The
Rules of Attraction
Hospitals that refine their culture and policies can capture
the coveted magnet status, turning their workplaces into RN havens and
drawing more staff
their way
By Cathryn Domrose
October 17, 2002
At 9:30 p.m. May 30, 2000—the night of her birthday—Donna Poduska, MS, RN, received a call from her boss at Poudre Valley Hospital in Fort Collins, Colo. Margo Karsten, MSN, RN, chief nursing officer, told Poduska she had just heard from the national Magnet Recognition Program for Excellence in Nursing Services: Poudre Valley would become the 18th health care organization in the country to receive a Magnet designation.
Unable to sleep, Poduska and Karsten dashed to the hospital, picking up vanilla ice cream and root beer on the way. They announced the award amid cheers and handed out root beer floats. Larger and more formal celebrations would follow, but Poduska vividly recalls the exhilaration of that night, when nurses, physicians, support staff and even patients celebrated Poudre Valley’s admission to a select group of hospitals recognized for their commitment to nursing.
For Poduska, director of resource services for Poudre Valley, the award was a crowning achievement in her career, coming after an 18-month application process that included extensive documentation and a site appraisal. “It was the best birthday present I think I’ve ever got,” she said.
Since 1994, the Magnet Recognition Program, run by the American Nurses Credentialing Center, has recognized health care organizations “that provide the very best in nursing care and uphold the tradition within nursing that supports professional practice,” according to the center.
In Magnet hospitals, nurses participate in decision-making. Nurses are considered peers with physicians. Nurses have time to spend educating and caring for their patients. Nurses are encouraged to think.
“You have from the very top of the hierarchy identified nursing as a valued priority for that hospital,” said Julie Sochalski, Ph.D., RN, FAAN, associate professor at the University of Pennsylvania School of Nursing, research faculty member at the Center for Health Outcomes and Policy Research, and co-investigator on a number of studies on improved patient outcomes in Magnet hospitals. “You establish a culture that says nursing is a real asset.”
As a result, nurses, physicians, administrators and a growing number of patients consider Magnet hospitals the cream of the crop for patient care and for nursing as a profession. As of mid-September, more than 50 health care organizations have received Magnet designation, and more are in the process of applying.
Until the advent of the nursing shortage, a Magnet award usually meant a boost to staff morale and well-deserved accolades for hospitals that provided a professional environment for nurses. But in the last few years, as the program has become better known and the nursing shortage has worsened, hospitals have started to view the award as a potential marketing and recruitment tool.
Many nurses, both experienced and new graduates, put Magnet hospitals at the top of their lists of places they want to work. In some regions, after one hospital has received Magnet status, others have applied for the award or expressed interest in doing so. Magnet hospitals mention the award on their letterhead, in their advertising, even on lab coats and scrub tops.
In the last two years, inquiries about the Magnet program have increased sharply and applications have gone up nearly fivefold since 1999. But earning a Magnet award is no easy, overnight process, say appraisers, Magnet program coordinators and hospital administrators who have been through the process. In order to receive a Magnet award, they say, a hospital first must prove a deep commitment to nursing.
Hospital magnetism
The Magnet Recognition Program began during a nursing shortage in the early 1980s. The American Academy of Nursing appointed a task force to see why nurses weren’t working in hospitals. The task force found a number of hospitals that seemed to be nurse “magnets,” attracting and retaining well-qualified nurses when other organizations couldn’t.
The task force recommended that the academy identify a number of these hospitals and examine what made them successful, according to Ada Sue Hinshaw, Ph.D., RN, FAAN, and Margaret McClure, Ed.D., RN, FAAN, authors of Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses.
The academy chose 41 Magnet hospitals from 165 nominated. Nominated hospitals had to demonstrate that nurses considered them a good place to work, that they had relatively low turnover rates and that they had competition for staff from other institutions and agencies.
Studies of these 41 hospitals showed certain common characteristics:
- Participatory management styles.
- Knowledgeable and strong leadership.
- Well-educated directors of nursing at the executive levels in the
organization.
- Competitive salaries and benefits.
- Adequate levels of well-trained nurses.
- Educational and career development opportunities.
- Flexible scheduling.
- Professional practice.
- High quality of patient care.
- Autonomy for nurses.
- Good support staff.
- Nurse/physician collaborative practice committees.
- Interdisciplinary quality assurance and improvement committees.
- Ways of tracking patient outcomes influenced by nursing.
Using these studies, the American Nurses Credentialing Center developed a list of standards to recognize and reward hospitals that demonstrated their commitment to nursing. Health care organizations that prove they meet these standards, through extensive documentation and a site visit, are designated as nursing Magnets. Health care organizations must be redesignated every four years.
