The Magnet Recognition Program® was established by the American Nurses Credentialing Center to not only help attract, recruit, and retain good nurses, but also increase quality patient care.1 Changing to a culture of research, empowerment, and learning isn't always easy, and often organizations are apprehensive as they grow and change. For supervisory staff (primarily nurse managers), administering change throughout the Magnet® process is challenging; it's the transformational leader who has the ability to stimulate and inspire followers to achieve great outcomes.2,3
At the first hospital in South Carolina to attain Magnet recognition in a semirural county with a population of 250,000, a descriptive study was conducted using qualitative techniques to gain perspectives from nursing staff and managers about changes that occurred within the organization throughout the Magnet process. The Magnet process started in 2003, and recognition was awarded in 2005.
Participants and methodology
A total of 35 nurses participated in the focus groups of this study. Of these nurses, over half (n = 19) had a BSN or MSN degree, 97% (n = 34) were White, and 97% (n = 34) were female. The median tenure was 20 years of practicing nursing, with 34% (n = 12) having over 20 years experience within this hospital system. The majority of the participants were full-time employees (94%, n = 33). The median age was 40.6 years, and only two nurses were under age 30. The majority of participants (n = 31) worked first shift. Six of the participants held nurse manager positions; all managers were female.
After Institutional Review Board approval, nurses were asked to be part of small focus groups to answer questions about the change to Magnet status. The Magnet journey took approximately 18 months, and nurses were asked about the changes that occurred during that time. There were 16 groups convened over 4 months; if less than three people attended a focus group, they were asked to attend another group to protect identities and ensure that the focus group process was optimal in collecting data.
Nursing supervisors were asked to invite their nursing staff to focus groups that were convenient for each nurse. Of these groups, two were specifically assigned for supervising nurses. Each group was anonymous; outside of facilitator introductions, no one was asked to share other identifying information with the group or facilitators. Questionnaires were distributed to each participant as they entered the group.
Five questions were asked about changes in the hospital, including changes experienced by each nurse, overall impact of the Magnet process, the culture (before, during, and after), and research practices and opportunities since the change. Each question was reviewed by a facilitator and discussion ensued. The group understood that this was a voluntary discussion and they could leave at any time.
Change and leadership theories were used in the analysis of the data. Kotter's change model (establishing a sense of urgency, creating a guiding coalition, developing a vision and strategy, communicating the change vision, empowering employees, generating wins, producing more change, and anchoring new approaches in the culture) was compared with the actual process of change described by the nurses.4 Descriptors used to describe leadership during the Magnet process were compared with the basic tenets of transformational leadership. These data comparisons provided a theoretical framework for the analysis.
Qualitative analysis was conducted utilizing inductive thematic methods. Participant data were reviewed and scrutinized in detail. To identify themes, data were coded and categorized. For example, if nurses shared comments involving pay, time, or staffing needs, it was coded as "resource." Major themes were identified and agreed to by the facilitators. Three major thematic areas emerged from the nursing dialogue and data collected: recognition, resources, and culture.
Theme 1: Recognition. Recognition was consistently identified by most of the participants. Interestingly, nurse managers had considerably different insights and observations than staff nurses. Managers were unified and felt strongly that since Magnet recognition, the hospital and the nursing staff received many accolades and much recognition for their hard work, collaborative efforts, and overall quality of care. Additionally, managers felt that nurses were retained and recruited in huge part because of this highly sought status. They shared that nurses were regularly recognized for the merits of their work and were habitually rewarded in many ways, including support for educational opportunities.
Nurse managers felt strongly that Magnet status was efficiently marketed internally; however, both nurses and their managers lacked examples of external marketing strategies. Staff nurses were very vocal about the implementation (or lack thereof) of adequate recognition strategies after being awarded Magnet status. Staff nurses reported that Magnet is a concept that isn't widely understood by the hospital, let alone the greater community where the hospital is located. Nurses felt that a huge public relations campaign was warranted and should have been elevated to the state and regional level because they were the first hospital in the state to get Magnet recognition.
Regardless of the frustration with lack of recognition at the macro level, nurses expressed a sense of great pride to have earned Magnet status. It was understood by most participants that Magnet recognition wasn't handed out randomly or capriciously, but was the result of an enormous effort by the numerous departments and employees working tirelessly to gain Magnet status, and it was recognized as a huge achievement. As one nurse put it, "We already had a good quality of care, but now it is qualified."
Theme 2: Resources. As with so many human service organizations, resources are typically perceived as scarce, and direct support personnel are often left to make sure the work gets done regardless of resource availability. A main outcome of Magnet recognition was the overall gain of human resources.
Again, nurse managers felt very differently about staffing resources than their nurse employees. Managers were very proud that nurses were attracted to the hospital because of Magnet status. They shared stories that nurses returned to this hospital for less money than they received elsewhere. Managers admitted there were still staffing issues, but it wasn't as distressing as the pre-Magnet period. Magnet was identified as a key factor in raising retention rates and lowering overtime expenses.
