Walker, Jane A. PhD, RN; Urden, Linda D. DNSc, RN, CNS, NE-BC, FAAN; Moody, Rachel MS, RN
To attract and retain qualified nurses, many hospital leaders have been working to create positive, professional work environments. Those who have succeeded in creating positive work environments and excellence in nursing care frequently seek designation as a Magnet® hospital. Magnet is a prestigious credential bestowed on hospitals by the American Nurses Credentialing Center (ANCC).1 To meet Magnet criteria, evidence-based practice (EBP) and research activities must take place in the facility. In addition, frontline nurses must have access to clinical experts, such as advanced practice nurses (APNs). An APN who is usually hospital based and frequently involved with EBP activities is the clinical nurse specialist (CNS). Clinical nurse specialists are effective in the hospital setting as clinical experts and resources to frontline nurses because of their education in 3 spheres of influence: patient, nurse, and organization.2
Using their education in the 3 spheres of influence, CNSs are instrumental in transforming the work environment and leading systemwide changes such as ensuring that nursing practice is evidence based and that frontline staff nurses have mentors and consultants to foster their practice.3 It has been said that CNSs may be considered "invisible champions" despite the many positive and significant contributions that they make to quality improvement.4 Because of their key role in quality, EBP, and safety, CNSs often identify major quality issues systemwide and lead interdisciplinary teams to implement practice changes, leading to improved patient outcomes, efficiency, and cost-effectiveness.4,5 For example, falls, medication errors, pressure ulcers, and urinary tract infections are costly adverse events that CNSs frequently impact in their practice. Using data from a recently published study that examined the costs of adverse events, the cost per case for each of the previously mentioned adverse events ranged from $334 to $2,384.6 Thus, it is easy to calculate the positive impact that a CNS could have in an organization by making practice changes that eliminate those adverse events. In addition, CNSs provide one-on-one care and consultation for complex patients and assist the interdisciplinary team in coordinating comprehensive care for patients.4,5 Finally, in their role as experts and consultants, they serve as role models and mentors for staff to continue their education and seek certification.7
Anecdotal comments indicate that facilities that achieve Magnet designation were able to do so because of the work of CNSs. According to these comments, CNSs play an important role in transforming the culture and work environment. They provide support and mentorship for the frontline nurses, focus on quality and EBP, and enhance interdisciplinary relationships. However, there is no published evidence to support these anecdotal comments in relation to achieving Magnet designation.
Overview of the Magnet Recognition Program®
In 1983, the American Academy of Nursing Task Force on Nursing Practice in Hospitals8 conducted research that identified and described factors in the hospital environment that attracted and retained well-qualified registered nurses. Of 163 hospitals, 41 were described as having these characteristics and excellence in quality patient care. These 41 hospitals were described as "magnet" because of their ability to attract and retain professional registered nurses. The factors or characteristics that seemed to distinguish "Magnet" hospitals from others became known as the Forces of Magnetism (Table 1).9 Subsequently, the Magnet Recognition Program® (MRP) was developed by the ANCC to recognize healthcare organizations that provide excellence in care. The program also provides a mechanism for disseminating best practices and research in the areas of clinical practice and work environments. The program is based on quality indicators and standards of nursing practice. It is thought that when the Forces of Magnetism are present, there is a strong visionary nursing leader who advocates and supports development and excellence in nursing practice. Thus, a professional practice environment leads to excellence in outcomes and elevates the reputation and standards of the nursing profession.10
The MRP recently announced the creation of a new model that will serve as a framework for nursing practice and research in the future and will serve as a guide for those implementing the Forces of Magnetism into the work environment. The model was created by conducting statistical analyses of Magnet appraisal team scores from evaluations conducted during the Magnet evaluation phase.11,12 The new model consists of 5 major components in the context of the impact of ever-changing global issues on nursing and healthcare. The 5 model components are (1) transformational leadership; (2) structural empowerment; (3) exemplary nursing practice; (4) new knowledge, innovation, and improvements; and (5) empirical quality results.11 The 14 Forces of Magnetism continue to serve as the foundation for the program and are configured into the 5 model components. With this new vision, Magnet-designated organizations will be solidly grounded in the core Magnet principles, flexible, and continuously searching for innovation and higher levels of excellence.
