The P components for our framework were primarily derived from Parsons (2004), Parsons et al. (2004) and MacPhee (2007). Parsons constructed a theoretical SPO framework similar to ours to guide the creation of a magnet-like work environment. In Parson’s study, nurse leaders facilitated shared decision making via participatory change management: engaging staff in project teams to make the work environment more magnet like. The nurse leaders also promoted shared decision making by ensuring staff had access to requisite empowerment structures, such as information and resources to carry out their project work. We adopted many of the shared decision making sub-processes used by Parsons, such as orienting the project team to the project purpose and background, and providing clear directions with respect to project team communications and participation in meetings and project work. The orientation phase is a critical time for engaging team members in shared decision making, such as determining ground rules for respectful and inclusive participation during team meetings (Parsons). We included sub-processes for team-building and change management that provided additional opportunities for the team and leadership to engage in shared decision making, such as working collaboratively to identify key stakeholders and planning for specific action item implementation and evaluation (MacPhee 2007, Parsons 2004). Specific tools related to change management, such as Plan-Do-Study-Act cycles, were adapted from the Institute of Healthcare Improvement (IHI) website. We also felt that it was important for teams and leadership to address plans for sustainability, rather than viewing their project work as finite (MacPhee 2007, Parsons 2004).
Outcomes (O component) for our framework were adapted from Parsons et al. (2004) and Kramer et al. (2008). After engaging nursing staff and leaders in work environment transformation, Parsons et al. (2004) documented positive outcomes from their year-long project using observations, group feedback and pre-post-implementation surveys. At the unit level they found tangible practice improvements; staff were more satisfied and empowered; the organization experienced decreased nurse vacancies and turnovers; and patient surveys revealed increased satisfaction. Staff involved in team work reported increased pride and enthusiasm, a greater sense of professional autonomy, and a shift towards independence – away from external facilitator support (Parsons et al. 2004).