Wolf, Gail PhD, RN; Finlayson, Susan DNP, RN; Hayden, Margaret MSN, RN; Hoolahan, Susan MSN, RN; Mazzoccoli, Andrea PhD, RN
Managing a healthcare organization today is very different from even 5 years ago largely due to the complexity of today’s environment. The future is unclear except for 1 commonly agreed-upon conclusion: healthcare must change. The question is how. Amid all the uncertainty and complexity, the Magnet Recognition Program® (MRP) continues to be a beacon illuminating the way to achieving better patient, staff, and organizational outcomes.1-7 Behind the sources of evidence required for Magnet® designation is a transformation of culture critical for success; however, the phases of development and the improvement process are often unclear. Managers are aware they need to transform their department, but often do not know what that transformation should look like, or how to accomplish it. The purpose of this article was to explore a 4-level developmental framework that can potentially be used to create a Magnet culture. Part 2 will discuss how to assess a department and identify strategies that help to transform the organization.
Developmental Levels of Organizations
Nelson and Burns8 have developed a framework for transforming organizations. Their High Performance Programming (HPP) model illustrates 4 developmental levels: reactive, responsive, proactive, and high performing. These levels can apply to individuals, the organization as a whole, or to a specific work unit. Each level requires different leadership strategies in order to progress to the next level. For purposes of this discussion, we will apply the model to a work unit such as a nursing unit, or clinical department. All of the authors have successfully used this model to develop a variety of organizations in different geographical areas, many of which have become Magnet designated.
The Reactive Work Unit
The reactive work unit is not the state in which departments begin, but rather a state of disintegration that occurs when the leader fails to keep the department focused on its purpose.8 Decay and disorganization occur. Typically employees are pessimistic and cynical, with little enthusiasm for anything other than survival. There is a significant mistrust of management and a “we/they” mentality. In turn, managers often use punitive and corrective means to get anything done, or choose to ignore the problems out of either ignorance or fear. In the absence of effective leadership, strong staff personalities often emerge and attempt to control the environment for their personal benefit. Subordinates are unwilling to tell their bosses bad news unless it can no longer be hidden, and bosses, in turn, often engage in blame. Members of reactive work units are among the least willing to risk change, even though the environment is so painful, either because the rules they have learned the hard way may change, or because their informal leadership position would be threatened.
The Responsive Work Unit
The responsive work unit is focused on achieving near-term goals, which they help to develop and implement.8 They typically work as a cohesive team and are able to adapt as they identify and solve problems. This environment fosters a team perspective, rather than the self-centered perspective of the reactive work unit. Employees are willing to do what is expected of them and to “follow the rules.” The boss is seen as a leader and coach that motivates employees, resolves problems effectively, and focuses on goals through planning and evaluating. This environment feels much healthier than the reactive environment, and many people feel that by achieving this level they have achieved a Magnet environment. However, for true transformation to occur and be sustained, a more expansive frame of reference needs to be developed.9
The Proactive Work Unit
The proactive work unit looks to the future and takes the initiative.8 Members view the future as an opportunity rather than something with which they must cope. This chosen future is framed in a widely held shared vision that is compelling, and for which people are willing to put forth significant effort. Employees feel the organization values them personally and professionally and that their contributions are what make the organization successful. The organization, in turn, is committed to higher-order values. For example, rather than being solely focused on the bottom line, proactive organizations focus on the greater good. Because the organization and employees are so well aligned, there is less need for formal policies, rules, and regulations. There are trust and mutual respect between management and staff, and as a result, potential problems are typically identified and resolved before they become significant. It is at this level that transformation begins to occur. Most Magnet-designated organizations function at this level. As exciting as it is to be engaged in this type of environment, some Magnet organizations have moved even further.
The High-Performing Work Unit
In high-performing units, the focus is on achieving high standards of excellence by identifying new potentials, by seeking out new opportunities, and by releasing the flow of energy necessary for accomplishing those innovations.8 The focus is on continuing transformation and renewal. The frame of reference goes beyond identifying results to creating new ways of being. High energy, creativity, and innovation are built into the operative values and cultural norms, and people are given great freedom to pursue it. Organizations or departments at this level are the trail blazers to our successful future.
The Magnet Recognition Program
Prior to 2008, the MRP was built around 14 Forces of Magnetism (FOM).10 Research using that model found that as organizations moved through the developmental levels of the Nelson and Burns8 model, there was a statistically significant increase in staff nurse’s perceptions of the FOMs being present. In addition, at each developmental level, specific FOMs were found to be more important than others at a statistically significant level, thus providing a roadmap for focus.10
Building on the original Magnet work, and after intensive analysis and evaluation of the 14 Forces of Magnet, the MRP introduced a dynamic new model9 in 2008 based on 4 components: transformational leadership, structural empowerment, exemplary professional practice, and new knowledge, innovations, and improvements. These 4 components result in empirical outcomes for the patients, organization, and profession. By applying the Nelson and Burns8 HPP model to these 4 Magnet components, organizations can assess the current condition of their departments and develop strategies for evolving and developing their organization to a level where Magnet designation is achievable and sustainable.
