Formal recognition for nursing services is a key initiative in promoting a professional practice environment, nursing recruitment and retention, and quality of care.1 The two highest international credentialing programs associated with nursing excellence are the American Nurses Credentialing Center's (ANCC) Magnet Recognition Program® and Pathway to Excellence® (PTE) Program. ANCC launched Magnet in 1994 based on a study supporting the efficacy of program components related to retaining well-qualified nurses who promote quality patient care. Over more than 20 years, Magnet has evolved its focus to promote innovations in healthcare and improvements in patient outcomes.2 Healthcare organizations applying for Magnet recognition undergo a rigorous appraisal process that involves submission of required documentation demonstrating operationalized processes supportive of Magnet principles and a formal onsite evaluation validating enculturation of those principles.3
For organizations demonstrating the principles of positive practice and work environments, ANCC launched PTE in 2009, which formally recognizes qualifying healthcare facilities for improving nursing satisfaction, engagement, and retention.4 Facilities pursuing PTE designation undertake a similar rigorous appraisal process involving submission of required documentation and validation of the presence of positive practice environment elements through achievement of satisfactory outcomes on the online Pathway Nurse Survey (PNS). Nurses' participation in the PNS ultimately determines attainment of PTE designation. Six underpinnings of a positive practice environment are evaluated and verified throughout this process: 1) empowerment of nurses through interprofessional shared decision-making, 2) engaged nurse executives and managers, 3) organizational processes ensuring safety, 4) nursing involvement in quality initiatives, 5) participation in well-being initiatives, and 6) engagement with formal professional development activities.5-7
As of November 2018, 648 healthcare facilities in the US and internationally have obtained Magnet recognition or PTE designation.2,6 In this article, we profile how our healthcare system strategically became the first in the world to obtain systemwide ANCC organizational credentials with a combination of Magnet recognition and PTE designation using an evidence-based mentorship model.
About the project
Baptist Health is an eight-hospital system based in Kentucky, with one managed community hospital, Hardin Memorial Hospital. The only hospital in the system outside the state is Baptist Health Floyd, located in New Albany, Ind. The system employs 16,983 active staff members and physicians. Of these employees, 4,019 are RNs. In 2015, nurse executives within Baptist Health established a systemwide goal as part of a corporate nursing strategic plan to have all facilities achieve Magnet recognition or PTE designation by 2018. A mentorship model founded on published evidence was developed to execute this strategic goal and support nurse executives, PTE coordinators, and steering teams. Baptist Health Lexington and Baptist Health Louisville were Magnet recognized at the project's onset.
Mentorship is a relationship with a seasoned professional who possesses advanced expertise in a specific skill and empowers the development of others through a supporting, nurturing, and nonjudgmental association.7,8 Over the last 2 decades, formal applications of mentorship resources have been cited in published literature as an intervention to enhance knowledge and performance related to professional development skills, including writing competencies.9-12 As part of a clearly defined implementation plan, both Magnet and PTE involve an appraisal process that requires submitting an extensive volume of documentation to the ANCC and its constituents who evaluate the presence of operationalized standards, such as sources of evidence and elements of performance (EOP).
Often, nurse executives are faced with the challenge of leading teams through an effective and efficient journey with limited resources, including development of the final document. Given these considerations, the Magnet project coordinator at Baptist Health Lexington was designated as a system mentor who collaboratively identified the need for developing a process model with nurse stakeholders from Baptist Health LaGrange. By outlining a structured process, nurse executives, designated PTE coordinators, and novice steering teams were empowered with the knowledge and skills to autonomously design individualized journeys. In its infancy stage, the system mentor collaborated with the PTE coordinators from Baptist Health LaGrange to pilot and evaluate elements of the model formally disseminated across the system. Mentorship was the guiding beacon and exercised between all key stakeholders involved. These stakeholders served as mentors for their internal workgroups participating in the journey, which fostered an enriched climate of interprofessional collaboration and professional development.