Although the Forces of Magnetism reflect standards for nursing administrators, CNS practice and influence can contribute to their attainment. Table 1 provides examples of CNS work that relate to each of the 14 Forces of Magnetism. Based on this comparison of Magnet forces with the role of the CNS, it is likely that many opportunities exist for CNSs to positively influence the Magnet journey. Because of the lack of previously published studies examining the role of the CNS in relation to the Magnet program, the purpose of this study was to examine the role of the CNS with respect to achieving and maintaining Magnet status and to determine the extent to which CNSs contribute to the 14 Forces of Magnetism.
A descriptive cross-sectional research design was used for this study. The method of data collection consisted of an anonymous survey mailed to the chief nursing officer (CNO) from Magnet-designated hospitals. To obtain a representative sample size, a modified version of the Total Design Method (TDM) was used to administer the surveys.13 The TDM includes strategies to optimize survey response rates, such as the use of personalized communication, cover letters, stamped return envelopes, and follow-up contacts. To identify the CNOs, a list of Magnet-designated facilities at the time of the study was accessed from the ANCC Web site. The Web site for each facility was then visited to obtain the name of the CNO. Each CNO was sent a letter of invitation, a copy of the survey; and a stamped, self-addressed envelope. The CNO was informed that he/she could choose to forward the survey to the facility's Magnet coordinator to complete. Follow-up reminder letters and surveys were sent to all CNOs at 2 and 4 weeks after the initial invitation.
The study was designated as exempt by the Purdue University Office of Human Protection. Consent to participate was implied by completing the survey, and there was no compensation provided to the study participants.
Data Collection Tool
The data collection tool was developed by the investigators. The tool was an 18-item survey that addressed descriptive information about the hospital and its Magnet designation, demographic information about the survey respondent, descriptive information about CNS employees, perception of the importance of the CNS in attaining and maintaining Magnet status, and perception of the role of the organizations' CNSs in relation to the 14 Forces of Magnetism. The initial 6 questions focused on descriptive information about the hospital and the time frame of Magnet designation. The last question in this section asked whether CNSs were employed at the hospital. If not, the respondent was thanked for participating in the study. If CNSs were employed, respondents were then asked to complete the remainder of the survey. Perceptions of the importance of the CNS in attaining/maintaining Magnet status and perceptions of the CNS role in relation to the 14 Forces of Magnetism were rated on a scale of very important, important, somewhat important, not important, and not sure. The entire survey took approximately 10 to 15 minutes to complete. The internal consistency reliability of the perceptions portion of the survey was established with a Cronbach α of .92. Face validity was achieved through review of the survey by practicing CNSs from Magnet organizations, indicating that the survey reflected CNS practice.
The study's convenience sample consisted of 222 Magnet-designated hospitals listed on the ANCC Web site at the time of the study.14 There were 208 distinct CNOs listed in the 222 Magnet hospitals because some systems had 1 CNO for more than 1 hospital. We mailed a total of 208 surveys in 3 waves. Of the 154 surveys that were returned, 6 had been copied and forwarded to additional persons in the organization to complete, resulting in an overall response rate of 72%.
The demographic and hospital characteristics of the respondents can be found in Table 2. From this table, it can be seen that the CNO/vice president of nursing was the most frequent survey respondent. The size of the hospitals varied considerably, with half reporting fewer than 400 beds and half reporting 400 beds or more. Most of the hospitals (69.5%) were teaching hospitals. With respect to the type of hospital, nearly all (90%) were nongovernment and nonprofit. Through the years, the annual number of hospitals designated as Magnet grew considerably. Before 2000, only 9 of the respondents had initially achieved Magnet status. This number grew to 46 between 2000 and 2003 and continued to grow from 2004 to 2007. In fact, approximately 63% of the hospitals achieved Magnet designation in 2004 or later.
Of the 154 respondents, 134 (87%) responded that they employed CNSs. At this point, the 20 respondents who did not employ CNSs were excluded from further analyses. Also excluded due to the potential for bias were 3 surveys submitted by CNSs. Finally, we excluded 5 surveys that did not clearly differentiate among APNs with respect to the CNS role. For example, 1 respondent crossed off the word CNS and wrote in APN. Therefore, the total number of surveys used for remaining analyses was 126.
