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If at first you don't succeed...

Dickey, Susan M. MSN, RN

doi: 10.1097/01.NUMA.0000413098.69585.5d
Feature: Magnet®Excellence

Magnet® status is highly sought after across healthcare facilities, but what happens when you're denied?Read what one organization did to turn their rejection into recognition.

Susan M. Dickey is the director of nursing excellence and innovation at The Christ Hospital in Cincinnati, Ohio.

The author has disclosed that she has no financial relationships related to this article.

From devastation to designation, how one hospital picked up the pieces after being denied Magnet® recognition and embraced the opportunity for improvement.



The Magnet® journey is rarely smooth and many organizations face challenges along the way. A successful journey is realized by organizations that are committed, strong, and able to directly face opportunities for improvement as they strive for excellence in the provision of patient care. The Christ Hospital (TCH) is a 555-bed tertiary care teaching facility that recovered from the devastation of being denied Magnet recognition. To keep staff members motivated while correcting deficiencies, we found a way to involve them in a process of change that transformed our model of care. This led to our successful recognition less than 3 years after the initial rejection.

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Optimistic expectations

The nursing staff at TCH formally began their journey toward Magnet recognition in 2004. Champions from each patient-care area were identified as the Magnet Steering Committee and completed a gap analysis. We were confident as we prepared our Magnet document, which was submitted in August 2006. Shared governance had empowered the staff members and they were proud of their accomplishments.

The enthusiasm was palpable during the 3-day site visit in December 2006. During the exit summary, we heard that we'd most likely receive three exemplars and that there were two areas in which we might be given recommendations for improvement. The team leaders explained that in some areas nurses had trouble describing our model of care, and it would be beneficial if TCH provided further education to the staff about the application of ethical principles. Overall, the summary was extremely positive and everyone felt great about the visit.

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Reality strikes

It was standing room only in the auditorium when the CNO gathered everyone to share the news regarding Magnet recognition. There were audible gasps of disbelief when she announced that we wouldn't be receiving Magnet recognition. Even while sharing this unexpected message, the CNO never allowed the staff to feel defeated. She emphasized the positive processes, structures, and outcomes that were recorded in the Magnet document and verified during the site visit. Staff members felt motivated to move forward, believing that our goal of obtaining Magnet recognition was only delayed.

The transformational leadership team never wavered when it came to obtaining Magnet recognition—they submitted a second letter of application a few months after the initial rejection. To build positive momentum and keep staff motivated to correcting deficiencies, the Magnet Steering Committee planned activities that truly engaged all staff members. Magnet recognition can only happen when everyone in an organization takes ownership.

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Picking up the pieces

The Magnet Steering Committee reconvened to evaluate TCH's opportunities for improvement. The appraisers determined that, collectively, our staff members were unable to articulate how TCH's model of care influenced their nursing practice at the bedside. Our professional practice model (PPM) of care was described as patient-and-family-centered care rooted in Florence Nightingale's examination of evidence for practice. The model was linked to the core values of the institution, shared governance, and nursing practice directed by evidence-based research. Although the model was described in words, there were no pictures or illustrations to depict how these fundamental concepts were linked. We realized this was potentially the reason that staff members had a difficult time describing the model of care, so we decided to create a visual representation of the model.

The CNO extended an invitation to direct care nurses to evaluate and possibly reform the model of care, ensuring it reflected nursing practice. A task force convened that included 24 direct care nurses, representing each of the six nursing councils, as well as additional RNs who expressed an interest in this important process. In an attempt to include as many staff members as possible, a survey was extended to all RNs regarding the PPM. Nearly 500 nurses participated in this process, representing 48% of the staff.

The task force conducted a literature review and explored PPMs from numerous healthcare institutions. They reviewed definitions related to models of care and considered the mission, vision, and core values of the organization. Over the next several months, members of the task force sought input from their peers regarding essential components to be included in the PPM.

The foundation of the revised PPM includes the core values for all staff: excellence, compassion, efficiency, leadership, and safety (ExCELS). Another structure that's fundamental to the PPM is the shared governance model, which had been in place for many years. The model includes six housewide councils: research, performance improvement, professional development, education, safety, and professional practice. The councils ensure that RNs share the responsibility of decision making related to all aspects of nursing practice.

The PPM illustrates that all nursing care is influenced by the fundamental teachings of Florence Nightingale: health promotion, nursing practice, optimal patient outcomes, evidence-based practice, and the environment. Clinical expertise, interdisciplinary relationships, patient advocacy, and unit-based care delivery models also influence the staff members' ability to provide patient-and-family-centered care for all patients.

A schematic representation of the PPM was developed, along with definitions of each component of the model. (See Figure 1.) Dry erase boards were provided for each patient-care area so that the model could be described and personalized for various units. Each unit found unique activities that fit all components of the PPM. This process ensured that the PPM was truly a reflection of the care delivered. Everyone owned the model and could articulate how it influenced the care they provided.

Figure 1

Figure 1

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Sustaining the enthusiasm

Although it was critical to address TCH's opportunities for improvement, we also needed to ensure that we continued to meet all standards inherent in Magnet organizations. The leadership team and clinical managers motivated staff members to continue in their efforts to maintain the outstanding clinical outcomes that led to the initial site visit. The shared governance councils and the Magnet champions were critical in this process by leading initiatives and providing examples of how the Magnet standards were met. These nurses were also instrumental in maintaining enthusiasm and confidence among their peers.

Many units hosted open houses that allowed staff members to focus on the accomplishments related to their unique patient population. Nursing directors visited patient-care areas weekly with the Magnet cart, reinforcing the fundamental elements of Magnet recognition.

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Achieving success

Exactly 3 years after submitting the original Magnet document, the second edition was prepared and shared with the survey team and Magnet office. TCH was once again awarded a site visit in January 2010. There was no request for additional documentation related to our model of care and, ironically, only two nurses reported that an appraiser asked any questions regarding the model of care or PPM. Staff members were cautiously optimistic after the 3-day survey and were elated when they heard that we received Magnet recognition! This reality was possible because the direct care nurses embraced opportunities for improvement and implemented a structure that was reflective of nursing practice at TCH.

Denial of Magnet recognition is undoubtedly a huge disappointment. Nurse leaders must work diligently to involve direct care nurses in addressing the areas where deficiencies are noted by the appraisal team. It's imperative that the bedside staff members be involved in the entire process of reevaluating issues so they have ownership of the solutions. By taking this approach, we found that our model of care was clarified and enhanced. Staff members were able to personalize the model of care for their specific nursing unit, which made it a reality instead of an abstract and artificial concept.

In addition, it remains extremely important to keep the Magnet momentum strong and alive. Nursing leaders, managers, and RNs must continue to remain focused on nurse sensitive indicators and provide resources to support processes led by RNs that improve patient outcomes and professional development. A hospital that's truly Magnet worthy can overcome the devastation of initial denial as it proceeds to Magnet recognition.

© 2012 by Lippincott Williams & Wilkins, Inc.