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Discussion

The benefits of Magnet status for nurses, patients and organisations

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The Magnet programme recognises healthcare organisations that create positive work environments for their nurses, through a stringent process requiring a culture change

Abstract

The Magnet Recognition Program is an international accreditation system that recognises nursing excellence in healthcare organisations. Run by the accreditation wing of the American Nurses Association, it is based on research showing that creating positive work environments for nurses leads to improved outcomes for staff and patients. Evidence suggests that Magnet hospitals have higher percentages of satisfied nurses, lower turnover, fewer vacancies, improved clinical outcomes for patients, greater nurse autonomy and enhanced patient satisfaction than non-Magnet hospitals. This article gives an overview of Magnet, its process and potential benefits, and highlights how the journey towards recognition involves culture change.

Citation: Jones K (2017) The benefits of Magnet status for nurses, patients and organisations. Nursing Times [online]; 113: 11, 28-31.

Author: Kerry Jones is Magnet programme director at Nottingham University Hospitals Trust.

Introduction

The crisis in nurse recruitment and retention in the UK is fuelling an interest in the Magnet Recognition Program (MRP), an international accreditation system for nursing excellence developed in the US. Built on creating work environments that attract and retain nursing talent and empower nurses to deliver exemplary patient care, Magnet is overseen by the American Nurses Credentialing Center (ANCC), an affiliate of the American Nurses Association (ANA).

Magnet recognises healthcare organisations for nursing excellence and high-quality patient care, as well as for achieving higher satisfaction and less burnout among nurses (ANCC, 2017a). It is based on research showing that creating positive professional environments for nurses leads to improved outcomes for staff, patients and organisations (ANCC, 2017b).

This article describes the fundamentals of Magnet and discusses its outcomes from the perspective of the Magnet programme director at Nottingham University Hospitals Trust, one of three UK organisations currently engaged in the process of obtaining Magnet recognition.

Recruitment and retention crisis

The percentage of nurses and midwives leaving the NHS has risen every year since 2011; in 2014 alone 17,800 nurses left before retirement age (National Audit Office, 2016). Figures released in summer 2017 show that, for the first time, more nurses and midwives are leaving than joining the two professions: in 2016/17, 45% more exited the register than entered, with a notable rise in the exodus of nurses in the early stages of their careers (Nursing and Midwifery Council, 2017).

Aside from retirement, the main reasons nurses gave for leaving were:

  • Working conditions (including issues such as staffing levels);
  • A change in personal circumstances (such as ill health or caring responsibilities);
  • A disillusionment with the quality of care provided to patients (NMC, 2017).

The Royal College of Nursing estimates that vacant nursing posts have doubled in number since 2013 and there are now 40,000 unfilled nursing posts in England. It warns that retention is a significant issue and that “there are not enough nurses to provide the care that patients need and, most importantly, that the NHS has funding for” (RCN, 2017).

Interest in Magnet

Against this background, interest in the MRP is growing. There are currently no Magnet-recognised organisations in the UK, but an RCN discussion paper noted this is likely to change, “driven in part as a result of the Francis inquiry and successive reports, which have focused on reforming nursing education and investing in numbers, skill-mix and better retention.” (RCN, 2015).

The Shape of Caring review on future workforce needs recommended that Health Education England examine the potential for “developing and implementing Magnet principles” (HEE, 2015).

Nursing and Midwifery Excellence UK is an informal network of organisations interested in pursuing Magnet recognition; it is hosted by the Oxford Institute of Nursing, Midwifery and Allied Health Research. Three organisations in the UK – Nottingham University Hospitals Trust, Oxford University Hospitals Foundation Trust and The Holly Private Hospital in Essex – are currently engaged in the process of obtaining it.

What is Magnet?

Magnet recognition is awarded to healthcare organisations that meet ANCC standards for “quality patient care, nursing excellence and innovations in professional nursing practice” (ANCC, 2017a). It provides a framework to create a work environment with an excellent workplace culture, the highest standards of care and exemplary patient outcomes.

