By Heather Stringer
Sandy Lovering, a nurse at a hospital in Saudi Arabia, knew the Magnet Recognition Program is generally considered a gold standard of nursing, but she never imagined it would be something her hospital would ever consider. But in 2005, Lovering’s CEO, Tariq Linjawi, MD, asked her a question that surprised her. “What was the highest credential in nursing?” he asked. Although the hospital had Joint Commission accreditation, he wanted to set the bar higher.
“I told him it was Magnet recognition,” Lovering, DHSc, RN, CTN, executive director of nursing affairs at King Faisal Specialist Hospital & Research Center in Jeddah, said. “He asked if the hospital could achieve this recognition and if I could lead us there. I said yes, but I had no idea what was required and whether it was possible.”
That day marked the beginning of what became more than a six-year journey to receive Magnet designation from the American Nurses Credentialing Center, a subsidiary of the American Nurses Association. While Lovering’s hospital was the first to achieve Magnet status in Saudi Arabia in 2013, its sister hospital in Riyadh, Saudi Arabia, followed suit shortly thereafter. At present, seven hospitals outside of the U.S. have Magnet designation in Canada, Lebanon, Australia and Saudi Arabia, and more are on the Magnet journey.
Why the interest in Magnet?
“There has been a steady increase of interest in the last five years because more people are attending the ANCC’s national Magnet conferences, more information is published [on the program] and people have access to the ANCC website,” Jan Moran, BSN, MPA, RN, director, Magnet operations at the ANCC, said. “We have many organizations all over the world who call our office inquiring about how to implement Magnet, such as [facilities in] Thailand, Japan, the Philippines, Belgium, Germany, Italy and Brazil.”
Nurses and CEOs from international facilities — like their American counterparts — are drawn to the Magnet program because it is a roadmap for nursing excellence, Moran explained. “People who want to change the culture of their organizations and create better outcomes are interested in implementing the programs required for Magnet recognition, such as shared governance, interdisciplinary work, recognition for the nurses and more autonomy.”
The ANCC awarded the first Magnet recognition in 1994 to the University of Washington Medical Center in Seattle, and the first hospital overseas to receive the designation was Pennine Acute Services NHS Trust in the United Kingdom in 2002. There currently are 420 hospitals worldwide with Magnet recognition.
Persevering through the process
Lovering began the journey by learning what was required, which prompted her to fly to the U.S. for the annual Magnet conference 10 years ago. Also, she and Fiona Haines, MCur, RN, King Faisal hospital’s Magnet coordinator, began reading everything they could find about the program, including the work of Ada Sue Hinshaw, author of “Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses.” Although Lovering knew about the Magnet program, she was keenly aware that this was not the case for the vast majority of the hospital’s nurses, who represented more than 30 different countries. To introduce them to the value of the program, the hospital invited Hinshaw to speak at a nursing conference in 2007.
Lovering also discovered organizations could hire a nurse consultant through the ANA’s Nursing Knowledge Center. The consultant is trained to help hospitals working toward the Magnet goal. Nurse consultants have held nursing leadership roles as CNOs or Magnet program directors, for instance. They can request translators when working with overseas facilities. Lovering’s facility hired consultant Vicki George, PhD, RN, FAAN, a managing partner with Nurse Consulting Partners based in Wisconsin, to perform a gap analysis. The analysis revealed the hospital needed to start benchmarking nurse-sensitive indicators, such as bloodstream infections, urinary tract infections, fall rates and ventilator-associated pneumonia. They quickly encountered a significant hurdle: There were no international benchmarking databases available.
Lovering contacted the National Database of Nursing Quality Indicators, based in the U.S., to explore whether the organization would consider allowing non-U.S. hospitals to join the database, and in 2007 King Faisal became the first to do so. The database allows the hospital to compare its nursing quality measures to other nursing units and hospitals in the U.S. and throughout the world in areas such as patient outcomes, nurse satisfaction with the work environment and nurse staffing levels.
