Magnet® designation through the American Nurses Credentialing Center (ANCC) is a prestigious achievement reflective of years of dedication, innovation, mentoring, staff development, persistence, and leadership support. The recognition designates exemplary nursing performance and quality outcomes in a culture of caring, professionalism, and respect. Much has been written regarding the Magnet “journey,” building infrastructures while forming healthcare partnerships and focusing on quality. Research findings from an earlier study conducted by this research team revealed that staff nurses experienced slippage after the achievements and excitement of the initial Magnet designation.1 As challenging as the initial attainment of Magnet status can be, sustaining the success and becoming redesignated is considered even more difficult by many chief nursing officers (CNOs). However, there have been no published reports indicating how to be successful in Magnet redesignation. Therefore, the purpose of this study was to determine CNO perspectives on how to sustain the infrastructure required for successful ANCC Magnet redesignation.
Several organizations have shared their individual efforts in achieving Magnet redesignation.2-6 These efforts focused on leveraging a strategic plan inclusive of nursing leadership, practice, education, research, role clarity, and culture3; implementing programs to develop a culture of safety for improved outcomes5; restructuring the nursing leadership team to promote a culture of professional nursing practice6; streamlining the transition of CNOs during Magnet redesignation2; and using a continuous improvement framework rooted in building positivity.4 However, these publications are limited to singular accounts of redesignation efforts, and there are no published reports exploring the infrastructure needed for Magnet redesignation following research methodology. Findings from research efforts are important to serve as the basis for the implementation of future evidence-based practices (EBPs) surrounding Magnet redesignation.
Human subject institutional review board of the investigator's university provided study oversight. Grounded theory qualitative approach was used for the study because it seeks to understand change, processes, and life experiences from the perspective of individuals.7 Data were collected through telephone interviews with CNOs who had successfully attained at least 1 redesignation.
A purposive sample was used to recruit and ensure a diverse group of CNOs geographically, by bed size and hospital type, and was selected from the online listing of ANCC Magnet-designated institutions. Organizations in the research team's geographic area, those with no redesignations, and systems were not included in the sample. Chief nursing officers of each organization identified were recruited via an email that described the study and participant expectations. A research assistant (RA) sent the study invitation and was the only person who maintained participant information during the study. All identifying information were blinded from the investigators. Those agreeing to participate were sent a demographic survey to complete and return via email, and it was considered consent to participate in the study invitation letter to the identified CNOs. Upon email consent, the telephone appointment time was scheduled by the RA and then assigned a code number known only to the RA.
An investigator-developed demographic survey requested title, highest education degree, gender, years as a nurse and in a leadership position, and certifications. The interview guide (IG) provided a brief overview of the study with 6 backup probing questions if the conversation lagged, which rarely occurred. The appointment lasted 45 to 60 minutes, and comments were digitally recorded for transcription. Upon initial contact by a member of our research team, the CNO was welcomed following the IG guidelines with the question, “As a CNO, what have you done to sustain and grow your Magnet environment?” As the discussion proceeded, additional questions were asked to clarify, validate, or obtain additional details.
Audiotapes were transcribed verbatim, transcripts were reviewed for accuracy, and any data that could potentially identify the CNO or organization were removed. Content analysis was conducted using 4 steps as described by Charmaz.7 “Initial coding” captured word-by-word, line-by-line, and incident-to-incident data. “Focused coding” was more selective, directive, and conceptual. “Axial coding” related categories to subcategories, giving more coherence. “Axial coding: is more integrative, specifying possible relationships between developed categories, and serves to move in a theoretical direction. “In vivo” codes are participant “special words” that have a special meaning in their world (in vivo codes were identified in this study). Finally, a model was created reflective of the findings. The research team read all of the transcripts, independently coded the data, and grouped them into subcategories. Together, the team revised and labeled subcategories until consensus was achieved. Demographic data were collected and analyzed using descriptive statistics.
The sample consisted of 14 chief nurses. Average years as an RN was 34.2 (range, 22-47). As for gender, 12 were female and 2 were male. Average years in nursing leadership position was 27.0 (range, 16-40); average number years as an RN leader in their organization was 19.0 (range, 2-27). Certifications held were NE-BC (4) and NEA-BC (10) with additional Medical-Surgical-BC, CEN, and FACHE, with organizations being redesignated 1 to 4 times. Six themes with a total of 15 subthemes emerged (SDC #1, https://links.lww.com/JONA/A833). Theme definitions are listed in Table 1.