The Baptist Health Mentorship Model (BHMM) is composed of seven key elements illustrating steps to empower and guide steering teams from the onset of the journey to crossing the finish line. (See Table 1.) Translating the model into practice, the system mentor initially collaborated with nurse executives and PTE coordinators at each facility through phone conferences and onsite visits to enhance expertise regarding the credentialing and appraisal process, support the design of an individualized journey reinforced by a well-defined implementation plan based on the unique needs of the organization, and mentor the development of the final seamless document required for submission. Steering teams were responsible for developing the final document and coordinating learning activities for nursing staff to engage and prepare for the online PNS.
Upon formal dissemination and at the onset of hospital journeys, the system mentor presented a 2-hour writing workshop for each team providing orientation to the utility of the model as an autonomous roadmap and the basic and advanced writing skills necessary to develop succinct narratives for the final document as required in the application manual.
Coordinating prejourney nursing surveys, gap analyses, and kickoff events
The first step of the BHMM encouraged teams to collect data through confidential prejourney surveys completed by internal nursing staff. The primary purpose of these surveys was to evaluate nurses' perceptions of and satisfaction with the existing practice environment and identify gaps in current institutional processes and programs. The system mentor provided coaching on selecting the most appropriate assessment sample and instrument. Workgroups conducting the prejourney surveys were mentored on various methods to collect data and desirable outcomes.
Once the prejourney surveys and gap analyses were completed, the system mentor collaborated with the steering teams to design formal kickoff events announcing commencement of the journey, the benefits of PTE, and the final implementation plan. Events were designed using an underlying theme for entertainment and as an educational strategy to heighten awareness of the journey and engage all nursing staff housewide. Themes such as The Wizard of Oz were used to define incremental stages of the journey and achieve the overall goal.
Using evidence to establish or redesign processes and programs
Guided by the BHMM and using the outcome data retrieved from the prejourney surveys, the system mentor provided consultation about how to redesign existing or establish new institutional processes and programs to support the required underpinnings of a positive practice environment. Modifications were made based on published evidence and best practices available in the literature.
Examples of modifications included, but weren't limited to, development of initial preceptor programs, incorporation of peer appraisals during leader performance evaluations, and ensuring the existence of a productive shared governance infrastructure. Particularly necessary for demonstrating empowerment, the system mentor collaborated with the steering teams to ensure engagement of nurses and interprofessional staff members on shared governance councils as appropriate, which enabled the provision of input, participation in shared decision-making, and improvements in care delivery and patient and family outcomes described in the final document.
Defining a journey to create the final document using nurse-led interprofessional teams
Including a separate and clearly defined journey for creating the final document as part of the comprehensive implementation plan is imperative. The system mentor coached steering teams on defining a tangible timeline depending on the outcomes and activities related to the prejourney surveys (ranging between 3 and 12 months) and guided by an internally developed accountability grid assigning roles and deadlines. The system mentor coached on the optional use of a primary writer and/or the steering team to lead the development of the final document. The goal of either option was to ensure consistent application of a single writing style within individual narratives composing the final document that best reflected the nurse executive and nursing workforce.6
If a team was chosen, the system mentor coached on the optimal interprofessional composition of the nurse-led group, involving those responsible for identifying examples that best represented nursing in congruence with the required EOPs and creating draft narratives for peer review. For example, interprofessional staff members from ethical committees supported the development of narratives for the shared decision-making standard and others from risk management, performance improvement, and human resources addressed EOPs for the safety, quality, and well-being standards.
Developing a succinct final document for submission
Initiated during the original workshop, the system mentor coached on consistent application of standardized writing guidelines that were defined, approved, and applied by the steering team throughout the development of the final document. Emphasis was placed on succinctly describing operationalized processes and related examples as required by each EOP. Use of the guidelines facilitated the development of a seamless document that promoted ease of reading and effortless evaluation by an external reviewer.
The guidelines outlined the average length of individual narratives, translation of keywords from each EOP into each narrative, the use of subtitles as a framework, professional presentation of the names of involved nurses and interprofessional staff members, and consistent presentation of references to documented evidence. Use of numbering and bulleting was advocated to completely define operationalized processes, such as external and internal benchmarking, reporting a safety-related event at work, and communicating concerns about staffing. Incorporation of tables was encouraged to accurately illustrate professional development activities for nurse executives and educational sessions for employees facilitating respectful communication and collaboration.6,7
Adopting peer review for editing the final document
A critical step is the inclusion of a formal peer-review process implemented after completing all of the initial narratives in the final document. Peer review is often underappreciated by novice writing teams, yet it garners significant rewards when conducted effectively. The purpose of this step was to ensure a consistent writing style, validate compliance with preestablished writing guidelines, and prevent avoidable errors through the eyes of internal experts not directly involved in the development of the original narratives.10,13,14 Incorporation of peer review minimized the risk of requests for additional documentation from the ANCC after initial submission and increased the probability of identifying zero deficiencies. Successful completion of this phase augmented high levels of nursing morale and prevented avoidable financial expenditures.
