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Journal of Nursing Administration:
Departments: In My Opinion

The Magnet Pregnancy: Phases of the Journey to Excellence

Houser, Beth DNSc, RN, FNP, CNAA; Milton, Doris PhD, RN

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Authors' affiliations: Director (Dr Houser), Critical Care Services; Director (Dr Milton), Nursing Research and Education, Scottsdale Healthcare, Scottsdale, Ariz.

Corresponding author: Dr Houser, Scottsdale Healthcare, 9003 E. Shea Blvd, Scottsdale, AZ 85260 (

The nursing shortage, considered by some to be a public health concern,1 is often the catalyst for considering Magnet designation. A growing body of evidence demonstrates that the Magnet Recognition Program may be a solution to the nursing shortage for those hospitals engaging in the process.2,3 This prompts hospital and nursing executives, as well as hospital board members, to invest in developing a Magnet culture, one consistently producing superior nurse, patient, and organizational outcomes.4

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Magnet Journey Compared With Pregnancy

The decision to take the Magnet journey is a leadership initiative. When the 14 forces of magnetism are studied, it is clear that one force, the quality of leadership, drives the remaining 13. Only when organizational leaders fully embrace and support the remaining forces of magnetism can the journey be successful. Nurse leaders pursuing Magnet designation commonly refer to the experience as a journey and often think that the journey was more valuable to the organization than the designation. Hearing the word "journey" conjures up an image of adventure, excitement, and discovery. The Magnet journey is all of that and more. The myriad of emotions and behaviors associated with Magnet is as predictable as are those of the trimesters in pregnancy.

The Magnet pregnancy has 3 distinct trimesters but the gestation period is more aligned to a pachyderm's (22 months), and at times, it feels to nurse leaders that the Magnet baby might be the size of an elephant. The Magnet pregnancy is exhilarating, exhausting, and earned. The impact on the work environment can be priceless-just like the effect of a newborn.

The first author's experience as a Magnet Project Director and Magnet Appraiser led her to view the Magnet journey as having 3 distinct trimesters: first-Ignorance Is Bliss; second-Wow, Are We Tired; and third-Bring It On. Inherent strengths and weakness of an organization drive specific strategies; however, organizations on the Magnet journey have more in common than they have differences. Nurse leaders who anticipate these phases can facilitate decision making, team building, and confidence as the Magnet trimesters unfold.

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The First Trimester-Ignorance is Bliss (6-18 months)

When nurse leaders make the decision to pursue obtaining the Magnet designation, they often view the process as simply preparing the documents for review. More often than not, this happens at good organizations that are industry leaders and highly competitive. The most frequent approach is to form a committee and organize the "Magnet project." With the known information in early first trimester, these good organizations believe they are Magnet already but may need to polish a few systems.

The Magnet manual, measuring less than 1 inch thick, can lead nurse executives to think "How hard can this be?" What is commonly overlooked is that just less than 3% of all hospitals in the nation attain Magnet designation. There is a very valid reason for this exclusivity-Magnet designation represents excellence not standard care. The gap analysis is often skewed by an underestimation of resources present and required. "How hard can this be?" will become fodder for laughter at some point in the third trimester.

During the Magnet first trimester, there is a buzz of excitement surrounding the recognition of excellence. All staff like to be recognized and feel proud of their workplace. There is a thirst for information and understanding of what this "project" will mean to the organization. Just like first-time mothers who rush to the book store to buy the pregnancy bible entitled What to Expect When You Are Expecting- Magnet applicants turn to the literature only to discover there are few roadmaps. Each Magnet organization is built from similar elements, but the arrangement may be as unique as a newborn's DNA code, making it difficult to create a meaningful roadmap. Magnet culture is created during the journey using the required 14 forces, but this is not known yet.

Valuable resources are available to help in the process. These include organizations already designated as Magnet and, more importantly, the American Nurses Credentialing Center Magnet Program office staff. Elements such as shared governance, professional incentives, professional development programs, interdisciplinary collaboration, and evidence-based practice are essential, but the expression of these elements within Magnet measurement allows operational latitude.

This latitude of Magnet expression creates a level of excitement and empowerment. As the Magnet word spreads, many direct care nurses know what the work environment should look like, and the discussion of change is brisk and embraced by some. The energy in the nursing organization is positive and almost contagious. Ignorance is bliss; relish the moment. This is the perfect opportunity to solidify the early direct care nurse buy-in and develop the Magnet leaders who will become crucial in the coming trimesters.

By the end of the first trimester, some of the high-profile discussions about Magnet, such as Magnet kick-off programs and early Magnet education, create some "project" obstacles. "Ignorance is bliss" is becoming tainted by an acute awareness of impending change. Some of the concerns expressed include the following:

* Magnet is only for nursing. This starts the discussion of whether pursuing Magnet might fracture the organization into a nursing versus ancillary departments. Why does nursing get everything?

