adult patients also want to know as much as possible about their health and believe that nurses are the best sources of information. Communication, additional questions, and respect in relationships are integral for nursing care. If employees are usually taught how to develop such relationships in settings, patients need more time to understand care peculiarities.
The way of how nurses cooperate in a team determines the quality and delivery of care services. Patients are free to demonstrate different attitudes in a hospital, while a nurse should rely on the already received knowledge and skills. If nurse-patient relationships may develop in a variety of ways, cooperation between nurses should be organized in a definite manner. Patient-centered care is achieved by interprofessional collaboration, where nurses exchange knowledge, participate in various interventions, and share new improvement ideas (Salmond and Echevarria, 2017, p. 21; Upenieks, 2002, p. 572). In nursing care, such concepts as trust, self-respect, and tolerance gain a significant meaning because every nurse wants to have a solid backup while offering help to people. There are many additional outcomes of cooperation between nurses. Park, Gass and Boyle (2016, p. 284) say about increased work satisfaction and decreased retention rates in hospitals where nurses know how to work and support each other. Care safety and quality may also be improved if nurses demonstrate competency and mentoring (Melnyk et al., 2020, p. 343). Nurses will create appropriate work environments to promote health, educate patients, and prevent complications.
Importance of Work Environments for Nurses
Many factors affect the choice of nurses about a hospital where to work. Some nurses consider the location of a building, while many employees check financial or organizational aspects. However, in any case, the work environment plays an important role in nurses’ work because it contributes to high productivity, job satisfaction, and positive patient outcomes (Capuano et al., 2005, p. 235). In current studies, much attention is paid to creating an effective environment for nurses, what conditions to promote, and what decisions to avoid. For example, in Swiss hospitals, nurses want to participate in hospital affairs, choose the staff, and get access to adequate resources (Desmedt et al., 2012). American nurses focus on promoting a positive scheduling climate and professional management (Cimiotti et al., 2005, p. 388). In China, the success of the work environment is determined by the level of support, innovation, clarity of tasks, and workload (Shao, Tang and Ye, 2017, p. 318). As such, the work environment is never stable for nurses because of the possibility to affect people and processes and promote high performance, job satisfaction, and retention.
When nurses work in a healthy and supportive work environment, they are ready to demonstrate good performance and a desire to develop. Kramer, Maguire and Brewer (2011, p. 6) introduce eight elements of the environment for nurses, namely cooperation, competency, autonomy, education, adequate staffing, support, control, and adoption of cultural values. In the study by Ma and Park (2015, p. 570), such characteristics as communication and strong administrative support are also mentioned to attract the attention of nurses in hospitals. On the one hand, nurses need control and leadership to understand what kind of work has to be performed and within what limits. On the other hand, there has to be a balance between professional expectations, obligations, and freedom. Nurses want to work in a hospital where their autonomy is appreciated (Hickson, 2013, p. 294). In this case, it is easy for them to define their needs, offer changes, and recognize what is good and bad for a hospital. In other words, nurses want to participate in all working processes and never neglect their interests and personal goals.
Many nurses want to understand how to choose a work environment and not to miss other opportunities. For this purpose, researchers recommend focusing on job satisfaction and the identification of personal needs (Ștefan, Popa and Albu, 2020, p. 125; Stimpfel, Rosen and McHugh, 2015, p. 54). The nursing profession requires high dedication to each step and each decision made during either a single shift or the entire career. Sometimes, a nurse is satisfied with positive feedback or a fast recovery of a patient because of properly offered services (Hickson, 2013, p. 298). In some cases, nurses want to improve their working methods, have a bigger team, or find additional resources. The environment is not always the same as expected, and nurses can take steps and promote changes. As a part of their research, Fischer and Nichols (2019, p. 28) offer to enable nurses to act and create an environment where they actively listen, support each other’s decisions, and treat others with respect and dignity. All these characteristics of the work environment are subjective and depend on nurses’ background, cultural and social aspects, and even the country.