Table 1 -
|1. Keeping the Magnet fires burning
| Being mindful, purposeful, and intentional; thinking and acting systematically and methodically; looking back to move forward
|2. Honoring the staff voice
| Engaging staff and involving them in conversations continually and often; creating opportunities for staff participation in multiple arenas
|3. Cultivating teamwork sustains the success
| Galvanizing staff and interdisciplinary partners working in teams for achieving excellence in outcomes; sharing evidence and best practices
|4. Stirring the secret sauce
| Creating an environment for all healthcare team providers and executives to work together and sharing Magnet qualities and principles; acknowledging collaboration as the means to achieve excellence
|5. Inspiring and mentoring the MPD way
| MPD imparting Magnet knowledge to all staff and disciplines/departments; mentoring and enabling staff leadership; inspiring Magnet qualities and principles across the organization
|6. Monitoring and constant vigilance of the environment
| Keeping up with Magnet Program® standard changes and requirements; creating a sense of urgency; scanning internal and external environments for issues and trends
Keeping the Magnet Fires Burning
Being Deliberate About the System You Are Creating
Several techniques were described: “…developing a strategic plan that bridges Magnet with the organization,” “…surrounding yourself with experience and excellence,” “…being proactive and never stop working on it (Magnet),” “…keeping a strong team that has a passion for their work,” and “…being vigilant all the time regarding changing Magnet standards and requirements.” Also emphasized was “…using information to help drive practice, engagement, and changes within the organization.” Another important action voiced by several CNOs was “…creating and implementing a succession plan for all staff roles.”
CNOs reported: “Having a good leadership staff who available to staff to listen and promote autonomy,” acknowledging that “…a strong leadership team keeps it (Magnet) alive,” “…hiring for fit and success” was critical, and “…managers are the CEOs of their own little own world” and “create a culture of learning and growing.”
Remaining Vocal, Visible, Accessible, and Self-aware
This was characterized as follows: “…engaging staff continuous and often,” “…being proactive—never stop working on it (Magnet),” “…involving yourself and being a hands-on leader,” “…having (consistent) conversations with medical staff and executives and the board,” “…preparing the whole team,” “…keeping all staff involved in the conversations,” and “…identifying and addressing gaps in practice leading to innovation and change.” In addition, they reported “…having a strong base knowledge about Magnet” and “…keeping Magnet in front of people all of the time.” One CNO offered that “…instilling a strong sense of pride with individual and team accomplishments” promoted interdisciplinary partnerships and collaborations across the organization.
Honoring the Nursing Voice
Nurturing and Energizing Shared Governance
Chief nursing officers unanimously indicated that shared governance (SG) was the most important component of starting their original Magnet journey and that “maintaining a really active and dynamic SG structure” grounded their culture. One respondent stated: “We just do not do anything around here without the voice of bedside nursing being involved, and that (their voice) is heard at all levels of the organization.” Another said: “Taking the time to really involve staff in decision-making takes more work. So, councils may take a back seat a little bit to their other priorities. I see and ebb and flow of work-life balance and who are on committees at that time and what's going on with their lives.” “The managers push a little harder to get more involvement, but they never let go of it (Magnet activities).” One CNO articulated that “as leaders, we continue to look for ways to keep the staff motivated and interested in being involved in their professional practice activities that promote shared governance.”
Attaining the Magnet Self-fulfilling Prophecy
One CNO reported: “It is that continued state of readiness that's so important. And it's a challenge because it's kinda human nature—you know—once something's not new anymore, it does not seem like a big deal. So, I think it is how we do create cultures in which Magnet is a 1st designation of pride and such a belief in the demonstration of excellence of what that means, that people absolutely will not let it go.” “It's all about practice, and improving practice, and staff having a voice in the practice.” Another CNO stated that she sees “staff having a self-fulfilling prophecy of hey—I'm involved. I have some ownership, responsibility and accountability. I think that breeds others to want to be involved.”