* Magnet seems fuzzy and hard to describe. What is Magnet really and how does it apply to my practice? The Magnet language and approach may also seem foreign.

* What is in it for me? Nurses see that resources are being allocated to Magnet projects and question whether the investments should not go directly to salaries. The vision around Magnet is narrow because the concept is poorly understood, dissemination of information is still minimal, and the fruits of the process are not yet seen.

* We've announced to the world the baby is coming. Nurse leaders, hospital executives, and board members in the community are aware that the organization is applying for this recognition and this places external pressure on internal progress.

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Second Trimester-Wow, Are We Tired! (12-24 months)

As the second trimester arrives, it is clear that organizational change is occurring. Magnet recognition is no longer just a "project;" it feels much bigger than that. The phrase "Magnet building" often replaces the first trimester concept of preparing the documents. The Magnet definition and measurement of excellence become clearer and the breadth of the impact is becoming obvious. Similar to when pregnant mothers recognize nothing they own fits any longer, Magnet building has placed the organization in front of a full-length mirror and the image cast does not always match what leaders expected to see.

Nurse leaders begin to focus intensely on the data and the strategic plan around the results. Data drill downs on nurse and patient satisfaction can translate into adoption of new tools (eg, Nurse Work Index-Revised) and new methods (eg, patient scripting and/or customer service training). The perceived increased workload around Magnet building sends the message that things are not as good as once thought. There are moments when it is hard to breathe and fatigue has set in, both in pregnancy and Magnet building, but for very different reasons.

Leaders in the "good" organization begin to struggle with the value of "great." Within executive leadership, pockets of dissension and resistance to change begin to surface. Organizational status quo is challenged, and for some leaders, this has not occurred in many years. Nursing leaders are central to the organizational change and predictably the target for the dissension. Questions such as, "Do we really need to change? Is this the proper allocation of finite resources? Is the juice worth the squeeze?" threaten to derail the good to great movement.

Approximately midway through the second trimester, the Magnet Morse Code has been fully cracked, and organization leaders can see the enormity of what needs to be accomplished. Just like the ultrasound during the 20th week of pregnancy, the picture is clear, and the enormous responsibility for Magnet culture can create leadership anxiety and angst. The Magnet journey now feels like an elephant in the middle of the room that will not fit through the door. The understanding that Magnet is an "All or Nothing" achievement of the 14 forces of magnetism contributes to this perception. Leaders and staff nurses begin to express that there is not enough time to "do everything Magnet is requiring." The finish line is too far away to see and some begin to wonder if finishing is possible. A core of Magnet champions (the cheerleaders) continue to move the agenda while many sit on the side lines for a short time expressing, Wow, are we tired.

Enthusiasm can be visibly dampened by the depth and breadth of Magnet excellence; the journey becomes a leadership challenge that can be likened to "cat-herding." Just when it seems that the momentum is building, the herd begins to scatter, and it is well known how difficult and exhausting it is to reorganize a herd of wild cats. Loretta Ford, RN, EdD, FAAN, birth mother of the nurse practitioner movement, offers some wise advice for cat-herding woes: "Get some cat nip, sit in the middle of the circle, and make them come to you" (Loretta Ford, personal communication, February 2003). This is simple and very effective advice; build the infrastructure and systems around what is valuable to the participants and make them come to you.

By the end of the second trimester, nursing leaders in an organization recognize that Magnet is not just a "nursing award;" the principles touch all aspects of the hospital from housekeeping to the chief executive officer. No department or organizational leader escapes involvement. The team becomes paramount to the Magnet mission and ancillary departments often begin to develop measurements of excellence within their fields. The "way we have always done business" is being replaced with strategic planning that is proactive rather than reactive.

Direct care nurses acknowledge that their voice is necessary to meet the organizational vision and evidence of Magnet work is obvious. The sense of staff empowerment is real and positive. Shared governance has placed professional practice and shared responsibility of outcomes on the hands of the direct care nurse. Even strong models of shared governance become more efficient and effective during the second trimester. Direct care nurses become leaders, and their pride is palpable.

Some of the thoughts expressed during the second trimester include the following:

* "I don't have time for all this Magnet work." By the end of the second trimester, some nurses recognize that all the work is ultimately saving time. Proactive measures reduce reactive crisis.

* "We need to do this for Magnet." Magnet can become a point of resentment. Replacing Magnet with "excellence and outcomes," which is the definition of the process, makes it difficult for anyone to argue. Call it what it is.

* "Look how far we have come." This can be a dangerous phrase. There is no credit for most improved; Magnet recognition is a measure of operational excellence.

