Magnet®, first used to describe a set of hospitals successfully navigating a serious nursing shortage, today highlights organizations that commit to high satisfaction of nurses and patients and dedicate themselves to the achievement of quality patient care. One choice that leaders of healthcare systems desiring Magnet recognition must make is whether to pursue this recognition as a system or strictly as individual entities in the system. Undoubtedly, this strategic decision, which requires time and energy to appropriately make, will impact the system and each entity in the system. If a system applies to the Magnet Recognition Program® as a system, then all entities in the system must meet the Magnet requirements. Ultimately, if successful, the system and all its entities achieve recognition and reap the benefits; however, should it fail, then neither the system nor any entity in it achieves the recognition. On the other hand, if one entity falls short of meeting the requirements, the money, time, effort, and resources invested are wasted-none of the entities achieve the Magnet designation.
In the early 1980s, in the midst of a serious nursing shortage, the American Academy of Nursing named a task force to address this shortage. Taking a novel approach, rather than identifying reasons for the shortage, this group identified the key characteristics of hospitals that were able to attract and retain professional nurses. These 41 hospitals, the first referred to as "magnet," had a set of common organizational features that made them successful in attracting and retaining nurses. For example, they had flat organizational structures and unit-based decision making.1
Based on the original study, in 1993, the American Nursing Credentialing Center (ANCC) started the Magnet Nursing Services Recognition Program. The program recognizes healthcare organizations that have achieved excellence in professional nursing practice and quality patient care. Through the years, although the application process has remained similar, the conceptual approach has evolved. Initially, it focused on the American Nurses Association's Scope and Standards for Nurse Administrators. Then, 14 Forces of Magnetism were identified, and organizations applying for recognition were to demonstrate evidence of each force.2
In 2007, responding to continued changes in healthcare, the ANCC's Commission on Magnet Recognition's® 14 Forces of Magnetism progressed into a new Magnet model (Table 1). The new model is composed of 5 components: transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovations, and improvements; and empirical outcomes. Dynamic in design, the 5 model components complement each other and focus on measuring empirical quality outcomes to demonstrate excellence. Today, the highly sought-after Magnet designation informs consumers, nurses, and other healthcare providers about the quality of care in a given healthcare institution.1 The latest data reflect 382 healthcare organizations in nearly all 50 states and the District of Columbia, as well as 4 international ones, have achieved Magnet status.3
Although numerous articles exist in the literature related to Magnet, most narrate community hospitals' and academic medical centers' journey to Magnet recognition. Thus, the process in this regard is well documented. On the other hand, little exists in the literature related to this pursuit as a system. The ANCC4 provides baseline or minimal requirements that a system must meet for system recognition. Pinkerton,5 using the new model as her organizational framework, also provides some initial guidelines in this regard. To further investigate the key considerations related to a system's decision to pursue Magnet recognition, this article uses the new model's 5 components as a guide and identifies ways and means to best make this decision.
The ANCC allows hospital system designation to be pursued for "either a multihospital or a diversified single hospital system. A multihospital system is 2 or more hospitals owned, leased, sponsored, or contract managed by a central organization. Single, freestanding hospitals may be categorized as a system by bringing into membership 3 or more, and at least 25%, of their owned or leased non-hospital preacute or postacute healthcare organizations."4
Systems, formed through mergers and acquisitions, often continue to function as separate hospitals. Although now linked from a legal perspective, day-to-day operations of the entities continue in isolation from one another. Corporate restructuring becomes essential, yet the newly formed organization may be composed of hospitals that have been diametrically opposed in their previous working relationships. Cultural differences are often ignored, and work environment decisions are assumed to be easily overcome.
Systems, looking to address the cultures of very different hospitals, may choose Magnet as a platform. In doing so, the system is guided with a model to achieve excellence. For instance, in terms of creating a new mission statement, Magnet requires there to be one organizational mission for the entire system. Completing this process requires separate entities to come together. The group has to work through the process of who they now are as an organization, what difference(s) they will make together, and what makes them unique as a merged group of hospitals.
Geographical boundaries must be taken into consideration. If distance precludes the entities from physically meeting on a regular basis, other technologies can be pursued. Although technology can be used for various aspects of operations, its use for strategic work should be evaluated. Geography may be one reason for hospitals to pursue designation individually and not as a system.