The programme was created in the US in the 1990s in response to a nurse shortage, not dissimilar to that in the UK today. A study commissioned by the ANA identified 41 hospitals that had successfully attracted and retained professional nursing staff during this shortage. The hospitals were found to have 14 characteristics in common – referred to as the ‘forces of Magnetism’ – which have since been grouped under five domains (Box 1), and form the basis for the accreditation standards that distinguish Magnet organisations (ANCC, 2017a).

Box 1. Magnet domains and the ‘forces of Magnetism’

1. Transformational leadership

  • Quality of nursing leadership
  • Management style

2. Structural empowerment

  • Organisational structure
  • Personnel policies and programmes
  • Community and the healthcare organisation
  • Image of nursing
  • Professional development

3. Exemplary professional practice

  • Professional models of care
  • Consultation and resources
  • Autonomy
  • Nurses as teachers
  • Interdisciplinary relationships

4. New knowledge, innovation and improvements

  • Quality improvement

5. Empirical outcomes

  • Quality of care

Over the last 30 years Magnet has been refined and extended beyond hospitals to include all healthcare organisations. In 2000, it went worldwide to become the only international accreditation scheme for nursing excellence. Today there are two programmes: the Magnet Recognition Program itself and the Pathway to Excellence, an intermediary programme for organisations at an early stage of their journey to Magnet recognition (ANCC, 2017a). Both are built around three principles:

  • Raising the bar in terms of professional development by investing in nurses’ degree and specialist education;
  • Giving nurses autonomy, which is the authority to lead care and use their own outcome data to decide where to focus energy for improvement;
  • Improving clinical outcomes and raising the satisfaction levels of patients and staff.

In the US, there are around 600 Magnet hospitals (8% of all US hospitals); they include most of the country’s leading medical centres. Seven Magnet hospitals are outside of the US: three in Australia, two in Saudi Arabia, one in Canada and one in Lebanon. Interest is growing in Europe, with hospitals in Belgium, Germany, Spain and the UK seeking recognition (ANCC, 2017a). Rochdale Infirmary in Greater Manchester was awarded Magnet recognition in 2002, but failed to renew it after a trust merger, despite measurable improvements in nurse outcomes (Aiken et al, 2008).

The ANCC stresses that Magnet “is not a single project, but an ongoing process that promotes a culture of nursing excellence” and “involves the dedication and commitment of the entire organisation” (ANCC, 2017a). It has three goals:

  • Promoting quality in a setting that supports professional nursing practice;
  • Identifying excellence in delivering nursing services to patients or residents;
  • Disseminating best practices in nursing services.

Journey to recognition

Magnet recognition typically takes 3-6 years and involves meeting an evidence-based set of standards. The organisation must show:

  • Its chief nurse has a master’s degree in nursing, and all nurse managers have nursing degrees;
  • Annual increases in the number of nurses with certification in clinical specialty areas;
  • A shared governance model in which nurses are active partners in formulating and delivering care;
  • Two years of ward/unit-level data on clinical outcomes from nursing care (for example, for falls or pressure ulcers) to meet the standard required to be in the top 50% of organisations for six clinical indicators using international or national benchmark data – whichever is higher. If this data is not available, internal benchmarks based on professional standards, literature review and/or internal trended data should be used (ANCC, 2017c);
  • Ward/unit patient satisfaction data for the same period, as well as from an annual nurse satisfaction survey, showing that the organisation does better than most in these areas;
  • Other forms of qualitative and quantitative evidence as required, to demonstrate Magnet standards, in areas such as nursing research, practice changes, work environment changes and community involvement.

The process is lengthy but can be a revealing self-assessment exercise, providing valuable feedback and creating opportunities for improvement. As achieving Magnet status requires a commitment over several years, it offers a long-term framework for quality improvement and for engaging and empowering staff at all levels.