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Third Trimester-Bring It On (6-12 months)

By the time the third trimester has arrived, many on the team can now see the finish line. Concerns about Magnet deficits have been erased by creating new systems that are already producing greater efficiency and effectiveness. The confusing Magnet language is now a common language, and the definition and application are being enculturated. Data drill downs satiate a newfound curiosity rather than evoke a sense of dread. Scholarship around problem solving is becoming second nature. Professional practice is solidifying into peer-driven credentialing and professional development. The measurement bar is rising, and the direct care nursing leaders, rather than the chief nursing officer, are commonly setting the new goals.

Direct care nursing leaders now recognize that all the resources devoted to Magnet building is all about them versus the first trimester when they were asking what is in it for me? Staff can articulate that work environment changes enhance their practice and increase their overall satisfaction.

By the middle of the third trimester, direct care nursing leaders begin to express concern about the appraiser's ability to understand just how good we are. Nurses and ancillary staff commonly ask when will we hear if we get a site visit? Staff has seen the 15 inches of evidence and express pride and amazement when viewing the organizational scrapbook of excellence created over many years. Often, this is the first time that all the organization's excellence has been compiled into 1 document. The crib is built and the house is being readied for the arrival of the appraisers-Bring it on.

By the end of the third trimester, all units have moved into the final phases of the process. If there is question about the status of Magnet achievement in a unit, describe the trimesters of the Magnet pregnancy and direct care nurse leaders can quickly identify their level of Magnet attainment. Units commonly last to arrive are emergency department, operating rooms, and critical care units; the most independent and autonomous nurses often will wait to see that the process is real before investing in the change.

The final realizations in the Magnet journey are similar to pregnancy; there is no turning back, and this commitment is formidable and forever. The Magnet designation carries less importance at this final stage because the depth of the journey's impact on organizational strength has been realized. Let there be no mistake that everyone wants the obelisk in the case, but if, for some reason, that does not occur, it is very easy to hold one's head high at the end of the journey, irrespective of the outcome, because the organization has transformed itself to a new level of excellence. Leaders and staff in those organizations who do not receive designation should have enough insight to appreciate where the future work lies to become successful the next time. Those in organizations who do receive designation should have enough wisdom to know that the journey is continual and redesignation means being better with each year that passes-daunting when the organization is already recognized in the top 3%.

Some of the thoughts expressed during the third trimester include the following:

* All the hard work was worth it. Managers and direct care nurses now understand that the Magnet framework has allowed them to create more time by becoming more proactive. All have participated and feel that they produceda piece of the Magnet culture.

* It doesn't matter who the appraisers are…we are ready. Staff can articulate their excellence and do not feel intimidated to do so. Magnet appraisals and the Joint Commission on Accreditation of Healthcare Organizations visits are different, and staff need a preparation that is tailored to each.

* When will nursing know if WE have earned Magnet. Ancillary staff feel ownership in the process and outcome. Nursing could not be on the journey without the entire team.

* When we get Magnet what does this mean? The message is clear that Magnet is a way of doing business and not just an award.

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The trimesters of the Magnet journey can be summarized in the following thoughts:

* Only the brave attempt Magnet designation because the journey requires a great deal of introspection and willingness to change a good organization into a great organization. The difficulty of the Magnet change is the comprehensive nature of the framework.

* Only the committed will persevere to create comprehensive systems supporting the excellence inherent in the forces of magnetism in an all or nothing manner.

* Only the deserving will obtain Magnet status. The rigors of the Magnet program are consistent with maintaining that the Magnet designation represents excellence. Conventional wisdom would dictate not putting the organization forward if there are doubts about comprehensive achievement of Magnet principles. However, if an organization receives Magnet recognition, there is no greater morale booster.

The Magnet journey is a professional privilege that many will never have the opportunity to experience; however, if ever given the chance, it is a journey well worth taking. Magnet designation may be a nursing award but, in reality, is a hospital achievement that creates the rare trifecta in healthcare-superior nurse, patient, and organizational outcomes. Organizational leaders understand that the most inexpensive method of providing healthcare is with nurses in an environment supportive of excellent care for patients and their families.

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1. Kimball B, O'Neil E. Healthcare's Human Crisis: The American Nursing Shortage. Health Workforce Solutions for the Robert Wood Johnson Foundation. Princeton, NJ: Robert Wood Johnson; 2002.

2. Aiken L, Smith H, Luke E. Lower Medicare mortality among a set of hospitals known for good nursing care. Med Care. 1994;32(8):771-787.

3. Kramer M, Schmalenberg C. Magnet hospitals, Part 1: Institutions of Excellence. J Nurs Adm. 1988;18(1):13-24.

4. McClure M, Hinshaw AS. Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses. 1st ed. Washington, DC: American Nurses Publishing; 2002.

© 2006 Lippincott Williams & Wilkins, Inc.