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Modern Magnet: Five model components shift focus to outcomes

Magnet hospitals today are working from a simplified program model that has evolved to focus on proven outcomes, rather than simply theories of best practice.

The American Nurses Credentialing Center launched its next generation model for the ANCC Magnet Recognition Program in 2008. It was then that the 14 forces of Magnetism were revised to create the five Magnet model components.

Today’s Magnet model, according to ANCC Executive Director Karen Drenkard, RN, PhD, NEA-BC, FAAN, eliminates the previous model’s redundancies. “The new sources of evidence are framed by five model components: structural empowerment; transformational leadership; exemplary professional practice; new knowledge innovations and improvements; and empirical outcomes,” said Drenkard, who led the model’s transformation. “The program went from 164 requirements to 88. So, it became a lot tighter and a lot more concise.”

The 14 forces remain imbedded in the five components, according to Drenkard. However, the model has evolved from one more concentrated on structure and processes, to one focused on outcomes. “Now, if you don’t have excellent outcomes, you cannot be Magnet. You have to score on the top for clinical outcomes, patient satisfaction and nurse satisfaction. That’s the key difference, the focus on outcomes,” Drenkard said.

With an increasing number of hospitals pursuing the sought-after designation (only 8% of U.S. hospitals have achieved Magnet status), Drenkard said there are two things hospitals need to do in preparation for the Magnet journey. First, start collecting data for clinical measures for nursing, patient satisfaction and nurse satisfaction. You need to have two years of data, above the 51st percentile, before you can apply for Magnet status. Next, do gap analyses to determine where your hospital might not be meeting benchmarks in Magnet requirements. The process includes, not only implementing plans to close those gaps, but also reporting on your outcomes.

Why put in all this effort? Because, Drenkard said, Magnet is a proven road map to excellent patient care. “Magnet is a credential; it’s not an award, and it’s not a prize. The credential says that you have been peer reviewed by the top people in your field … and they have said you meet, not just the minimum but rather have reached a scale of excellence,” she said. “There are 88 sources, so there’s a lot to manage. But if you manage these variables, it all comes together in this amazing tapestry of unbelievable nursing care, nursing practice, nursing autonomy and collaboration with other disciplines.”

There are 383 Magnet-designated facilities, and applications for Magnet designation have grown an average of 32% each of the past five years, according to ANCC’s book, “Magnet: The Next Generation — Nurses Making the Difference.” Here are the five model components followed by real-life examples from nurses:

Transformational leadership

“It is relatively easy to lead people where they want to go; the transformational leader must lead people where they need to be to meet the demands of the future.”*

Nurse retention at The Heart Hospital Baylor Plano (Texas) was relatively stable at 92.8%, but a re-occurring issue came up in exit interviews. There was a gap between what nurses felt they needed to move up in the organization and what they were receiving. “They felt they were not given resources to better themselves personally and professionally,” said Melissa Winter, RN, MSN, CNO and vice president of patient care services at the facility. “So our Magnet coordinator and I sat down and came up with a yearlong nursing succession program, implemented [in] March 2010.”

The program was launched in the form of a fellowship, and Winter got the word out to the facility’s nearly 300 nurses that there was a new opportunity for them to learn what they need to know to move up in any organization. To apply for the fellowship, nurses must have worked at the Heart Hospital for at least six months, be free of disciplinary actions and have met a minimum standard on their most recent performance review. They also need to have earned a BSN or be pursuing the degree.

The professional development program features expert speakers, tutorials, mentoring and other educational opportunities. Nurses learn, for example, leadership skills, job interview pointers, and the differences between a curriculum vitae and resume.

Ten nurses have since completed the program, and 15 new fellows started in July. Of the first 10 fellows, four already have moved up in their roles. Three have been promoted to supervisor and one obtained a full-time charge position, Winter said. “They’re just so unbelievably changed from the beginning to the end of the year. They know how to handle situations differently. I have two mentees that meet regularly with me, and one said just the other day that her coping and stress management skills are incredibly better. That’s very rewarding because ultimately that’s better for the patients.”

Baylor Health Care System plans to implement this program at two other facilities, and Winter has been named COO and CNO of the new 400-bed Baylor Medical Center at McKinney, opening next summer.

Staff empowerment

“Staff needs to be developed, directed and empowered to accomplish the organizational strategic plan, structure, systems, policies and programs.”*

Angela Creta, RN, MS, CNL, BC, Magnet site coordinator at The Miriam Hospital, Providence, R.I., said nurse empowerment is vital. “Shared governance is the organizational structure that allows nurses the opportunity to have a voice and be professionally engaged,” she said.

The Miriam Hospital, a 247-bed acute care teaching facility, which recently received its fourth Magnet designation, instituted the nursing finance council to help staff nurses make decisions about resource allocation and staffing. Nurses on the finance council redesigned the charge nurse preceptor program based on what they learned, Creta said.

“The finance council helped improve the practice environment. We have our assistant managers, charge nurses and staff nurses attending those meetings and getting an understanding of the larger picture of resource allocation at the unit level,” she said. “Their engagement and sharing during the meetings allows them to make day-to-day operational decisions.”

When nurses identified the need for a nursing ethics committee, Miriam launched a nurse-specific branch of the hospital ethics committee. “From that, nurses have become more proficient in dealing with complicated ethical issues,” Creta said. “We also have a program that was initiated from the nursing ethics committee called Walking Ethics Rounds. The rounds resulted from one nurse’s idea that staff nurses can’t always come to the luncheons to listen to these cases; so, maybe we should go to the nurses and talk to them-more on a rounding type basis.”

