Hutt Valley DHB achieves magnet recognition: going for Magnet recognition has proved a valuable experience at Hutt Valley District Health Board. Everyone involved in the process has learnt a lot about nursing.

Last month, Hutt Hospital became New Zealand's first Magnet hospital and only the second hospital outside the United States (US) to be awarded this "gold standard of nursing" recognition.

Hosting an appraisal visit by representatives from the American Nurses Credentialing Center (ANCC) in March this year was a milestone in Hutt Valley District Health Board's (HVDHB) four-year journey to seek Magnet recognition. Magnet recognition is granted by the credentialing arm of the American Nurses Association (ANA). It is awarded to health care organisations that achieve excellence in nursing services and validates an organisation's ongoing commitment to quality care. (1)

The purpose of Magnet recognition is to promote nursing settings that support quality professional practice; to identify excellence in the delivery of nursing services; and provide a mechanism for the dissemination of best practice in nursing services. (2)

In December 2002, the Ministry of Health (MoH) announced its support of a pilot project for a New Zealand DHB to apply for Magnet status. Given the United States (US) origins of Magnet, the pilot was to ascertain its value to the Aotearoa context. HVDHB was identified as an organisation that was ready to embark on this journey because, like many organisations, the features of Magnet were largely (albeit loosely) already believed to exist. HVDHB is the first New Zealand health organisation to apply for Magnet recognition. Princess Alexandra in Brisbane, Australia, is currently the only other health care organisation to hold this recognition outside the US.

To understand why Magnet recognition might be important to an organisation like HVDHB requires consideration of its origins. During the national nursing recruitment and retention crisis in the US during the 1980s, some organisations appeared to prosper despite the shortages. A study was commissioned to understand why these organisations succeeded in creating an environment that attracted and retained nurses. Of an initial 163 hospitals originally studied, 41 were found to have a common set of characteristics. (3,4) These characteristics have since been developed into the 14 "forces of magnetism". See Table 1.

Described as the heart of the Magnet Recognition Programme, these forces may be thought of as attributes or outcomes that collectively exemplify excellence in nursing. Full expression of the 14 forces is essential for an organisation to achieve Magnet recognition.

Why become a Magnet organisation?

Since 1981, a substantial body of research has been published examining the conceptual framework on which the programme is based, and the professional and organisation-wide benefits of being Magnet accredited. Research findings have consistently highlighted the nursing benefits of a positive practice environment (ie adequate staffing, supportive managers, good interdisciplinary relationships, opportunities for professional growth, autonomy, participation in decision-making, improved job satisfaction), which in turn reduces nursing turnover rates and subsequent recruitment and retention costs. (5,6,7,8)

While there are clear gains for nursing, there is also a measurable, positive organisation-wide impact on clinical and financial outcomes. These include reduced turnover costs, enhanced patient satisfaction, and better patient outcomes, such as reduced mortality and morbidity. (9,10,11)

Researchers have systematically set about using patient outcome measures to confirm the value of supportive practice environments. Several pieces of research demonstrate a positive correlation between reductions in 30-day patient mortality and failure to rescue, with nurse educational levels and adequate staffing. (12,13,14)

These findings have found resonance internationally; including in New Zealand. (15,16) Taken together, this research presents a compelling argument that substantiates and advances the initial Magnet findings and demonstrates currency for today's health care system.

Some organisations have looked at the literature and progressively implemented the changes they saw necessary to achieve the gains expected from moving to a Magnet-like organisational focus. While there are benefits to the exercise, the gains do not appear to be as substantial as undergoing the scrutiny of the application process. (17) Having just completed our final audit, the reality of our own experience is that the intense level of critical self-examination and the rigour of justification to external examiners do indeed add an additional edge that, in principle, implementation alone probably would not achieve.

Why so focused on nursing?