Another vital issue in understanding what defines a healthy work environment is the level of retention and the challenge of nurse shortage in a hospital. When nurses are satisfied with their jobs, they do not have strong arguments to change their workplaces or leave the nursing profession (Saunders and Vehviläinen-Julkunen, 2016, p. 518). Governments and organizations that support nursing practice want to create the most favorable conditions for nurses and avoid employment problems. The intent to stay in the current job becomes a serious criterion for many studies either as dependent or independent variables (Lacey et al., 2007, p. 203). However, despite a variety of opinions and findings, it is evident that a nurse who is satisfied with the work environment from organizational, social, and financial perspectives will never leave the place (Tubbs-Cooley et al., 2017, p. 8). Nurses create the conditions under which they are eager to work, and if there is a chance to change something and achieve better results, it cannot be neglected. Still, if a nurse feels some limitation in action, additional sources of inspiration and motivation should be found.
Motivation and Needs of Nurses
The examination of the work environment in nursing practice is never simple because this task touches upon different areas of motivation. Many hospitals continue searching the ideas in order to support and motivate the staff: the introduction of magnet hospitals is one of the options to retain nurses and raise their interest in the profession (Desmedt et al., 2012). Observations and original research prove that motivation and integration of knowledge into practice depend on nurses’ backgrounds, education, and attitudes (Wilson et al., 2015, p. 13). A nurse is usually interested in the environment and possibilities they get with the chosen facility. However, not much time is required to see if a hospital offers enough support and meets the promises given. Therefore, hospitals have to learn their nurses’ needs and the resources to support professional growth and development. Motivation is not a single task for employees but for their leaders who should identify what they can do to reveal the strongest abilities of their people.
In the healthcare system, motivation is not only an obligation for managers but a requirement for self-actualization and progress. Employees are most motivated when their needs of different levels (basic, emotional, or psychological) are met (Ștefan, Popa and Albu, 2020, p. 138). When a person is properly treated, does not experience a shortage of water and food, and works under safe and convenient conditions, the chances of demonstrating good results rise. With time, additional needs emerge like the necessity to have a good team or to feel support and understanding. Satisfaction cannot be achieved if at least one need of a nurse is neglected (Ștefan, Popa and Albu, 2020, p. 129). Thus, employees have to motivate their employees by replacing the needs that are hard to complete at the moment with other options. Career advancement is closely related to motivation and the expansion of efforts in the workplace (Alluhidan et al., 2020). In hospitals, nursing efforts include different interventions to improve care quality, avoid medical errors, support patients, and collaborate with colleagues.
Regardless of the intention to develop the sphere of nursing, many challenges exist and prevent effective motivation and support. Shao, Tang and Ye (2017, p. 320) conclude that not all nurses, even with their master’s degrees, can work as research coordinators or clinical specialists, which results in poorly defined functions and responsibilities, new restrictions, and decreased motivation. Pressure and urgency begin to dominate, promoting workload and reducing the intent to stay (Lacey et al., 2007, p. 201). Nurses do not understand why they cannot achieve a desired goal and try to find new ways of how to implement their knowledge and advance their experiences. Sometimes, they are ready to change the environment, and sometimes, they can find another sphere of work where similar skills and knowledge are required. Thus, motivation and the choice of sources for inspiration are critical in nursing.
Motivation, being properly applied in the workplace, has its benefits and consequences in nursing. Employees are well-directed, confident, and persistent in their steps, which results in excellence and high-quality care. A work environment that permits the full expression of human knowledge and skills plays a crucial role in how nurses stay motivated (Desmedt et al., 2012). People should feel support and encouragement to work and develop in the chosen profession. With time, more positive outcomes are observed in practice because nurses develop strong values, respect, and a desire to promote equity and fair relationships in the workplace (Upenieks, 2002, p. 570). It is necessary to remember that the nursing work environment is a complex system that consists of different elements (Gu and Zhang, 2014, p. 437). Nurses expect managerial support, cooperation with professional leaders, adequate staffing, and collaborative relationships under equal conditions. Still, in addition to all these factors, many modern nurses want to obtain control over their practice, make autonomous decisions, and conduct new research projects that expand their professional horizons.