Monitoring and Constant Vigilance
Identifying and Confronting Challenges Head-on
During executive turnover, the CNO is the “rock” that keeps everything going. With system integration, “I think we benefit from some economy of scale, but it is a big change for both hospitals (academic medical center and a community hospital)…some positions had to be eliminated, and (the other) hospital was not knowledgeable about Magnet.” Also reported was “not to redesignate,” “postpone,” or “only go as the original hospital.” Working with unions was both an opportunity and a challenge: “…Changing union leadership with different opinions about Magnet” occurred, and “nurses were told by union reps how to answer surveys”; however, “collaboration when documenting evidence was a positive experience.” Awareness of all external regulatory requirements as well as Magnet was crucial: there were some “aged-out Magnet standards that were not keeping with current practice,” “needing to interface with customers regarding what is valuable in practice today such as newer generation of workforce,” “eliminating rigidity (like the Joint Commission),” and “and creating more menu options.”
Achieving Redesignation Is No Cheap Date
One must “…have a consistent robust process (infrastructure) in place to maintain Magnet.” Chief nursing officers reported “making difficult decisions regarding budget,” “getting creative to work around cost issues,” “having challenges to cut down overtime related to SG activities,” “a decreasing ability to engage staff to pursue their BSNs,” “lacking protected time for staff participation in research and evidence-based practice (EBP) activities,” and other SG work.
Avoiding Magnet Slippage
Chief nursing officers addressed Magnet slippage: “Shifting quality work to others without adequate knowledge base” was a concern voiced by 1 CNO. These types of actions pointed to “…experiencing slippage” and “the inability to maintain momentum during times of stress.” It was during these times that creativity and innovation were necessary to “turn around” the downward direction. One CNO stated: “I do not want to have rose-colored glasses on and say that we do not have slippage, that's not the case. We do have to build up that enthusiasm again.”
Cultivating Teamwork Sustains the Success
Lifting the Entire Organization Through Collaboration
Some CNOs reported that interdisciplinary teamwork already existed: “Being a complex organization, we have a lot of multidisciplinary teams so there is a lot of collaboration; they already had an interprofessional approach to care.” Evident throughout respondent comments was the respect for nursing by interdisciplinary team members and increased RN-MD partnerships, creating innovative communication and care models. One respondent reported “…realizing many of the outcomes you cannot specifically say were related to nursing per se.” Another relayed that “…we do not want it just to be nursing.” Other departments were “…looking at nursing success with Magnet and patterning things in their departments” and “…nursing led the way for other disciplines in the organization regarding SG and lifelong learning.” One CNO stated that Magnet “…focuses on all (strategies/initiatives) for the entire organization, rolls up, down and throughout.” Another CNO summarized the criticality of a team: “…need to make a commitment and to really lay the foundation that is an organizational commitment. Yes, it's really a commitment by nurses, but it is really the team effort, that allows an organization to achieve Magnet status…we could not do this by ourselves. You know it is a financial commitment and is definitely an inter-disciplinary commitment as well, we need to have good outcomes.”
Driving Practice Changes
Evidence-based practice and research was elevated with each succeeding Magnet redesignation. Chief nursing officers noted “…using EBP to drive practice change and find new ways of doing things,” “…having a robust EBP program to guide and mentor staff,” “embedding EBP into the organization,” “…encouraging more and more staff in a spirit of inquiry,” and “…having clinical nurse specialists (CNSs) serve as role models by teaching and supporting EBP.” They described programs “…requiring all new graduates and nursing staff to complete an EBP project by the end of their 1st year of employment.” Research and EBP councils were opened up to other disciplines within the organization. In addition to having research resources (nurse scientists and CNSs) available in the organization, EBP and research partnerships with academic colleagues were established.
Sharing Best Practices
Staff were encouraged to disseminate their EBP, research, and innovations via posters and presentations at conferences (local, regional, state, and national/international) and in publications: “Encouraging staff-led research projects resulted in a greater number of overall studies (in the organization).” A sense of accomplishment and pride was realized by those who were involved. Financial support was provided to staff regarding time to conduct the research and to present their findings in the appropriate method.