Whereas geography may deter pursuing Magnet as a system, financial implications, on the surface, can be beneficial. Applying as a system translates into one application fee for the organization. A single application is completed and submitted on behalf of the system. The calculated fee is based on the number of RN FTEs and is paid for the system as opposed to an application fee for each individual hospital. The costs incurred for documentation review can also be less; with the system paying only one fee as opposed to a documentation review fee for each entity. The required documentation addresses both the system's eligibility for Magnet status as well as each entity's evidence of achieving the Magnet Forces based on the current model. Site visit fees also increase when designating individually as opposed to as a system. Whereas cost-benefit analysis may indicate system designation as more cost-effective, pursuing designation based on a purely fiscal perspective can be far more costly. As previously mentioned, should the system fail in its pursuit because one entity in the system cannot be recognized, then neither the system nor any of its entities will be designated as Magnet. Careful evaluation must be given to the reputation that may form in the system's community, and at large, as to why the organization did not achieve Magnet recognition. Such opinions, of key stakeholder groups, can negatively impact the system for years.
To determine one's readiness for Magnet, a gap analysis can be completed using the 2008 application manual. Begin by reading about the evidence and its source, and based on the source, determine organizational readiness. One tool that ANCC has posted on its Web site is a redesignation checklist. By using this tool, a redesignating hospital can focus on potential areas of deficiency. The tool also could be a resource for systems to use as a part of the evaluation process for determining readiness for system, as opposed to individual entity, designation. Answering each of the questions, for each entity involved, illuminates potential issues for pursuing system designation.
This component, defined by Pinkerton5 as that leadership that "leads people to where they need to be to meet the demands of the future,"5(p323) requires the system to operate under one organizational mission, vision, and set of values. Assuming system-wide mission, vision, and value statements exist, then one begins to look at the how these documents are operationalized in the different system entities. If such system documents do not exist, then one must ask: Does it make sense to explore a higher mission as a system? Does the system serve one geographic or service area with similar or like populations? Are services duplicated among the various entities? If the desire is to move to one mission, vision, and set of values, then consider the steps required to do it.
Creating a vision statement does not mean merging the existing statements into one larger statement or declaring one of the previous visions as the new statement for the organization. The process begins with generating ideas for the way you want to do business. This new image becomes something describable to employees and begins the thought process of operations in a new environment. Mission statements can follow based on this same approach and thus create a means for how the organization will do business. With vision and mission articulated, it still takes time to replace one set of values with another. Each entity had a previous way of doing business, and none of them were wrong. The organization's success now will depend on the sum of its parts.
Transmitting the values of the new system and culture begins the process of changing individual employees' behavior. Unfortunately, parroting the new vision and values is not the same as applying them. Employees have to understand how operating as a whole, rather than in part, will benefit patients and themselves alike. This type of engagement begins in the development phase. Involving staff, across entities, in the creation of a shared vision can seem to be an insurmountable task. Using a shared governance approach, which is both an invaluable structure and a necessary requirement for Magnet organizations, stakeholders can more readily participate in process development and feedback sharing. A nursing council or committee with representatives from across the system participates in shared decision making and develops strategies for system-wide nursing initiatives. Nursing staff participate in this shared decision making through unit committees that have representatives on the nursing councils (Figure 1).
Ultimately, the achievement of this system mission requires the vision and leadership of a single chief executive officer (CEO), and Magnet rightfully requires the system to be led by a single CEO. In addition, one governing body should exist and set the direction for the system. Within the organizational structure, is there shared and participative decision making by a leadership group that operates at the system level? Are there forums or mechanisms established to allow for frequent communication and decision making among this group, particularly if entities in the system are separated by distances that prohibit frequent travel among them?
In addition to a singular system CEO, Magnet also specifies requirements for nursing leadership. For example, the designated RN executive leader, who maintains day-to-day operations at each entity in the system, must meet the system's chief nursing officer's educational requirements. These nursing leaders with responsibility for nursing services have detailed knowledge and are strategically positioned to effectively support nurses in the clinical practice of nursing. Rather than operating in silos, Magnet provides a platform for focusing these executives as they lead staff in the achievement of organizational needs and strategic priorities.