Results pertaining to the pattern of CNS employment with the institution can be found in Table 3. The pattern of CNS employment was explored by asking respondents to indicate the number of CNSs employed, the length of time CNSs had been employed by the hospital, intentional hiring of CNSs to achieve Magnet status, CNS base of practice, type of specialty, position to whom the CNS reported, and division of time according to spheres of influence.2 Forty-two percent of the hospitals employed 5 or fewer CNSs and 72% employed 10 or fewer CNSs. However, 3 of the respondents employed 60 to 70 CNSs. The number of CNSs employed ranged from 1 to 70, with a mean (SD) of 10.2 (11.6) CNSs. Much variability existed with respect to the number of years CNSs had been employed by the hospitals, with a range of 2 to 40 years and a mean (SD) CNS presence of 17 (8.5) years. The vast majority of hospitals (93%) did not intentionally hire CNSs to achieve Magnet status. With respect to the base of CNS practice, most CNSs were specialty based (75.6%); fewer CNSs were unit based (43%). The top 3 specialties reported were adult acute and critical care, cardiovascular, and medical-surgical. The largest percentage of CNSs (42%) reported to a nursing director or manager with the hospital. Finally, the respondents estimated that CNSs spent most of their time in the nurse sphere (39%), followed by the organization sphere (33%) and the patient sphere (27%).
With respect to the importance of CNSs in achieving Magnet status (see Figure 1), the large majority of respondents (88%) indicated that CNSs were either important or very important, whereas 5% indicated that CNSs were not important. With respect to maintaining Magnet status, an even higher percentage (92%) indicated that CNSs were either important or very important, with 3% indicating that CNSs were not important. In addition, most respondents thought that it would have been very difficult or difficult to achieve Magnet status without CNSs (Figure 2).
Respondents rated how important CNSs were with respect to each of the 14 Forces of Magnetism (see Table 4). The relative contribution of CNSs to the 14 Forces of Magnetism clustered into 3 tiers. The Forces of Magnetism in the top tier addressed APN and educational resources for staff nurses, as well as expectations related to staff nurse participation in education. The middle tier consisted of 9 Forces of Magnetism that, although rated highly, were somewhat lower in terms of importance. These Forces of Magnetism were related to care delivery, quality improvement, nursing leadership, and organizational climate. The lowest tier consisted of 2 Forces of Magnetism that were rated as being less important with respect to CNS contribution. These Forces of Magnetism were primarily focused on the hospital policies and outreach.
Finally, many of the respondents wrote comments about the role of CNSs in their organizations. Many of the comments were positive and reflected the perceived importance of CNSs with respect to the Magnet process. For example, one respondent wrote, "During the 1990s where many institutions downsized and/or eliminated CNSs, our organization continued to hire additional CNSs. They play a pivotal role in advancing our professional practice model through mentoring, role modeling, promoting education and EBP and our quality and safety programs." Another wrote, "CNSs are and were critical in the development of research and EBP with staff at the bedside." Some of the comments reflected the perception that it is not just CNSs but also APNs in general that support the Magnet work. For example, "We do not use a typical CNS model but have many masters prepared nurses and nurse practitioners who function as role models and mentors and are important to our success as a Magnet organization. The small number of CNSs makes it difficult to measure their individual impact." Finally, one respondent indicated that "It is the staff nurse who drives the Magnet journey!"
The large majority of respondents indicated that they employed CNSs, and most had employed CNSs for a long time. Therefore, the presence of CNSs generally preceded attainment of Magnet status, with only 8 respondents indicating they had intentionally hired CNSs to help with the Magnet journey. The nature of the relationship between attainment of Magnet status and employment of CNSs before attaining Magnet status is unclear. The assumption could be made that CNSs impact patient outcomes in a positive way and that they provide mentoring and support to staff nurses, thus facilitating the Magnet journey. In fact, some hospitals intentionally hire CNSs specifically for their positive impact on patient outcomes and for the mentoring and staff nurse support they provide.15 However, because of this study's descriptive design, a cause-and-effect relationship between the presence of CNSs and achievement of Magnet status cannot be determined.