Magnet and Non-Magnet Hospitals
There are many ways for nurses to improve their environment, and one of them is to choose magnet designation. This status is a relatively new concept for American hospitals that was introduced in 1994 by the ANCC (Kutney-Lee et al., 2015, p. 550). The MRP was introduced to several organizations as a model with guidelines to develop a supportive nurse work environment (Desmedt et al., 2012). Its history can be traced back to the early 1980s when the American Academy of Nursing (AAN) offered an initiative to reduce the nursing shortage and retain employees by choosing right motivation (Desmedt et al., 2012). Today, this status is internationally recognized by leaders of healthcare facilities and medical centers to demonstrate nursing excellence and professionalism (Melnyk et al., 2020, p. 337). Magnet program participants have to follow specific education, research, and certification standards to achieve career advancement and create opportunities for EBP (Wilson et al., 2015, p. 19). In a short period, many nurses were attracted by this program and wanted to work at magnet hospitals and study its distinctive features.
The concept of magnetism was properly implemented into nursing practice. Before 2007, there were 14 major components, but the number was reduced to five forces that defined the idea of magnet hospitals (Desmedt et al., 2012). The offered framework consisted of transformational leadership, structural empowerment, exemplary professional practice, new knowledge/innovation/improvements, and empirical quality results (Desmedt et al., 2012; Fischer and Nichols, 2019, p. 30; Melnyk et al., 2020, p. 337). Each element of this model has a specific impact on nursing and establishes new perceptions of a supportive work environment. Transformational leadership allows stimulation and inspiration for followers in any working process with the possibility of change and education (Fischer and Nichols, 2019, p. 27). Structural empowerment makes it possible for nurses to control resources and achieve goals through exchanging information and skills (Kutney-Lee et al., 2015, p 556). Exemplary professional practice is based on respect, equity, coordination, and cooperation. Innovations in nursing practice promote new designs and ideas that employees develop regarding their abilities. Finally, empirical quality results focus on processes that lead to positive organizational and patient outcomes.
In the 21st century, the US healthcare system and several systems worldwide offer nurses two types of hospitals: magnet and non-magnet. With time, nurses learn more about magnet-aspiring and magnet-conforming hospitals (Lacey et al., 2007, p. 200; Saunders and Vehviläinen-Julkunen, 2016, p. 515). Each type of a hospital has its definition and relation to magnet designation. Magnet hospitals are characterized by a healthy working environment for nurses with a variety of assessment tools for evaluating nursing processes and care outcomes due to their participation in the MRP by ANCC (Gu and Zhang, 2014, p. 437). In magnet facilities, employees strive to achieve nursing excellence, which results in increased attention among nurses and the possibility of retaining nursing staff (Middleton et al., 2007, p. 367). Magnet-credentialed organizations demonstrate better nurse-physician and nurse-patient collaboration, which creates safe environments and appropriate working conditions.
A non-magnet hospital should not be treated as a facility where poor quality services are offered or unprofessional employees are hired. This type of a hospital is defined by the absence of magnet certification at the moment. Non-magnet hospitals might have higher nurse turnover rates due to environment-related causes compared to magnet hospitals (Park, Gass and Boyle, 2016, p. 289). The level of knowledge and perception of EBP culture is usually lower among the representatives of non-magnet facilities, but both magnet and non-magnet types could demonstrate poor competencies (Melnyk et al., 2020, p. 345). Such findings mean that nurses from non-magnet hospitals have all chances to improve their services and develop the necessary knowledge.