From the staff nurses' perspective, recruitment and retention weren't greatly affected by the status change. Staff nurses criticized that resources were still an issue, both human and otherwise. Having enough time to spend with patients was problematic because of paperwork and regulatory compliance. Salaries were still a concern. Finding time for research, although important at one level, did take them away from patient care. Communication was still not as effective as it could be. Although there were clearly changes in resources, as reported by the nurse managers, the same issues seemed to plague the staff nurses as before the change to Magnet status.
Theme 3: Culture. Staff nurses and nurse managers at all levels had some expectation that a significant event would occur when they were awarded Magnet recognition. Although there were considerable cultural changes seen from the nurse management perspective (research, retention, and overall increase in quality of care through empowerment and autonomy), the changes were incremental. Because transition occurred over a long period of time, the changes weren't noticed by staff nurses. Because of this lack of event, nurses didn't experience a revelation in the change to Magnet. In fact, many stated that nothing had significantly changed. One nurse described the culture as one of high expectations, "We have always been empowered to do our best. Magnet hasn't affected our department or my unit because the expectations have always been there. They just call it Magnet now."
Although many suggested that unit work was business as usual after the change to Magnet, a change in administration and leadership style was noted. Pre-Magnet, the organizational chart was hierarchical, whereas one nurse described the current organization as flat. This suggests that empowerment and autonomy are occurring more so than before and are encouraged and supported. One nurse said, "It wasn't a change in Magnet status that made us better, it was a change in leadership that made us better."
Some nurses were annoyed with the culture shift in education expectations encouraging BSN preparation. Specifically, there were issues with the assumption that education was more important than experience. Although staff nurses agreed they were being supported to gain educational opportunities, they felt their experience was equally as important, especially in the areas of quality of care and nursing competence.
Lastly, the overall culture of the hospital was a change that nurses perceived. On the positive side, physicians and nurses were relating to one another better than before Magnet recognition. Nurses and managers felt that physicians appreciated empowered nursing staff, and because of this relationship strengthening, respect naturally grew between the two groups. Conversely, nurses felt that not all hospital employees delighted in the Magnet journey. Because Magnet is focused on nursing practice and professionalism, many of the entitlements and benefits established to promote nursing prompted jealousy from other departments who wanted an equal share.
Discussion and recommendations
On all counts, nurses and their supervisors commented on higher levels of empowerment, feeling challenged and inspired, enjoying better relationships, and having more respect in the workplace. Nurses gained increased feelings of professionalism, enjoyed empowered decision making, had more educational opportunities, and experienced a better work environment. The three themes that emerged—recognition, resources, and culture—may be helpful to other hospitals preparing for Magnet recognition. Several recommendations can be gleaned from the data.
First, publicizing short-term wins and minor transformations while enhancing recognition of the changes may have an impact on the perception of all nurses, not just nurse managers. It may be helpful to implement an internal and external public relations campaign and a long-term recognition plan. Ensuring that communication is consistently occurring and nurses have the opportunity to witness the progression of transformation and providing timely recognition for nurses during the process may boost morale and benefit overall retention efforts. Showcasing requirements and the outcome results achieved by the hospital to the public not only shares pride within the community, but also serves as an effective recruitment vehicle for staff.
Secondly, education advancement is important for nurses and the healthcare institution. The controversy over various levels of education for entry into nursing practice has continued for decades across the nation. In this study sample, rather than seeing opportunities for positive professional development, many nurses took umbrage with the push for BSN degrees; some thought that their experience lacked appreciation or value. However, Magnet standards were designed to raise the level of nursing to the baccalaureate level, and hospitals are expected to provide creative ways to support nurses to achieve higher education.
Based on the strong feelings of staff nurses around education, this still needs to be addressed. A recommendation for other leaders during the Magnet process may be to provide a vision around this mandate and inspire nurses to understand the value and necessity of advanced degrees. It may be helpful to couple recognition and rewards for both experience and education during and after the Magnet journey.
Lastly, although most participants agreed with the overall cultural changes, staff nurses overwhelmingly perceived a continued need for more resources and recognition. It may be beneficial for leaders to monitor and share human resource data, including turnover rates, increases in staffing, nurse/patient ratios, budget increases, and other information, that would illuminate the positive changes that occur as a result of the Magnet progression. And although the nurse managers felt these changes were occurring, this activity would assist with articulating resource changes, especially if compared before, during, and after Magnet recognition.
The data offer many insights for hospitals undergoing the Magnet journey, but the study does have limitations. Given the constraints of focus group methodology, caution must be exercised about making statements of transferability to other Magnet hospitals or hospitals preparing for this designation. This study didn't investigate the actual turnover and recruitment data to determine if the change in Magnet status did have an actual effect. And although other studies found generational and educational differences, this study didn't explore these areas due to the small sample size.5,6 These topics may be avenues for further research in future studies.