Nurses participating in Miriam’s evidence based practice council also identify practice issues and initiate changes, Creta said. “We’ve instituted bedside-nurse-driven protocols, including oral care and Foley catheter discontinuation. Additionally, we are currently developing a hypoglycemic protocol that is nurse driven,” she said.

The evidence based practice council examines best practices, recommended practice and current research and compares those to what exists in the workplace. “When there is a gap between recommended guidelines and practice, nurses can really have an impact in advocating for change,” Creta said.

Exemplary professional nursing practice

“The true essence of a Magnet organization stems from exemplary professional nursing practice. This entails a comprehensive understanding of the independent and dependent role of nursing.”*

This component encompasses all things in the practice environment that allow nurses to do what they do in excellent fashion, said Patricia Reid Ponte, RN, DNSc, FAAN, NEA-BC, senior vice president of patient care services and CNO at Dana-Farber Cancer Institute, and executive director of oncology nursing and women’s services at Brigham and Women’s Hospital, Boston.

For the past decade, Dana-Farber has committed to consistently encouraging nurses to talk about their successes and challenges, and taking action on issues raised during those conversations, Ponte said. Informal opportunities for nurses and leadership occur during executive patient safety rounds and practice rounds, she said. During these rounds, Ponte, along with the chief medical officer and chief operations officer, make it a point to chat with nurses. “We ask them questions like: What’s going well? What’s not going well? What’s keeping you up at night? What’s getting in your way of safe effective practice?” she said.

These informal, yet deliberate, interactions produce ideas that lead to excellence, she explained. For example, nurses brought up a recent challenge: The staff had moved into a new ambulatory center and it was stressful for patients and staff to settle into the environment. “One of the suggestions from the staff was, ‘Well, if we’re going to try to figure this out, let’s figure it out with one of our patients in the room,” Ponte said. “We have such a commitment here, in that patients and families actually sit with our nursing staff and others and help develop improvements in how we do things.”

Nurses stay in Magnet environments because of the standards and programs that support them, according to Ponte. “They know they’ll have an opportunity to interact with senior leadership if something’s bothering them. We’ll figure out the solutions together. There is a nursing council — a place to go that’s formal. But there’s also a place to go that’s informal,” she said.

The results are staff satisfaction, less staff distraction, safer and higher quality care, and patient satisfaction, she said.

New knowledge, innovations and improvements

“This concept is intended to move beyond a basic application of research to include evidence of redesign, new models of care, application of new evidence to guide practice, and visible contributions to the science of nursing.”*

Bedside nurses at Duke University Hospital, which recently earned Magnet redesignation, routinely meet with the hospital’s clinical practice council to discuss ways to incorporate new knowledge into practice, according to Mary Ann Fuchs, RN, DNP, chief nursing and patient care services officer for Duke University Hospital and Duke University Health System, Durham, N.C.

“This frontline group of staff has been trained to identify current evidence; compare that with our internal practice standards; update and educate the organization around those practice standards; and incorporate what’s new as a best practice,” Fuchs said.

These nurses also help to determine and fill gaps in knowledge by conducting research. “We have a whole list of … formal research studies that are now published that really have been generated by bedside nursing providers, who have used our institutional resources [to conduct research],” she said.

For example, Duke University Hospital nursing staff led a pilot study in two hospital ICUs, looking at using chlorhexidine gluconate bath cloths to determine if the practice would help prevent central-line infections and could be used throughout the organization.

“The group not only looked at this from a clinical practice perspective, but also to determine the time it took and how expensive it was for our organization. Broadly, we determined … that it would be wise to bring this bath cloth into our ICUs. We’ve seen decreases in infection, no real increases in expense, and the time that it takes the nurses in the intensive care setting to provide patient care has decreased,” Fuchs said.

“Our nurses have also partnered with our physicians and infection prevention staff to develop a comprehensive program for insertion and maintenance care of central lines. Our ability to form teams as such, was highlighted as an organizational exemplar during Magnet redesignation site visit,” she said.

Empirical outcomes

“The question for the future is not ‘What do you do?’ or ‘How do you do it?’ but rather, ‘What difference have you made?'”*

Deborah Zimmermann, RN, DNP, NEA-BC, CNO at Virginia Commonwealth University Health System in Richmond, described empirical outcomes this way: “Empirical outcomes are the ‘So what?’ to the story. We know as a profession we are continually rated as the most trusted of the professions, and people love our authenticity and value our practice. However, does the practice really make a difference? How do we know if we’re improving the lives of those that we serve?”

The proof is in the empirical outcomes, she said.

The VCU Heath System includes a 779-bed hospital, recently re-designated as a Magnet facility. The facility’s focus, according to Zimmermann, is to become the safest hospital in America. Everyone who works in the hospital, including bedside clinicians, work toward that goal, she said.

“Nurses demonstrate the goal through our prevention of hospital-acquired infections; specifically, urinary tract infections, ventilator-associated pneumonia and central-line infections,” Zimmermann said.

In their quest to eliminate hospital-acquired infections, VCU nurses not only apply the evidence, but also create it. For the past seven years, they’ve looked at best practices and found where the research is lacking. One example: Nurses found gaps in research related to oral care in the prevention of ventilator-associated pneumonia. They wondered if the method they used to brushed their patients’ teeth affected infection risk. So those nurses launched a research study on the practice.

That’s part of this component, Zimmermann said: supporting nurses when they want to find answers to their questions. “What we encourage in rounds, staff meetings and in our shared governance structure is the raising of the questions,” she said. “We currently have 62 research studies underway in which nurses are the primary investigators.”

The empirical outcomes: VCU Health System has reduced hospital-acquired infections over the past seven years by 85%, and nurses now know they’re making a difference.

* “Magnet: The Next Generation — Nurses Making the Difference” •

Lisette Hilton is a freelance writer.

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