The process can take up to two years from the time of the initial application, said Mary Moon Allison, assistant director of the Magnet recognition and accreditation programs for the American Nurses Credentialing Center in Washington, D.C.
Health care organizations must show documents such as employee satisfaction surveys and quality improvement reports to demonstrate how they meet 80 core criteria and 14 “forces of Magnetism” (see below), based in part on the characteristics identified in the original Magnet study.
If they meet these criteria, appraisers visit the site and talk mostly with staff nurses to see how well the organization has put into practice what it has put on paper. Appraisers submit information and comments to a commission that decides whether to bestow Magnet status.
“The point of a Magnet is that you’re just not going to make it if your only focus is on recruitment and retention,” Allison said. “You have to give more than lip service to issues like shared decision-making, support for professional development, all those leadership questions.”
RN component
The first Magnet-designated hospitals had established themselves for
some time as places where everyone from the hospital board on down believed
nursing was important. When the University of California, Davis, Medical
Center received its Magnet designation in 1997, “we didn’t
really change anything,” said Wendy Nugent, MSN, RN, Magnet program
coordinator for the medical center.
UC Davis had an all-RN staff, a strong collaborative relationship between nurses and physicians, a high RN-to-patient ratio and competitive salaries and benefits. The hospital’s chief nurse executive, Carol Robinson, MPA, RN, has always had an open-door policy, and nurses are encouraged to come to her with concerns, Nugent said. The hospital offered a high level of patient care and, as a university-affiliated hospital, had a strong research component. Most important, staff nurses were happy and enthusiastic, she said.
The University of Washington Medical Center in Seattle had a similar situation. The medical center was one of the 41 original Magnet hospitals and was the first organization to successfully apply for and receive the official designation under the program established by the credentialing center, said Catherine Broom, ARNP, CNS, Magnet project coordinator for the University of Washington Medical Center. The hospital received its second redesignation this summer.
Staff nurses were much more involved in the redesignation process than they had been in the past, Broom said. Nurses showed their work at poster fairs and submitted work to a Magnet newsletter. “We saw it as an opportunity to tell our story of excellence and we involved as many nurses as we could,” she said.
Wendy Reiner, RN, an ambulatory surgery nurse who has worked at the University of Washington Medical Center for 12 years, said she was not aware of her hospital’s Magnet status and what it meant until about two years ago, when the hospital began preparing for redesignation.
“Now everybody knows about it and we’re proud of it and it’s helped us become proud of ourselves as nurses,” she said. “We knew we were different. We just didn’t know why.”
Reiner didn’t need an award to tell her she wanted to work at the University of Washington. “I’ve worked in a lot of places and this is the only place I’ve stayed for very long,” she said. She appreciates the career options and the ability to move around and learn new things without having to quit her job. She also likes feeling part of a team with physicians.
“We’re treated like peers and there’s a lot of cross-communication with the physician,” she said. “We discuss together what the treatment method is going to be. We can make recommendations and not feel intimidated.”
Like Reiner, Leigh Anne Saunders, RN, decided to stay at University of Washington Medical Center after working for short periods at a number of other hospitals. “It was so comfortable here and everyone was so genuinely nice and helpful and team-playing here,” said Saunders, who works in the cardio-thoracic surgical step-down unit. “Everybody’s involved in the care of the patient. You hear about that at other hospitals, but I’ve never really seen it until now.”
Instant attraction
As the Magnet Recognition Program becomes more widely known, nurses around the country are applying to hospitals specifically because of their Magnet designation. Hinshaw, dean and professor at the University of Michigan (Ann Arbor) School of Nursing, said a number of nursing schools now give seniors a pamphlet with a checklist of Magnet-like characteristics to check off when looking for an employer.
Children’s Memorial Medical Center in Chicago, which received its Magnet designation in December, reported a 39 percent increase in the number of RNs with experience last year and a 5 percent increase in the number of new grads, said Elaine Graf, Ph.D., PNP, RN, research and funding coordinator in the department of clinical education and Magnet project coordinator at the hospital.
Susan Grant, MS, RN, chief nursing officer and associate administrator for patient care at the University of Washington Medical Center, said the hospital’s Magnet status played an important part in her decision to move from Boston to Seattle.
“With a Magnet hospital, there’s an assumption that they value nursing at the executive level,” Grant said. “A nurse executive would not have to fight to defend nursing and say why it’s important for nursing to be part of the hospital’s strategic development. It allows the nurse executive to execute the professional practice of nursing.”
Magnet hospitals also attract other staff, said Magnet program coordinators and nurse executives. Graf said the chief medical officer at her hospital told her that several physicians and a director of medical technology came to Children’s specifically because they knew the hospital was seeking Magnet recognition. “They knew they would have a group of nurses in an environment they wanted to work in,” she said.