To earn Magnet recognition, the hospital also needed to implement a shared governance structure that would empower nurses to make decisions to improve the safety and quality of patient care. Lovering and Haines started educating themselves by studying Tim Porter O’Grady’s shared governance models, as well as the ANCC’s “Guide for Established Shared Governance: A Starter’s Toolkit,” which was co-authored by George.
“The biggest challenge many hospitals face with implementing shared governance is the change in the role of the nurse managers,” explained Bob Hess, PhD, RN, FAAN, executive vice president for education programming and credentialing for healthcare at OnCourse Learning. “It requires an entire nursing organizational shift that ultimately gives bedside nurses control over their clinical practice while extending their influence to areas previously controlled only by management.”
Hess, who also is founder of the Forum for Shared Governance and former vice-chairman of the American Nurses Credentialing Center’s Commission on Accreditation, was keynote speaker at Nottingham University Hospitals’ national conference “Expressions of Interest: Accreditation of Excellence” last July, which explored shared governance and the future direction of Magnet principles. His research pursuits have included the development of the only valid instruments that measure shared governance by professionals in healthcare organizations.
Lovering started introducing the concept of shared governance to units throughout the King Faisal hospital and organized training sessions to teach unit council chairmen about their new role, how to lead a meeting and manage conflict. The hospital began distributing benchmark data to all employees rather than only managers. If a particular unit saw a negative change in a quality indicator, the nurses discussed strategies for improvement during unit council meetings. Although some nurse managers were initially resistant to shared governance, within two years the benefits of the new structure became clear. “Now all the nurses love it,” Lovering said. “They could see it making a difference. All of our clinical outcomes started hitting benchmarks and nurse satisfaction improved. Eventually we started seeing better-than-benchmark results.”
Positive points in the process
Another Magnet requirement that has proven challenging for hospitals overseas relates to educational training. Magnet hospitals are expected to create an action plan to reach the Institute of Medicine’s goal to increase the proportion of nurses with a baccalaureate degree to 80% by 2020.
Many countries do not have RN-to-BSN programs, and international nurses who are interested in enrolling in one of the American programs must often have a U.S. nursing license to be eligible, said Julia Aucoin, DNS, RN-BC, CNE, a consultant with Magnet expertise at the Nursing Knowledge Center, who has worked with hospitals in Lebanon, Qatar and Jordan. It can be expensive to take the American licensure exam and maintain it, in addition to paying for a U.S. education, she said. Although this poses a challenge, sometimes employers will help by covering a portion of the cost of education.
Aucoin has realized there are advantages to being overseas for some aspects of the Magnet journey. For instance, Magnet hospitals are required to show examples of successful implementation in areas such as space design and acquisition of technology, but the governmental regulations in the U.S. can delay this process, she said. “The hospitals I have worked with overseas are very innovative and sometimes have an easier time implementing new technology because their countries do not have the equivalent of the FDA,” Aucoin said.
Magnet hospitals also must display exemplary patient outcomes, and the cultural attitudes in different countries can impact the ability of the patient and caregiver to work as partners to improve outcomes, Aucoin said. In the Middle East, for example, patients are highly respectful and cooperative with caregivers because they see healthcare as a privilege, while in the U.S. there is a value on independence and freedom of choice, Aucoin said.
Future of Magnet overseas
Although there are only four countries outside the U.S. with Magnet hospitals, nurses from other countries are hearing the Magnet message at conferences around the world. George recently spoke at a conference in Korea and Marsha Hughes-Rease, MSOD, MSN, RN, did the same in Singapore at an event attended by nurses from Malaysia and other countries in Southeast Asia. “These countries are interested because Magnet recognition is no longer a U.S. phenomenon,” said Hughes-Rease, a Nursing Knowledge Center consultant who has worked with hospitals in Japan. “Nursing is a worldwide profession and nurses have become global citizens, and it does not take long for the word to get out in terms of the best practices of nursing.”
The 2015 ANCC National Magnet Conference will be held Oct. 7-9 in Atlanta.
Heather Stringer is a freelance writer.
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