In addition to a number of evident distinctions between the magnet and non-magnet hospitals, new characteristics were introduced for magnet-aspiring and magnet-conforming facilities. A magnet-aspiring organization shows its intentions and begins preparations of obtaining the magnet status in a formally announced manner (Lacey et al., 2007, p. 200). In other words, such hospitals have already applied for the status and become meaningful participants in this magnet journey (Saunders and Vehviläinen-Julkunen, 2016, p. 515). There are also such hospitals whose leaders use the program as a “roadmap for excellence in advancing their nursing practice but do not aspire to formally apply for the Magnet designation” (Saunders and Vehviläinen-Julkunen, 2016, p. 515). In their assessments, the employees of magnet, magnet-aspiring, and magnet-conforming hospitals rate their EBP knowledge and skills higher than those from non-magnet hospitals (Saunders and Vehviläinen-Julkunen, 2016, p. 517). These findings prove that the status does not define the qualities of nurses, but their perceptions vary considerably.
Despite the existing research projects and articles about differences between magnet and non-magnet hospitals, most nurses believe that the status increases their chances to be satisfied with the offered job and avoid negative acts. Still, Hickson (2013, p. 297) shows that such problems as workplace allegations, work below the level of competence, intimidating behaviors, and unreasonable deadlines can be observed in magnet and non-magnet hospitals with almost equal means. Similar benefits like flexible scheduling, professional interactions, career advancement, and compensation are available to the magnet and non-magnet nurses with certain divergence (Hickson, 2013, p. 298). Thus, hospitals with and without the magnet status have the value of achieving nursing excellence by choosing qualified staff, promote culture, respect, and trust, and find a strong leader who empowers and collaborates (Kalisch and Lee, 2012, p. 38). The work environment of magnet and non-magnet hospitals could differ, but many things depend on nurses’ perceptions, knowledge, and intentions to change something.
Saudi Healthcare System and Nursing Care
Nursing practice has already been successfully implemented in all countries, and people understand the role of a nurse in any care process. These employees help patients cooperate with doctors, establish professional relationships with family members, and offer support and education when patients need it. Despite a number of funds and resources spent on the improvement of the nursing sphere, some countries experience certain financial and organizational challenges that affect the quality of healthcare services (Walston, Al-Harbi and Al-Omar, 2008, p. 243). In Saud Arabia, the government is ready to develop new programs and invite foreign experts to stabilize the healthcare system and choose the most appropriate resources. At this moment, the country does not have clear national human resources for health plan that investigates and improves the nursing profession (Alluhidan et al., 2020). Still, many scholars admit the presence of new policy opportunities and rapid reforms to change the situation (Alluhidan et al., 2020; Walston, Al-Harbi and Al-Omar, 2008, p. 243). Therefore, healthcare services and nursing practice achievements in Saudi Arabia deserve attention and recognition.
Today, the Kingdom of Saudi Arabia is one of the largest and most well-developed countries in the Middle East. Its healthcare services are free of charge for all native citizens and foreigners who have official work agreements (Walston, Al-Harbi and Al-Omar, 2008, p. 243). The Ministry of Health is responsible for the management and control of all healthcare policies in the country, including its funding in the public and private sectors. Due to the already established Saudi Vision 2030, the Kingdom continues undergoing certain transformations at national and international levels (Alluhidan et al., 2020; Rahman, 2020, p. 5). Changes touch upon the economic sector, financial operations, and organizational issues. The expansion of the healthcare system is not an easy task, but the government ensures that efficiency may be improved, and new values can be implemented. Nurses remain the large group of healthcare employees in the system; that is why the Saudi government is interested in reforming nursing, reduce shortage, and improve the work environment (Alluhidan et al., 2020). Nursing care cannot be ignored in the country because people expect to see support, mutual understanding, and cooperation in hospitals.