Although most patients aren’t aware of or understand the meaning of Magnet status, they seem to be catching on, say nurse leaders in Magnet hospitals. In some states like New Jersey, which has 12 Magnet hospitals, Magnet status has almost become a marketing tool, said Patricia Rowell, Ph.D., RN, senior policy fellow in nursing practice and policy at the American Nurses Association. “In New Jersey, people say, ‘If you’re not a Magnet facility, I’m not going to go to you.’ ”
Applications for Magnet designation have increased from 11 in 1999 to 50 so far this year, Allison said. But she and other nurse leaders see a change in the kinds of organizations applying for the award. She is receiving more inquiries from hospitals that are trying to develop their workplaces to meet Magnet standards. She is hearing from more private, for-profit hospitals, more small, rural hospitals and more specialty hospitals.
About 30 percent of health care organizations that apply for Magnet status do not receive it, Allison said. Almost all of those that don’t make it fail to meet core criteria in the first round of documentation, she said. She recommends that hospitals purchase a manual that lists standards for earning Magnet status and use it to determine which ones they meet and where they need more work.
When Graf came to work at Children’s in 1997, she knew the hospital was not ready for Magnet status. It had recently gone through a restructuring process that included cost-cutting and a high turnover rate. It had no recognized department of nursing. The staff was demoralized.
The right direction
A new administration began turning things around. It re-established the department of nursing and announced the hospital’s commitment to its nurses. It created or strengthened nursing councils for education, leadership and patient care. Administrators listened to what nurses had to say. As both physicians and nurses became happier at the hospital, their relationships improved.
“It turned around 150 percent,” said Mary Beth Benedict, RN, clinical manager for outpatient hematology and a member of the hospital’s Magnet steering committee. “There was a re-energized focus toward the importance of nursing.”
The hospital’s situation improved so much that Graf and others felt ready to apply for Magnet status about two years ago. When Children’s received the award 18 months later, she said, “the pride was palpable.”
“It wasn’t just a nursing award,” Benedict said. “The entire team was involved.”
Pamela Triolo, Ph.D., RN, FAAN, senior vice president and chief nursing officer at The Methodist Hospital in Houston, knew when she arrived at the hospital four years ago that she wanted to create a Magnet facility. “I always admired the Magnet process,” she said. “I thought it was the pathway to nursing excellence, and I had always wanted to take a hospital there.”
After assessing what the hospital had to do to meet Magnet standards, some nurse leaders were discouraged, Triolo said. “People didn’t think we could do it, it was too much work.” She invited the nursing leadership council to a retreat in her back yard.
“When are you going to be in a position to do something as fantastic as taking The Methodist to Magnet?” she asked them. They decided to go for it.
Triolo said she was careful not to apply for the designation—which The Methodist received this summer—until she felt sure the hospital was ready. “Basically, what you’re trying to do is show a culture of excellence,” she said, “and that takes time.”
Although Allison said she is happy that hospitals are using the Magnet program >> as a standard to improve their nursing environments, she worries that some administrators might see receiving the award as more important than creating a place where nurses are treated like professionals and patient care is paramount.
“Magnet is not something you get as much as it’s something you are,” she said.
Nugent fields daily calls from people asking how her hospital earned Magnet status and how they can attain the designation. “They’re kind of putting the cart before the horse,” she said. “I tell them, first you have to change your culture.”
First things first
Magnet project coordinators said hospitals that want to create a Magnet-style atmosphere need support from both leaders and staff. They need to make sure nurses are involved in decision-making at all levels of the organization, including financial decisions. They need to make sure they treat nurses as professionals, respecting the work they do and the decisions they make, giving them the responsibility and support to take care of their patients.
They need to have a way to collect data on nursing-related patient outcomes so they can measure how they are doing. They need to encourage and support continuing education, research and teaching.
They must show a commitment to keeping nurse-patient ratios manageable and nursing positions filled. Often, say Magnet project coordinators, people at other hospitals ask them if Magnet status is worth all the work.
“It is probably the most professionally rewarding thing that I have ever done in my career,” Graf said. “It is the single thing that has created pride and passion for a nursing staff.”
Allison recalls a call from a Magnet project coordinator from an East Coast hospital, just after it had been awarded Magnet status. The caller told her how, when she graduated from nursing school, she had wanted to work at a certain hospital, but it had no openings.
Instead, she worked at her local hospital, married and started a family. She hoped eventually to get a job at the prestigious hospital, but then her husband died and she decided to stay where she was to raise her children.
Eventually, she became the leader of her hospital’s effort to earn Magnet designation. “Now it’s the epitome of my career,” she told Allison, “to know that I am part of a team that is so respected and so excellent that we have earned this reputation.”
The prestigious hospital where she originally wanted to work, Allison added, is not a designated nursing Magnet.