The second model component, structural empowerment, refers to the system having structures in place not only to support nurses' involvement in decision making to impact patient care, but also to provide professional development. To secure system recognition, nurses' educational opportunities need to be the same across the system. Do nurses new to any entity in the system attend the same orientation program? Parts of this program can be facility specific, but a centralized system core is important to communicate the system's central mission, vision, and values.
Other educational opportunities, including support for certification, need to be available to any nurse in the system. Are nurses encouraged equally to advance their careers through professional certifications? Are any certification review courses equally accessible to all nurses in the system? Does the system support nurses' certifications by having some entities designated as examination administration sites?
Professional practice ladders and other growth opportunities must be consistent across the system. The criteria for advancement on the ladder must be the same for every nurse in the system (Figure 2). Similarly, the nursing education department provides education across the system, integrating the needs of each entity while serving the entire system. Educators, rather than focused on RN education at one hospital in the system, center on concepts and teach these concepts across the system. The department emphasizes the translation of evidence-based practice and regulatory standards into formats effective to meet individual employee's learning needs.
Another important aspect of professional nursing, patient and family education, also should be included as part of structural empowerment. To move the system's mission forward, a system-wide patient and family education committee can develop materials to be used across the system. Examples include the "Welcome" brochure or letter that patients receive on entry to any system entity. Other patient education materials, whether written or in a media format, can also be developed for use system-wide. For example, the use of a system-wide television/video system allows patients and families access 24 hours a day to any type of education available throughout any of its entities. With such convenient access, patients and families are offered yet another way to learn about and improve their health. Patient education booklets inform all patients, regardless of their setting, of key information that guides them through their hospital stay. Patients are aware, regardless of the entity they visit, of the commitment the system makes to them. When patients are ready for discharge, instructional materials are consistent as well. Developing materials of this magnitude, across multiple hospitals, requires interdisciplinary collaboration. Each entity, as well as key disciplines in each entity, should be considered for this interdisciplinary committee. In addition, ad hoc members can be identified and utilized on an as-needed basis. This keeps the working group at a reasonable number, while ensuring that specialty expertise is available when needed.
In addition to a system-wide education committee, a similar research committee also structurally supports the system and vice versa. Members are drawn from across the system, and each entity receives similar support for research.
Furthermore, the structural basis for empowering the nursing staff extends beyond the boundaries of the system. Nurses are encouraged to participate on community advisory committees and in community-sponsored events. Various community boards and charitable walk/run events all offer opportunities for the nursing staff to be of service "beyond the walls" of the system. Nurses can serve on community boards, raising awareness of needs as well as funds to meet new and rising community needs. Nurses can provide free screenings, health fairs, support groups, and community health programs. Organizational or nursing newsletters can include a section that highlights volunteer achievements. Formal programs, such as congregational nursing programs, can be developed, integrating health, caring, and healing in faith communities. Nurses may also volunteer their time in other ministries, such as community indigent population clinics, sponsored by the system or in partnership with other community organizations.
Exemplary Professional Practice
Building on the base of a system-wide mission and vision with the same core values throughout the system, a nursing departmental mission and vision with congruent values can be delineated. This allows for performance appraisals to be the same throughout the system. Does the system currently have this Magnet requirement in place? If not, how can the department and system move toward this goal and objective?
Another aspect to consider is pay and benefit packages for nurses. Are they the same throughout the system? A centralized nurse recruitment department can facilitate hiring as a system. Salary quotes then are made by these centralized nurse recruiters, and promotion/demotion rates determined by this same group with the assistance of those in human resources. Thus, the Magnet requirement of a standardized pay and benefit structure across the system can be met.
Policies and procedures also must be the same throughout the system. For example, pursuit of workplace advocacy initiatives would reflect employee rights and safe and healthy work environments for all employees, not just employees considered to work in high-risk settings. Limitation of hours worked and policies that address no tolerance for workplace abusive and offensive behaviors would likewise apply throughout the system. Benefits, such as relaxation rooms, educational programs on healthy life choices, smoking cessation classes, personal wellness offerings, or employee assistance programs, are available to all employees. Employees are knowledgeable of the organizational stance and process for promoting a safe, cooperative, and professional healthcare environment. Employees are able to independently, or with assistance, seek resolution of concerns.