Magnet requires a real culture change and demonstration of consistently excellent patient and staff outcomes. The stages are as follows (ANCC, 2017a):

  • Measure your organisation against the Magnet standards and identify any gaps;
  • Use this as a blueprint for a pre-application work programme that can include, for example, giving nurse managers access to degree-level education, developing shared governance, running a Magnet engagement programme, developing sources of evidence and starting data collection. This can take a couple of years;
  • Apply and set a date for submitting outcome evidence; this could be in 18 months or two years’ time;
  • Submit outcomes evidence showing you meet the standards required for each of the five Magnet domains and forces of magnetism;
  • If you meet the threshold for excellence, prepare for a site visit from MRP appraisers to verify the results;
  • After Magnet recognition, provide an annual update of monitored outcomes;
  • Prepare for renewal of Magnet recognition every four years, showing you are meeting raised thresholds for improvement.

At Nottingham, we have been working towards achieving Magnet status for several years through developments in education, research, nurse- and midwife-led innovation, and shared governance. Our application for Magnet recognition could take up to another three years.

Why seek recognition?

Magnet is not just a badge, it is a journey that creates cultural change. Nottingham University Hospitals Trust has been working towards delivering excellence in nursing and midwifery care since 2010, and alignment with the Magnet standards is the natural next step. The process provides a framework for us to truly empower nurses and midwives, and to create a culture that enables them to provide outstanding care, maximise their contribution and improve their job satisfaction. It is critical that we create roles and working conditions that enable nurses and midwives to have autonomy, deliver the best care and be fulfilled and happy in their careers.

The most compelling case for embarking on the Magnet process comes from research funded by HEE in the West Midlands, in response to growing concerns about nurse recruitment and retention. This showed that nurses felt they were part of a ‘production line’, lacked professional autonomy, and were undervalued and unappreciated. They wanted to deliver excellence but felt straight-jacketed by a heavily regulated, bureaucratic system that was inflexible and process driven (HEE, 2017). The research revealed that nurses and midwives wanted similar things in terms of job satisfaction, and these things closely matched the characteristics of Magnet organisations (Box 2).

Box 2. Characteristics of Magnet organisations

  • Decentralised organisational structure with active nurse representation in decision-making bodies
  • Professional models of care that give nurses responsibility and authority
  • Autonomy for nurses reflected in their concern for standard setting and monitoring of care at unit and organisational levels
  • Quality of care is paramount, with nurses feeling they work in an environment where excellence is valued
  • Nurses actively participating in assessing and improving care to bring about quality improvements
  • Positive image of nursing across the organisation so nurses feel valued and respected
  • Strong emphasis on personal and professional growth and staff development
  • Interdisciplinary relationships characterised by shared decision making and mutual respect

The principles of Magnet align with theories on promoting job satisfaction from the 1950s (Herzberg et al, 1959), shifting the focus from structure and process to outcomes in care quality, patient satisfaction and nursing environment. This creates a professional environment that promotes greater autonomy and responsibility, participatory decision making, clinical collaboration and increased opportunities for professional development and education (Drenkard, 2010).

According to the RCN, “Magnet provides an evidence-based framework which recognises that nursing has evolved into a profession which, although distinct from doctors, boasts a skills-set which is just as valuable to patients […] Magnet’s role has been to encourage care providers to recognise and embrace this vital contribution – supporting nurses as partners in the formulation and delivery of care” (RCN, 2015).

Quantifiable benefits

There are many benefits to pursuing Magnet status, even before accreditation is granted (Box 3). Studies suggest improvements in nurse turnover, staff and patient satisfaction, and clinical outcomes. Other quantifiable staff benefits include improved nurse education, less burnout and fewer occupational injuries (ANCC, 2017b).