Garnering CEO and Board Support
Chief nursing officers stressed the criticality of securing top-level sponsorship from executives and board members/trustees of the organization. This included thorough understanding of the ANCC Magnet Recognition Program®, including patient care quality outcomes, staff engagement and practice ownership, and market and fiscal implications of having the designation. Also imperative in this category is medical leadership and key stakeholders in the community. Chief nursing officers indicated “influencing the executive team that Magnet was the right thing to do” was a key component in preparation and ongoing discussions and updates about the progress.
Ensuring CNS Alignment With Magnet Strategies
Chief nursing officers also spoke to the importance of CNSs as a valuable resource as mentors to staff, performing the quality and EBP work, and, critical for staff professional development and autonomy, RN-to-RN and other discipline communication: “…the advanced practice nurse (APN) council is working on engaging staff in developing skills to take on leadership roles in other councils and quality initiatives,” also “…embedding APNs as mentors on SG committees.”
Inspiring and Mentoring the Magnet Project Director Way
Knowing All and Writing to the Magnet Standards
The Magnet Project Director (MPD) “knows the standards inside and out.” Additional CNO reflections included the following: “organized and detail-driven…perfect personality….” Many CNOs have shared the importance of having a “very proactive MPD” and the vital role the MPD plays with ensuring that Magnet standards are an “ongoing thing…these questions should be answered over the 4 years...not in the last year.”
Reinvigorating the Organizational Culture
“Coordinating and who's writing a story…really created a greater awareness and a different level of appreciation for the rigors of becoming Magnet….” As one of the primary functions of an MPD, “involving nurse leaders…to plant a seed a little bit rather than having one person be responsible for [writing]” is a key aspect of engaging leadership to support exemplars for Magnet submission. Being an MPD is “not just about writing the document. She's really involved.” Throughout the process of coordinating and writing the Magnet document, the MPD wears several hats by developing, teaching, and mentoring leaders, frontline staff, and interprofessional partners on how to tell their story from an organizational lens. The MPD is described as an “energizer bunny.” This was how the MPD identified opportunities to weave in Magnet standards into structures, processes, and outcomes.
Maintaining a Strong Relationship With the CNO
One CNO described it as “a very intimate relationship, and I'm just very thankful for it.” Magnet Project Directors are viewed as a vital role in every Magnet designation: “…the CNO/MPD role is one that needs to be very cohesive in order for an organization to be successful because we do rely on each other.” One new CNO reported they were “definitely relying and trusting on the MPD to lead me” (see SDC #2 for additional CNO comments, https://links.lww.com/JONA/A834).
Model for Successful Magnet Redesignation
The relationships among the resultant 6 themes with their subthemes are theorized in the form of a wheel with 6 spokes (Figure 1). Although there is no intent for hierarchical ordering, the criticality of the CNOs' leadership in keeping the Magnet fire burning and their constant monitoring and vigilance of the environment are depicted at the top and bottom of the wheel, respectively. When “set in motion,” the wheel gathers momentum and all of the model elements become coalesced into the organizational ethos.
Findings from this study provide a foundation for successful redesignation based on qualitative inquiry with 14 CNOs, previously limited to singular accounts of redesignation efforts.2-6 This study identified 6 themes reflective of the Magnet model components, supporting the need to focus and maintain an awareness on all components of the model even after initial designation.
There are implications for future research. For additional insight into successful redesignation, it may be beneficial to explore organizational changes and processes contributing to unsuccessful Magnet redesignation. This information would further support or contribute to the findings from this study in assisting organizations to attain redesignation. Future research may build upon the findings from this qualitative inquiry and begin the development of an assessment instrument to measure organizational status in actualizing Magnet Model components as an indicator of progression toward Magnet redesignation. Objective measures of organizational states may assist in modifying current or implementing new strategies to progress toward Magnet redesignation. Another area of interest would be to explore Magnet redesignation in times of extreme challenges, such as the global pandemic (data for this study were collected before the pandemic).
Our sincere appreciation is extended to the CNO participants in this study who shared their time, passion, wisdom, and comments. We wish to acknowledge Drs Laurie Ecoff and Ricardo Padilla for their insight and assistance during the conduct of this study and also RAs Carol Simone and Christy Hall.
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