Similarly, most respondents indicated that CNSs were either important or very important in achieving and maintaining Magnet status and that it would have been difficult to achieve Magnet status without their presence. As indicated in the "Results" section of this article, respondents noted that CNSs were seen as the role model for nursing practice, EBP, research, establishment of hospital standards of care, quality improvement, collaborating, and leading.
These responses reflect the unique combination of CNS skills that can positively influence the Magnet journey. It has been identified that CNSs use evidence to guide their practice and to influence patient and nursing care within their work environments.16 They are viewed as trusted and as important sources of knowledge. In addition, Lewandowski and Adamle17 recently published a comprehensive review of the literature describing substantive areas of CNS practice. Three areas that emerged included the management of complex populations, staff support and education, and facilitation of change and innovation. These areas of CNS practice are important in helping hospitals meet Magnet criteria. In addition, the National Association of Clinical Nurse Specialists (NACNS) framework,2 with its focus on the 3 spheres of CNS influence of patient, nurse, and organization, as well as the validated NACNS competencies,2,18,19 provide further evidence of the existence of a unique CNS skill set that can assist in the attainment of Magnet criteria. For example, within respect to patient specialty, CNSs influence care by collaborating with other healthcare providers; providing and recommending expert evidence-based nursing interventions; developing, implementing, and evaluating innovative patient education programs; increasing the quality of patient care; and explicating and evaluating attainment of nurse-sensitive outcomes. With respect to nursing staff, CNSs influence practice by developing nurses' knowledge and skills, articulating the evidence base for nursing interventions and innovations and making that evidence understandable and accessible, increasing job satisfaction, and decreasing the cost of care. Finally, within the organization, CNSs' influence includes integrating change strategies throughout the system, developing standards that are based on best practice and evidence, working with multidisciplinary teams to effect change, and using a system-level strategies to address clinical problems.2 Therefore, much of CNS practice aligns quite nicely with the aims of the Magnet program.
Although most of the comments regarding CNS practice were positive, some comments reflected uncertainty about the impact of CNSs with the organization. For example, these comments focused on role ambiguity among advanced practice roles. The respondents commented on the limited scope of CNS influence and the strong need for role clarification. Other respondents preferred not to differentiate between nurse practitioners and CNSs and chose instead to use the term APN. This lack of clarity may be related to the diversity in scope of the APN practice and role among the states. Ultimately, the needs of the patient population and setting also need to be considered to ensure a fit with the role of the APN. Finally, some of the participants commented on the lack of availability of CNSs in their geographic area, leading to the use of other APNs.
There were several limitations to this study. The first limitation was the study's descriptive survey design. Because an experimental design was not used, cause and effect cannot be determined. Other limitations exist with respect to potential discrepancies in the use of the CNS title and role definitions. The current APN regulatory environment is characterized by much inconsistency among the states. For example, CNS title protection exists in many states, but not all. Therefore, it is possible that the CNS title could be held by those not educated as a CNS. Because of the nature of this study, it was not possible to detect role inaccuracies. Finally, this study focused exclusively on the role of the CNS, and the relative contribution of all APN roles in achieving and maintaining Magnet status was not explored. As a result, the potential impact of other APN roles on Magnet status is not known.
A large majority of Magnet hospitals had CNSs on staff. The CNSs were perceived to have an important role in achieving and maintaining Magnet status. The Forces of Magnetism perceived as most influenced by CNSs included consultation and resources, nurses as teachers, and professional development of nurses. The Forces of Magnetism perceived as least influenced by CNSs included nursing leadership, personnel policies and programs, and community and hospital. Recommendations for future research include exploring the relative contributions of all APN roles in achieving and maintaining Magnet status and determining the relationship between the time spent in each CNS sphere of influence and achieving/maintaining Magnet status.
The authors thank Sandy Woodke, executive secretary, LaPorte Regional Health System Services, for her assistance with mailings; Heather Clark, MS, RN, and Melissa Grzybowski, BS, RN, graduate aides, Purdue University Calumet School of Nursing, for their assistance with data entry; and Carol Magliola, BS, RN, Purdue University Calumet School of Nursing Learning Resource Center coordinator, along with graduate aides Amy Burns, MS, RN, and Lisa Rose, BS, RN, for their efforts in obtaining the names of Magnet hospital executives.
© 2009 Lippincott Williams & Wilkins, Inc.