Box 3. Benefits of Magnet accreditation

  • Greater job satisfaction
  • Lower staff turnover and vacancy rates
  • High patient satisfaction associated with positive practice environments
  • Advanced culture of teamwork and nursing leadership, which has a positive impact on organisational decision making
  • Improved quality and safety of patient care
  • Greater engagement from nurses in care quality improvement (evidence-based care and innovation)

A study of the only UK hospital to achieve Magnet recognition, Rochdale Infirmary, showed measurable improvements in nurse satisfaction and quality of care. The nurse practice environment was also better than that of a national sample of other trusts (Aiken et al, 2008). Research on Magnet hospitals in Australia showed nurses rated positively the quality of care, leadership and management support, and relationships between health professionals (Joyce-McCoach and Crookes, 2011).

Studies have also shown improved patient outcomes including lower mortality rates, fewer medication errors, less post-surgical treatment for general surgery and orthopaedics, and fewer falls and pressure ulcers (ANCC, 2017b). A study by McHugh et al (2013) comparing 56 Magnet hospitals with 508 other hospitals across four US states showed mortality rates were 20% lower in the Magnet hospitals and they performed better on failure to rescue. They had slightly higher nurse-patient ratios, more nurses with degrees and specialist qualifications, fewer temporary staff, and were rated as offering significantly better work environments.

The Magnet programme has its critics, many of whom question the extent to which cultural change has been embedded in organisations (The Truth About Nursing, 2016). This reflects the need for Magnet to be fully integrated in the wider organisation’s priorities and be considered ‘business as usual’.

Oxford University Hospitals Foundation Trust commissioned an economic analysis of Magnet, based on the trust’s own data, as well as that from our trust in Nottingham. Reports indicate it is predicted that average savings of at least £3.74m a year per trust can be made via improved patient outcomes (such as avoidance of falls and pressure ulcers) and workforce factors (such as reduced staff turnover and agency costs) (Merrifield, 2017). These savings far outweighed the running costs of Magnet, which are estimated at £150,000-220,000 for the largest hospitals. The analysis suggested some of these savings could be made in the first year of preparing for Magnet application.

Progress and improvements

At Nottingham we are progressing and hope to complete the Magnet process by 2020. Recognition is the prize, but it is the journey that matters. We have already made good headway in shared governance and encouraging staff development in the academic field. We have also seen improvements in clinical outcomes, such as a reduction in the number of falls and catheter-associated urinary tract infections, as well as some excellent outcomes in nurse- or midwife-led innovation. It is now a matter of capturing that and building on it. Most of all, it is about cultural transformation that changes the workplace, so nurses and midwives feel engaged and empowered to deliver excellence.

Myth buster

The Magnet Recognition Program is American, so why should it work here? Although Magnet is far less established outside of the US, many of its benefits – such as reducing nurse turnover – appear transferable. Without research and evaluation, we will never know.

It is too expensive - Indications show Magnet could save trusts money through improvements in patient care and workforce factors such as reduced staff turnover and lower agency costs.

You need a nursing degree to work in a Magnet hospital - Magnet-recognised organisations must provide high-quality education across the board, so they have more nurses with specialist qualifications and degrees. To apply for Magnet recognition, organisations must ensure all their nurse managers have nursing degrees and have plans in place to give 80% of their nurses the opportunity to gain a nursing degree. At Nottingham, we are exploring ways to capture and recognise experiential learning for nurses who trained before a nursing degree was required in the UK, and to increase access to high-quality continuing professional development.

It is too bureaucratic - Magnet encourages organisations to use existing data and take their examples from things they are already doing. It is about seeking out the good work nurses are doing already, recognising it and celebrating it.

It might not be right for us - Magnet is a framework for continuous improvement and is open to all healthcare organisations. Organisations need not apply straight away; they can work towards application by gradually aligning themselves with Magnet standards.

Talking points

  • The Magnet Recognition Program is a global accreditation system for nursing excellence developed in the US
  • Its tenet is that creating positive work environments for nurses leads to improved outcomes for staff and patients
  • The nurse recruitment and retention crisis is fuelling interest in Magnet in the UK: three trusts are pursuing recognition
  • Magnet organisations promote greater nurse autonomy, empowerment, decision making, clinical collaboration and professional development
  • The journey towards Magnet recognition offers opportunities to improve quality, and engage and empower staff at all levels
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