The system mentor coached the adoption of a 2- to 4-week peer-review process conducted by the steering team in collaboration with the nurse executive. Guided by a standardized checklist, peer review was performed at the individual and group levels. Priority emphasis was given to one key inquiry during the review: “Does each completed narrative clearly answer all components of the required EOP?” Upon revision, the document was finalized and prepared for submission.
Measuring perceptions of the nursing workforce through postjourney surveys
Conducting a postjourney nursing survey after submission of the final document or at a more appropriate time determined by the needs of the organization is highly recommended. Using the same presurvey instrument, conducting a postsurvey had several pros for stakeholders to consider. Advantages included the ability to compare pre- and postmean nursing satisfaction scores, which energized the team by evaluating the impact of practice environment modifications.
A disadvantage was inducing survey fatigue among participants before administration of the PNS. It's worth noting that the majority of the teams chose to implement the postsurvey, which demonstrated improved outcomes compared with the presurveys. Often, these facilities had higher scores on the online PNS compared with those that didn't conduct a postjourney survey.
Designing celebration events
Upon submission of the final document and selection of the dates for conducting the online PNS, the system mentor reinforced the importance of designing and implementing celebrative educational activities for participating nursing staff. These activities centered on increasing awareness of revised and newly developed practice environment modifications and recognition of wins reaped throughout the journey. Each steering team was encouraged to use one or more online and/or traditional housewide learning activities that expedited face-to-face interaction with nurse executives, managers, and/or steering teams.15,16
Learning activities included Wheel of Fortune with questions about the six underpinnings of a positive practice environment, coffee or breakfast with the nurse executive, animated movie day focusing on how individual EOPs were achieved, nurse manager rounds on night shifts, and scavenger hunts. These activities bolstered nursing engagement throughout the facility on all shifts, ensured a connection with the journey's purpose, and prepared nurses for the PNS.
Outcomes and lessons learned
Utilization of the evidence-based mentorship model reaped several rewards, demonstrating a distinct level of commitment to nursing practice by executive leadership. Over the period of 3.5 years, all seven community hospitals successfully submitted the required documentation, of which six received zero deficiencies and proceeded straight to the online PNS. By July 2018, all seven facilities received PTE designation, and Baptist Health was recognized as the first system worldwide to receive ANCC recognition/designation for all of its hospitals using a combination of Magnet and PTE. (See Table 2.) We realized multiple benefits, including preservation of a practice environment that promotes increased nurse recruitment and retention and implementation of evidence-based care for enhanced patient outcomes.
Continuous application of the BHMM led not only to unique worldwide nursing recognition due to the combination of Magnet recognition and PTE designation, but also a structural empowerment mechanism to enhance transformational leadership among nursing and interprofessional staff members and raise the bar on professional practice. The core value of mentorship nurtured an advanced culture of interdisciplinary collaboration throughout the system. Rather than engaging in competitive silos, nurse executives and PTE coordinators across the system recognized the value of collegial partnerships. Throughout the 3.5-year journey, mentorship and interprofessional collaboration continued to be expressed as individuals supported the success of their peers. Currently, all PTE coordinators are planning to meet and collaborate quarterly during the interim of the credentialing cycle to promote sustainment of a positive practice environment.
Obtaining and sustaining global recognition through ANCC Magnet recognition and PTE designation goes beyond the institutional level. The mentorship model requires a structured, yet autonomous, approach to engage key stakeholders using a supportive and committed mentor to drive professional practice improvements. Innovations founded on published evidence and designed with a focus on mentorship not only result in the attainment of ANCC recognition/designation, but also cultivate nursing momentum across multiple settings. Nursing excellence significantly contributes to improved work environments and quality outcomes related to the provision of patient- and family-centered care.
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