There has also been some discussion about the largely nursing focus. Magnet is explicitly and deliberately focused on nursing, because nursing, as the largest health professional group, is inextricably linked to all other professions, and the structure and culture of the health care organisation itself. Every Magnet force requires evidence about nursing within the multidisciplinary context in which practice occurs. Interdependencies and collaboration are explicit throughout. Two forces are entirely dedicated to exploring interdisciplinary relationships (force 13) and the image of nursing (force 12) from others' perspectives. The state of nursing, therefore, is a key measure of the overall health of the DHB. Nursing is evaluated in the context of the entire organisation.

The process for Magnet recognition at HVDHB occurred in several phases over a number of years:

1) early preparation/planning and building the project team;

2) raising awareness and collating data;

3) writing and submitting our "portfolio"; and finally,

4) hosting the appraisers' visit earlier this year. Each phase had different challenges and revealed different aspects of nursing in our organisation. Our first challenge arose from changes to membership of the project team. Unfortunately, in the second year of the project (2004), the then director of nursing (DoN) resigned. The following year, the original co-ordinator also left. This delayed our application, as one criterion for recognition stipulates the DoN must have held the position for at least 12 months before the written documentation is submitted and must remain in that position throughout the appraisal process. So in 2005, the new DoN Toni Dal Din established a new project team. After the disappointments of the early false start, it speaks volumes that Dal Din was able to galvanise the nursing and wider DHB community to complete the gruelling process involved in submitting our application.

By the end of 2005, an "expo" was organised to showcase services and innovations from across the DHB. This event generated an incredible level of energy and became a milestone in launching us into the final run to submit our portfolio. The expo created an overall picture of nursing excellence and elevated the profile of nursing at HVDHB.

The past 18 months have involved a huge amount of concerted effort by a large number of people. Early preparation involved a steering committee and a number of working parties that focused on particular aspects of the Magnet programme, eg gap analysis, education, communication and the overall quality of nursing and interdisciplinary services. Awareness and the meaning of Magnet needed to be elevated at many levels of the organisation. Project "champions" were crucial, promoting an understanding of Magnet throughout the different DHB layers; in particular, to nurses providing direct care. Champions worked collectively and individually to disseminate information and to generate awareness of the issues in their units.

A core writing team was formed. People were seconded or simply made time within already full-time positions to contribute. They needed to collect an enormous amount of information that accurately described the state of nursing services at HVDHB against the Magnet criteria. Ultimately, our submission for Magnet recognition was dependent on individual nurses' ability to articulate the different facets of their practice. The writing team was therefore completely reliant on the energy and willingness of the nursing workforce itself and others in the organisation to compile written material, attend workshops, focus groups and study days over a sustained time period.

Nurses found articulating their practice difficult and indeed HVDHB itself found it a challenge to collate data identifying nursing-specific contribution to patient outcomes. In tight of this, the written material the team compiled has undoubtedly opened the eyes of those nurses themselves, their fellow nurses, multidisciplinary colleagues, managers, and HVDHB members. HVDHB board members were particularly interested in the nurse-led clinics that had been relatively invisible until a hospital advisory committee report showcased them and the Magnet writing process expanded on these innovations. As a result, more nurse-led initiatives are now being proposed or implemented.

The data collection process verified the interdisciplinary context of nursing. There were many stories that allied and medical staff told about individual nurses, particular groups of nurses, or wards/departments that consistently spoke of the integral role of nurses to successful patient outcomes. The overall message was that allied and medical staff held nurses at HVDHB in high regard for their professionalism, skill, autonomy and ability to communicate effectively. Similarly, nurses" stories told of their collaborative working relationships with other disciplines. So, white Magnet is unambiguously nursing-centred, it is not exclusionary, and is dependent on good collaborative relationships in which there is a high level of mutual respect. The writing team collated the evidence into a narrative, responding to specific criteria for each Magnet force. Each and every one of the 168 criteria (or sources of evidence) was scrutinised and debated. Of particular interest to the team was translating the criteria derived from a US into a New Zealand context. Checking back and forth with the US for clarification about the meaning of different criteria occurred frequently. Compiling the documentation was undoubtedly the most demanding aspect of the application. An entire room was set up with printers, desks, computers, white boards and telephones (and lots of coffee!) for three months of concerted effort to compile what was required and chase down gaps in the data. This group worked tirelessly, often from sunrise to well into the night, sometimes seven days a week, to compile the material in time to meet the deadline. Ultimately, the DHB submitted a 14-chapter, four-volume narrative against the required criteria and delivered it to the US on time.