Nursing problems are closely related to the conditions under which new people join the sphere. Saudi Arabia experienced multiple industrialization changes during the last several decades, and the educational sector was not focused on producing an adequate healthcare sector (Walston, Al-Harbi and Al-Omar, 2008, p. 245). As a result, not many professional nurses, physicians, and other medical workers understood the peculiarities of the Saudi culture, environment, and beliefs in care. Nursing was based on the principles that were popular abroad, and the government could achieve the gold standards in nursing practice for Saudi patients (Alsufyani et al., 2020). Nurses have to work with patients and their families, follow doctors’ prescriptions and treatment plans, and promote well-being in and out of hospitals. There are many positive predictions about the future of health care in the country: additional options for population insurance, the promotion of equal care, and cost control (Walston, Al-Harbi and Al-Omar, 2008, p. 249). As soon as locals observe the experiences of other countries, they want to try similar steps in their environments. Thus, the promotion of magnet designation in Saudi Arabia gained popularity in the 2010s.
Magnetism Status in Saudi Hospitals
After a thorough observation of recent achievements in nursing at a global scale and in Saudi Arabia in particular, one should admit that magnet hospitals might appear in the country in the nearest future. Lovering (2013, p. 619) reported magnet designation in Saudi Arabia and explained how Deborah Zimmermann, the MRP representative, offered the status to the King Faisal Specialist Hospital & Research Centre. The chosen hospital is a 350-bed facility for tertiary care, located in Jeddah. It has already gained Joint Commission International accreditation, but the leaders wanted to obtain a higher credential in nursing (Lovering, 2013, p. 619). Therefore, the idea to participate in the program and use magnet recognition was a long-term goal for the organization. Nurses and other care providers need to understand the possible Western impact and apply it to the Saudi hierarchy-driven environment. Empowerment, autonomy, and respect are critical elements for the work environment, but not all nurses are satisfied with the conditions they get at the moment.
The introduction of the status to Saudi hospitals is an important step in the development of the local healthcare system. However, nurses must understand that this accreditation does not imply additional resources and equipment that are delivered for free. The program provides a template for a team to achieve excellence and combine diverse cultural backgrounds (Lovering, 2013, p. 620). Managers have to evaluate the effect of the MRP and focus on such factors as nurse satisfaction, work environments, and patient care (Alsufyani et al., 2020). National guidelines for magnet hospitals help Saudi nurses improve the scope of practice. This approach introduces nursing functions, defines work-related procedures, and explains all responsibilities in a clear and comprehensible way (Alsufyani et al., 2020). As soon as nurses learn all elements of the program, they can assess their performance in terms of skills, competencies, and motivation. Many Saudi nurses lack the necessary skills because of poor training and the lack of workplace practice (Alluhidan et al., 2020). The MRP offers enough material to help nurses recognize their strengths and implement them in the environment.
In the United States, magnet hospitals have already demonstrated certain benefits for nurses. Employees show high job satisfaction levels, low retention rates, and improved care services. In Saudi Arabia, similar results are observed in the hospital with magnet status. Nursing satisfaction continued to grow from 25% in 2015 to 50% in 2019 (February and Holmes, 2020, p. 534). Retention of nurses led to the bankruptcy of many hospitals, and today, this cause is no longer evident in the healthcare system. Patient care quality and safety are also at high levels because nurses know how to exchange information quickly and up to a point (February and Holmes, 2020, p. 535). Magnet accreditation supports nurses and makes them ready to work hard and use all available opportunities. Nurses participate in new research projects, establish their rules in collaboration, and create a work environment that meets their needs. Magnet hospitals solve the nursing shortage problem by offering opportunities that affect the system and enhance relationships (Alsufyani et al., 2020). This status turns out to be a solution for Saudi hospitals to introduce healthy work environments and empower nurses.