Application of the High-Performance Programming Model to the Magnet Components
The Transformational Leadership Component
Unlike yesterday’s leadership quest for stability, leaders today must transform their organizations to meet the challenges of tomorrow. It is relatively easy to lead people where they want to go; transformational leaders must look to the future and design ways to help employees successfully manage the challenges they will encounter. That requires changing mental models, or the way one looks at a situation, and inspiring others to reach that future. Table 1 illustrates how this is accomplished in the Magnet model based on the respective developmental levels.
At a reactive level, the staff are disengaged and disassociated from the strategic vision of the organization. They see the bigger picture, as well as future success, as a management responsibility. The relationship with management is frequently perceived as “we/they” versus a partnership. At a responsive level, the staff begins to link unit performance to organization goals. Reward and recognition are linked to the nurse’s contribution to their department’s success and functioning. Nurses feel leadership “looks out for them” and turn to their leaders for advocacy. As the leader continues to develop the staff toward a more proactive state, leaders emerge among the staff willing to take responsibility and accountability for clinical practice. Involvement in professional organizations intensifies, and professional behaviors and activities begin to serve as the basis for reward and recognition. This evolution continues to a high-performing level where the staff members assume the authority, responsibility, and accountability for effective clinical practice and are recognized for those contributions.
The Structural Empowerment Component
Structural empowerment refers to the ways in which the workplace environment supports exemplary professional practice, new knowledge, and improved outcomes.9 The goal of this component is to develop an engaged and empowered workforce where leadership comes from multiple individuals and groups. In the Magnet Model, this occurs through 5 major concepts, which are illustrated in Table 2.
At a reactive level, the staff lack ownership for professional practice decisions other than those associated with their clinical assignments. They believe it is the organization’s responsibility to make decisions that support them in their practice. Even if there is structure for shared decision making, typically the reactive staff member does not engage in them unless required to do so. At a responsive level staff passively participates in councils and structures. They feel good about the opportunity to participate and appreciate being asked their opinion, but do not actively lead or own professional practice issues. At a unit level, the manager owns and drives the clinical agenda and actively leads the staff to decisions. There remains a greater sense of commitment to the unit/department than to the organization. As the department begins to evolve to a proactive level, there is a shift in clinical leadership from the manager to the staff. Through mentoring and development, staff members learn to anticipate the future and plan accordingly. Organization structures and committees are seen as valuable assets in resolving issues and building a larger professional community. The accountability and ownership of professional practice issues continue to deepen and expand beyond the unit as the unit moves to high performing.
Exemplary Professional Practice
The delivery of exemplary care is the goal of healthcare.9 In a reactive unit, nurses typically see professional practice as a series of tasks that needs to be done for each of their patients. They often see family members as a burden or another problem with which they must deal. Lateral violence is frequently tolerated.9 Nurses are often reluctant to speak up about problems, and minor safety infractions are often overlooked. Poor outcomes are typically blamed on the organization’s failure to provide enough resources or on others. In a responsive unit, nurses see their practice as more than a series of tasks, see themselves as patient advocates, and try to involve patients and families into their decision making. The nurses begin to take ownership of their clinical outcomes. The staff is motivated to improve but often lack the skill to handle complex or difficult situations with their peers or other disciplines. In a proactive unit, the staff considers the uniqueness of each patient and actively engages patients and families, as well as other disciplines, in designing care. Nurses own their practice as well as the outcomes they are able to achieve and take responsibility for ensuring good clinical results. They demonstrate good problem-solving skills and are actively involved in practice issues organizationally. This continues to evolve to a high-performance level, where nurses work to design care for their patients that goes beyond the current episode of care, involves families, and is well integrated with other disciplines. They consistently demonstrate highly developed levels of professional practice, are instrumental in disseminating that throughout the organization, and are seen as critical decision makers and stakeholders throughout the organization. In the Magnet Model,9 the differences between these various levels are illustrated in Table 3.
New Knowledge, Innovations, and Improvements
The challenges and complexities of today’s healthcare environment require the discovery of new approaches and knowledge. In the Magnet Model,9 this is accomplished through research, evidence-based practice, and innovation. Table 4 illustrates the developmental phases of each. At a reactive stage, nursing practice is largely based on experience or historical norms. Suggestions for improvement are typically met with “we don’t do it that way.” At a responsive level, the staff is more willing to consider alternative ideas. They are willing to implement evidence-based practice, especially if they feel this is a job or management expectation. It is at a proactive level that the staff members begin to question practice, explore new approaches, and seek different answers. This continues to evolve as the high-performance team creates new methods of practice based on evidence, applies research consistently in their practice, and helps to ignite new ideas and innovations. The application of these phases to the Magnet model can be seen in Table 4.
In this article, we have explored a 4-level developmental model that may be helpful in transforming a unit or department and creating a Magnet culture. In part 2, we will discuss how a leader can assess a department and the various strategies for developing a department from 1 level to the next.
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