Submitting the documentation was not the end of the process. The appraisers requested more information on a number of criteria, with short deadlines for submission. Particular challenges for us included New Zealand-specific issues, such as different nurse educational preparation, nursing structure and hierarchy, as well as legislative differences (eg finding the equivalent of the ANA's Bill of Rights).

Subtle differences in the use of the English language also contributed to the need for frequent clarification (eg to "table" an issue in the US means to discard it; "study day" versus "workshop"; "credentialing" and "privileging," etc.). Clarification was also needed because in some instances--despite our best efforts--our responses inadvertently missed details, or did not cross-reference information from one force to another, leading to a gap in our documentation. Requests for additional documentation gave us a very welcome chance to address these apparent gaps.

At the end of the submission and clarification process, we were confident we knew in the utmost detail where excellence in nursing was demonstrated, and our areas for improvement against Magnet criteria.

The goal of submitting documentation is to achieve a visit by ANCC-appointed appraisers. Approximately 40 percent of organisations who submit do not reach this point. (18) So, in November last year, when we heard that ANCC had decided we would be appraised, we celebrated this considerable achievement!

Appraisers meet staff across the board

Weeks of preparation went into hosting the site visit. The visit schedule was tightly timetabled. It consisted of back-to-back group meetings and unit/department visits, starting with breakfast meetings and ending with evening sessions. The meetings sought to verify, clarify and amplify the submitted evidence for all 14 forces of magnetism. These meetings brought the appraisers together with nurses from all shifts, medical staff, allied health, primary and community representatives, tertiary representatives, Nursing Council, executive management groups, patients and their families. In this way, all staff had every possible opportunity to have their say and appraisers could document their opinion of how nursing excellence is embedded in the systems and culture of HVDHB.

There is probably nothing more revealing than permitting a team of extraordinarily experienced nurses to examine your organisation from bottom to top. The appraisers, of course, were especially interested to hear from direct-care nurses. While initially anxiety-provoking, it was also an interesting and validating experience to speak, and to hear colleagues talk in depth to an expert panel--who in turn, were totally attentive to what was said--about your work. Collectively, the multitude of conversations across every shift and every context reveals much about the overall delivery of health care to the community and the crucial place nursing has in the delivery of that care.

Experience provides insights

As this article was prepared for publication, we heard that the ANCC had decided to award us Magnet recognition. We are tremendously proud of this achievement. However, we also know that "going for Magnet" provides an organisational learning experience that is valuable beyond the award of Magnet recognition. By undertaking an extraordinarily rigorous, in-depth, and systemic scrutiny of the state of our nursing service, we now have insights and knowledge that measure us against world-class standards. Going for Magnet has provided a 14-chapter analysis that, while tabled for external appraisers, is also valuable information for the internal practice and business decision-making within the DHB. The value of nursing is made clear, as are the best practices of our nurses, as well as a vision of where we want to go. Every level of HVDHB, as well as the Hutt Valley community, has learnt a lot about nursing.

Annie Vekony, RN, MN (Appld), was Magnet project leader between 2005-2006; Michele Halford, RN, BN, PG Dip (Appld), is the associate director of nursing; Theresa Fowler, RN, AND, BHSc (Nsg), is nurse consultant in primary and community health; Debbie Poutoa, RN, PG Cert, is nurse coordinator of the Magnet Recognition Programme; Toni Dal Din, RN, MA (Appld) Nsg, PG Cert Forensic PsychCare, is director of nursing; Brian Phillips, RN, PhD, is nurse consultant mental health; and Colette Breton, RN, MN (Clinical), is nurse consultant surgical.