In previous sections, an introduction to the chosen area of research and the background of the problem were developed. Several scholarly articles were analyzed to review the topic and clarify the importance and possible implications of the current study in nursing practice. The work environment plays an important role in health care and nurse since it determines employee motivation, job satisfaction, and the quality of services. The literature review shows that the environments of magnet and non-magnet hospitals differ, but many things also depend on nurses’ perceptions and attitudes (Lacey et al., 2007, p. 200). Culture and social norms should also be identified in the discourse about care and how the relationships between people are organized. The proposed research will be an effort to examine the workplace characteristics in magnet and non-magnet hospitals in Saudi Arabia. This section aims to describe the methodology with the help of which the offered research questions and a hypothesis will be analyzed and answered. The study setting, research design, sample, data collection methods and procedures, ethical aspects, and analysis steps will be recognized in this part.
The intent of this study is to address the differences that exist in the work environments of two hospital types – magnet and non-magnet. The workplace quality may be identified by nurses personally or findings from reports about healthcare services and patient outcomes. In most studies, systematic qualitative reviews and specific assessment scales were implemented to gather information and compare norms of magnet and non-magnet hospitals (Gu and Zhang, 2014, 439; Middleton et al., 2008, p. 367). Secondary data analysis was effective in categorizing quality factors and reasons for nurses to stay in hospitals or quit (Park, Gass and Boyle, 2016, p. 285). Thus, a general concept of this study is to cooperate with the hospital population in Saudi Arabia.
The setting will consist of the representatives of two types of hospitals under analysis. One setting should be the King Faisal Specialist Hospital & Research Centre in Jeddah or the King Fahad Specialist Hospital in Dammam, as these are two well-known Saudi hospitals with magnet status. These facilities are tertiary referral hospitals that aim at serving society with the best healthcare services and patient experiences in research and education (Lovering, 2013, p. 619). The other setting group will include non-magnet hospitals in the same region. For example, employees from Jeddah National Hospital or Jeddah Clinic Hospital or nurses from hospitals in other cities of Saudi Arabia, like King Fahd Medical City or Mouwasat Hospital in Riyadh can be invited. The possibility of cooperating with these settings will allow for choosing nurses with different backgrounds, interests, and needs.
This project will be based on a quantitative strategy, meaning that the examination of the work environment of magnet and non-magnet hospitals will include numeric data. A quantitative design is used to determine the relationship between several variables within a particular population. In this case, a descriptive approach will be implemented to establish associations between magnet and non-magnet hospitals and define nurses’ perceptions of the work environment. The assessment of differences in job satisfaction of nurses was organized according to the principles of a quantitative strategy and computational techniques in several studies (Capuano et al., 2005, p. 230; Tominaga, Tsuchiya and Sato, 2012; Upenieks, 2002, p. 566). Observational studies were also effective in understanding the differences between magnet and non-magnet hospitals (Fischer and Nichols, 2019, p. 28). A quantitative research design is a fixed methods to find correlations between different hospitals and nurses’ attitudes toward the offered work environments.
This descriptive quantitative research will represent how subject characteristics of different hospitals could affect the work environment and nurses’ relationships. Information obtained from nurses about their practice, opportunities, and responsibilities will be necessary to analyze human behavior within a particular setting. A survey design focuses on the collection of current attitudes, knowledge, and experiences in nursing. This method allows using a large sample size without significant expense. When the number of participants is clarified, it is expected to choose the most appropriate statistical computer program and analyze the answers to share the results and findings. Personal opinions transmitted into numbers will be effective for examining the workplace and addressing the peculiarities of the Saudi context in nursing.
A population in a research project is a number of units from which it is possible to gather information. In this case, the sample includes staff nurses who work in hospitals with and without magnet status in Saudi Arabia. There will be clear inclusion criteria according to which to select the population. All participants have to be registered nurses who work in the acute care setting at the moment of the study. One group of nurses should have experience in a magnet hospital, while another group of nurses will be from non-magnet hospitals. It is expected to find nurses who know English or, at least, work with a translator who can deliver all the necessary information. Retired nurses and students will be excluded from the study.
