Achieving Magnet® recognition has been equated with achieving excellence in nursing care. Many institutions achieving Magnet status are large, urban, teaching hospitals. Does this mean there's no place for community-based hospitals in a Magnet world? The answer is a resounding "no!" The road to Magnet recognition, and thereby excellence, is the same regardless of location, finances, or institutional size.
Inherent in the Magnet journey is the integration of research and evidence-based practice (EBP) into the delivery of care at every level. To accomplish this integration, there must be an understanding of what EBP is all about and how it relates to research, nursing, and the entire healthcare team. There must be a system-wide conviction that EBP is the right thing to do, even though it may be easier to continue to practice in a "business as usual" way. There must be an appreciation for the return on investment when staff members are being asked to critically examine how they practice and make changes if the evidence doesn't support that practice. There must be a game plan to keep everyone on track, and a commitment not to abandon or sabotage the journey if the road gets rough or requires an alternative route to stay on track. And finally, achieving and sustaining the excellence inherent in Magnet recognition requires hardwiring all of the above into an organization's values, mission statements, job descriptions, and operations.
Where to begin?
Yogi Berra, a famous New York Yankees coach, once said, "If you don't know where you are going, you could end up someplace else!" To know where you're going and to succeed in reaching that destination, you must know where you're starting from. With respect to the Magnet journey, this translates into obtaining baseline data that address current attitudes and perceived barriers associated with research and research utilization. Thankfully, instruments to assess nurses' attitudes and perceived barriers to research have already been developed. Two of the most commonly cited instruments in the scientific literature, recognized for their reliability and validity, are the Hicks Attitude Scale and the Funk, Champagne, Wiese, and Tournquist Barriers Scale.1,2
The Attitude Scale has been used to determine RN attitudes toward undertaking research. The Barriers Scale has been used to determine nurses' perceived barriers to research utilization. Both the Attitude Scale and the Barriers Scale instruments are user-friendly and available to use with the respective authors' permission. Each instrument uses a Likert scale format in which the participants select responses to statements along a continuum of agreement or disagreement. When the two scales were used in one community-based hospital system, coupled with general descriptive information (age, number of years practicing as a nurse, highest level of educational preparation, and employment status [full time, part time, or per diem]), the results provided a solid basis to determine the starting point of readiness. For some community hospitals, the emergent starting point relative to staff readiness may be more positive than anticipated and, as such, may become a catalyst to energize the nursing leadership to support and encourage their staff in the achieving excellence process.
Having the tools to gather the baseline data, however, is only part of the story. Getting nurses to respond in large enough numbers for the findings to be generalized to all the nurses in the community-based hospital setting is another. Areas to investigate to encourage nurses' participation in a baseline survey may include creating an environment of healthy competition within and among care units, as well as among other community-based hospitals interested in taking the Magnet journey.
Another factor to consider in maximizing survey participation is that of confidentiality and fear of retribution or job endangerment. This may be especially true for nurses working in a small community hospital. Even when staff members are assured that no names will appear on the survey, only numbers reflecting the number of nurses eligible to participate on a given unit, and that all the findings will be summarized and reported in the aggregate, the fear may still remain that an individual's responses can be traced back to them. Reinforcement that this isn't the case is key here.
Survey results that reflect a high score on Hicks' Factor 1, measuring the likelihood of nurses engaging in research, coupled with a majority of nurses holding baccalaureate degrees or higher, are positive indicators for Magnet journey readiness. It's expected that these nurses would have been exposed to research as part of their educational experience. Loyalty to the profession and a strong commitment to patient care may also be seen as positive indicators for achieving excellence readiness. Time spent in the practice of nursing and the age of the nurse may be helpful in getting some sense of these qualities. Also, developing a strategic plan to keep all nurses, particularly those who work per diem or float among units, actively engaged in the research utilization process is important.
With respect to perceived barriers to research and research utilization, community hospitals may not differ significantly in those perceived barriers identified by the large, urban hospitals. Typically, data derived from the Barriers Scale and reported in the scientific literature cited insufficient time on the job to implement ideas and a lack of awareness of research. If this is the case, neither of these two barriers is insurmountable.
Strategies for enhancing EBP
With the knowledge gleaned from a baseline assessment, a number of strategies can be initiated to support and nurture an environment in the process of achieving excellence. The following suggestions may be helpful to community-based hospitals seeking ideas for consideration.
* Develop a research and EBP council. Having such a council sends a message and sets the stage for nurses to discuss and evaluate current practices relative to issues that are important to them and the care they're providing. It provides a supportive forum to articulate the questions that underlie their concerns and offers a way to get answers. Including a librarian as part of the council helps nurses learn how to perform a literature review and become knowledgeable about the various databases. Make council members a visible presence throughout the hospital and specialty units. Colorful EBP pins could be worn as part of their professional attire.
To recruit members, be sure to stress that research isn't statistics. Many nurses have less-than-fond memories of the research courses they took in school and equate the two as being one and the same. Stress the skills inherent in being a researcher, including the ability to observe, to think critically, to ask why or why not, and to seek answers that provide enlightenment and truth. Include in council activities opportunities to learn how to read, interpret, and critically evaluate studies in the scientific literature. As the members become more proficient, have the expert or chair step aside and let individual council members select a study for the group to review and discuss together. As the members become more confident, have them create subcommittees on their respective units and conduct unit-based study reviews. As these individuals continue to learn, they then pass this knowledge to their colleagues.
An ultimate role of the council may evolve into overseeing all research and EBP activities related to nursing and patient care. This includes reviewing all nursing research proposals before Institutional Review Board (IRB) submission, assisting in study implementation, publishing in professional journals, providing consultation to other committees and councils, and being a resource to nurses advancing their education and needing assistance in their research courses.
* Tell everyone. Professionally designed, colorful plaques with a photo of some of the staff nurses could be mounted by the elevators on every unit and in the main lobby of the hospital. The plaques could define EBP or visually depict the caregiving model of EBP, including sources for determining best practices and the role of the interdisciplinary team and patient and family involvement in care decision making. They could also include information that gives the rationale for the why of EBP and be used to reinforce the commitment to providing the very best care.
In addition to the plaques, each unit could have a research poster board overseen by a research council member. Topics of interest could be identified and the scientific literature researched, with feedback based on the research displayed on the board. There could also be a section on the poster board for definitions of pertinent research terms and reader feedback. Again, these poster boards should be prominently displayed on the units. This might also be a vehicle to encourage interdisciplinary collaboration.
Monthly nursing newsletters are great vehicles for sharing news about current research projects and to give visibility to the staff nurses conducting their own original research or implementing best practices models. The newsletter could also be used to educate nurses about the role of an IRB and research council activities.
* Feed the masses. Conferences with research and EBP themes and applications are great ways to create excitement and interest, as well as providing nurses with continuing education credits. Recognition of nurses achieving levels of excellence in research and EBP activities could be a part of the conference agenda.
In the words of Steven Wright, as quoted in Influencer: The Power to Change Anything, "Hard work pays off in the future. Laziness pays off now."3 The nurses at the community-based hospital described here have embraced that message, and the approach they used in their journey of achieving excellence can be implemented in any community-based hospital. These strategies don't require any financial support; they require only a commitment to make it happen and the belief that the community hospital is a viable player in the Magnet world.