References

(1) Lundmark, V. A. & Hickey, J. V. (2006) The Magnet Recognition Program: understanding the appraisal process. Journal of Nursing Care Quality; 21: 4, 290-294.

(2) American Nurses Credentialing Center (ANCC). (2007) Goals of the Magnet Program. www.nursecredentialing.org/magnet/goals.html. Retrieved 15/05/07.

(3) McClure, M.L. (2005) Magnet hospitals: insights and issues. Nursing Administration Quarterly, 29: 3, 198-201.

(4) American Nurses Credentialing Center. (2007) History of the Magnet Program. www.nursecredentialing.org/magnet/history.html. Retrieved 18/05/07.

(5) Aiken, L. H., Havens, D. S., & Sloane, D. M. (2000) Magnet nursing services recognition programme. Nursing Standard; 14: 25, 41-46.

(6) Buchan, J. (1999) Still attractive after all these years? Magnet hospitals in a changing health care environment. Journal of Advanced Nursing; 30: 1, 100-108.

(7) Kramer, M. & Schmelenberg, C. (2002) Staff nurses identify essentials of Magnetism. Magnet Hospital Revisited; Washington DC: American Nurses Publishing.

(8) Upenieks, V. (2003) Recruitment and retention strategies: A Magnet hospital prevention model. Nursing Economics; 21: 1, 7-23.

(9) Aiken, L.H., Sloane, D.M., Lake, E.T., Sochalski, ,I. & Weber, A.L. (1999) Organization and outcomes of inpatients AIDS care. Medical Care; 37: 8, 760-772.

(10) Aiken, L. H., Smith, H. L. & Lake E. T. (1994) Lower Medicare mortality among a set of hospitals known for good nursing care. Medical Care; 32: 8, 771-787.

(11) Vahey, D. C., Aiken, L. H., Sloane, D. M., Clarke, S. P & Vargas, D. (2004) Nurse burnout and patient satisfaction. Medical Care; 42: 2 (Suppl), 1157-66.

(12) Aiken, L. H., Clarke, S. P., Cheung, R.B., Sloane, D. M. & Silber, J.H. (2003) Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association; 290: 12, 1617-1623.

(13) Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J. & Silber, J. H. (2002) Hospital nurse staffing and patient mortality, burnout and job dissatisfaction. Journal of American Medical Association; 288, 1987-1993.

(14) Rafferty, A.M., Clarke, S.P., Coles, J., Ball., J., James, P., McKee, M., & Aiken, L.H. (2007) Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records. International Journal of Nursing Studies; 44: 2, 175-82.

(15) McCloskey, B. A. & Diers, D. K. (2005) Effects of New Zealands' health re-engineering on nursing and patient outcomes. Medical Care; 43: 1, 1140-1146.

(16) Pearson, A., O'Brient Pallas, L., Thomson, D., Doucette, E., Tucker, D., Wiechula, R., Long, L., Porritt, K. & Jordon, Z. (2006) Systematic review of evidence on the impact of nursing workload and staffing on establishing healthy work environments. International Journal of Evidenced Based Healthcare; 4, 337-384.

(17) Aiken, L. H., Havens, D. S., Sloane, D. M & Buchan, J. (2000) Magnet nursing services recognition programme. Nursing Standard; 14: 25, 41-46.

(18) American Nurses Credentialing Center. (2007) History of the Magnet Program. www.nursecredentialing.org/magnet/growth.html. Retrieved 18/05/07.

By the Magnet Project Document Writing Team

Table 1: The Forces of Magnetism

Force 1:  Quality of nursing leadership
Force 2:  Organisational structure
Force 3:  Management style
Force 4:  Personnel policies and programmes
Force 5:  Professional models of care
Force 6:  Quality of care
Force 7:  Quality improvement
Force 8:  Consultation and resources
Force 9:  Autonomy
Force 10: Community and the healthcare organisation
Force 11: Nurses as teachers
Force 12: Image of nursing
Force 13: Interdisciplinary relationships
Force 14: Professional development