There are several ways to obtain the names of potential participants for the study. The researcher should contact the Human Resource Department and ask for permission to conduct the study. As soon as approval is obtained, it is necessary to read the list of nurses and learn the number of employees to define a minimal sample size to be chosen randomly. In previous studies, the number of nurses varied from 50 to 300, depending on the scope of the problem and the chosen collection instrument (Fischer and Nichols, 2019, p. 28; Tominaga, Tsuchiya and Sato, 2012). In this study, it is proposed to invite at least 200 nurses from magnet and non-magnet hospitals. The response rate may be low, which causes biases in data collection.
Quantitative data will be collected from questionnaires that will be developed for nurses by the researcher beforehand. A Likert-scale will be used to identify the answers and make sure all of them are organized in a simple manner. A questionnaire is a written method of data gathering where participants are asked to give replies to a list of questions. It is a quick and convenient way to collect standardized data about human attitudes, knowledge, and behaviors. A structured written questionnaire will be sent to every participant via e-mail or any other way that is defined as convenient by a participant.
There will be ten separate statements in a questionnaire to examine the work environment between magnet and non-magnet hospitals. The researcher can improve the list during the working process, if necessary. Thus, the extension of statements should be presupposed in this project. Participants should read all statements and answer them in the same format, namely “Strongly Disagree,” “Disagree,” “Neutral,” “Agree,” and “Strongly Agree”:
- I obtain enough support at the workplace
- I am satisfied with my working conditions
- I can develop my professional skills as a nurse in this particular hospital
- I have a good and strong leader in a team
- I participate in research activities, not at the expense of my nursing practice
- I develop trustful relationships with my colleagues
- I enjoy communication and cooperation at the workplace
- I have access to the necessary resources and equipment
- I follow the most innovative ideas in the chosen sphere
- My contributions to nursing practice are recognized and appreciated
Any research that involves human beings is based on a number of ethical issues that must be recognized and discussed before the study. Ethical approval is required from the Hospital Ethics Committee and a special board. As soon as the committee approves the researcher’s actions in a hospital, direct communication with nurses may be initiated. Cooperation between the researcher and participants (nurses) is organized according to the principles of confidentiality and beneficence. All nurses obtain guarantees that their participation in the questionnaire is anonymous, and only the researcher is aware of their true names. The informed consent is the main agreement between the researcher and participants. It contains the main aspects of the study, the goals, objectives, and available resources. Nurses should understand that their participation is voluntary, and they can withdraw the questionnaire any time they want. If a participant has some questions or issues to be clarified, the researcher is responsible for giving all the necessary answers.
There will be three main letters within the frames of this research project. First, the researcher writes to the committee to get approval for research. Such details as respect for persons, confidentiality, and non-maleficence are identified and explained in the specific context. The second letter will be addressed to hospitals where the study will be conducted. Its main idea is to introduce a project, its significance, and implication for future practice. A final letter will be sent to nurses to inform them about the peculiarities of the study and the worth of their participation.
Data analysis is a vital part of the research design and proposal. This process is necessary to understand how to apply gathered information and make sense of participants’ answers in a clear way. When all questionnaires are sent back, the researcher counts the received number of answers to report the expected and actual number of participants. In most cases, the reasons for withdrawal from the study are briefly mentioned to explain further limitations. Descriptive analysis will be conducted using numbers, so it is necessary to code each question and answer using appropriate scales. Regarding the background of the researcher, the services of a statistician will be obligatory to work with the data and apply the Social Packages for Social Sciences (SPSS) model. The frequency of responses will be calculated as a percentage, and the researcher will create tables to facilitate the presentation of data. Bar charts will be effective in introducing the results and proportions of the chosen variables. Chi-square and t-tests will be used to examine for any differences between the magnet and non-magnet hospitals. The analytical part is usually the hardest in research, and professional assistance may be required.
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