Having a common information technology system allows information to be easily shared across the system. The adherence to policies and procedures can be facilitated by an intranet that keeps everyone "on the same page." As the system adds entities, keeping up with and distributing hard copies can be challenging. By the same token, employees find it difficult to search for and locate information. By using technology, all of the system's policies and procedures can be made available to any employee at any time. Employees can also locate information in a timelier manner, searching for key words, instead of flipping through multiple books and pages.
One particular policy that enhances professional practice is financial support for any RN continuing his/her education, whether BSN, MSN, or higher degrees. For any RN achieving nurse practitioner (NP) status, the credentialing and privileging process is the same across the system. This process for NPs mirrors that of the medical staff. The chief nursing officer reviews NPs' applications and supporting documentation and approves/disapproves all applicants as the chief medical officer does for the medical staff.
Nursing staff are supported in their practice by a clinical documentation system that can be used across the system. Data can be extrapolated anywhere in the system regardless of the patient's specific location, and thus, it allows for expedited clinical decision making. A notable telehealth example relates to wound care at MCHS. To more efficiently and effectively provide this care across the system, the system validated that the wound, ostomy, continence (WOC) nurse's assessment was the same whether done in person or based on digital imaging forwarded to a central location. Thus, the WOC nurse was able to assess a patient's wound from a remote location and make recommendations for care without the patient waiting until he/she could schedule a visit 20 miles away.
A professional practice model adopted by the system can serve as the foundation for all RNs' practice. This model of care should define and promote the professional role of the RN, including accountability for one's own practice and continuity of care. An example (Figure 3) depicts how nurses provide the ultimate gold standard in quality care and patient satisfaction. Having such a model that transcends specialties and is applicable to nursing throughout the system supports professional nursing practice.
The professional practice model then drives the choice of a care delivery system. In turn, the care delivery model defines how nurses with the required skill sets will deliver care to achieve intended system outcomes. Structured to accomplish the delivery of high quality care, the care delivery model depicts the nurse as having the responsibility and authority to make decisions and accomplish patient care.
A professional practice model and care delivery model that can be adopted across disciplines provide a foundation and promote interdisciplinary patient care. The models can drive the permeation of the Magnet components across every discipline and department. In addition, policies and procedures, based on the professional practice model, are in place to govern interdisciplinary relationships and support the nurse to provide quality patient care.
The system also may use a centralized performance improvement methodology to support exemplary professional practice. Centralized performance improvement teams can be designed to monitor key patient outcomes. They can evaluate current practice techniques for consistency and best practice patterns. In turn, teams develop and implement action plans, including benchmarking best practices internally and externally.
As noted above, for the system to be designated Magnet, like clinical documentation systems, supportive of system-wide practice integration, must be in place. Not only does this system(s) support nurses in their practice, but it also facilitates the timely collection of data for quality improvement and research purposes. For example, data regarding patient falls or the impact of Foley catheter usage can be collected across the system and then analyzed without a laborious data collection phase. Changes in practice that need to be made based on the data can be assimilated into practice without unnecessary delays.
The original Magnet hospital study was completed over 25 years ago with the formal Magnet Recognition Program initiated more than 15 years ago. During that time, radical changes have occurred in the healthcare industry. One of those changes, the consolidation of hospitals from stand-alone single operations into horizontally and vertically integrated healthcare systems, brings to the forefront the issues discussed in this article. Hospitals, the systems to which they belong, and a growing discerning public recognize nursing as the cornerstone for quality patient care.
The Magnet Recognition Program is increasingly seen as the hallmark standard by which to gauge nursing excellence. It can provide the momentum to create and pursue a common vision and direction-a platform by which to strategically galvanize efforts across settings and sites. The healthcare system parameters outlined here allow a system to judge its commitment to and readiness for system recognition. More than a credential, this recognition represents a system's dedication to sustaining a culture and environment that support not surviving, but thriving during and through today's turbulent times.
The authors thank Dr Patricia Chamings, Interim Dean, School of Nursing, North Carolina Agricultural and Technical State University, for assistance in the preparation of this article.
© 2011 Lippincott Williams & Wilkins, Inc.