A Magnet Investment Pays Off

When applying to the Magnet Recognition Program®, Victoria Rich, PhD, RN, FAAN, did not simply prepare her staff of 1,400 nurses at the Hospital of the University of Pennsylvania (HUP) to do well. She encouraged them to do their absolute best. And that’s exactly what they did.

HUP earned Magnet status in 2007 without receiving any identified areas that needed improvement on the Magnet summary report, according to Rich, who is chief nurse executive for the University of Pennsylvania Medical Center, which includes HUP. “We met the requirements to the maximum,” says Rich.

With only 286 Magnet hospitals nationwide, it is notoriously difficult to earn this prestigious designation from the American Nurses Credentialing Center (ANCC). The hospital often must undergo a cultural change that both nurse leaders and staff nurses must embrace, says Janice Moran, MPA, BSN, RN, director of Magnet operations for ANCC. “It takes a lot of effort to get to that point,” she says.

Rich and her nurses can attest to the “work” aspect of achieving Magnet status. HUP leaders and staff put in about three years of dedicated commitment, wrote 1,000 pages (10 volumes) of narrative for the Magnet application, and budgeted millions for additional resources.

The payoff is much, much more than the right to display the Magnet logo, says Rich. The hospital has already started to see a return on investment—in nurse vacancy rates, in patient satisfaction ratings, and in an empowered nursing voice for clinical decision making and evidence-based practice.

A Commitment from on High

University of Pennsylvania Health System established a strategic goal to pursue Magnet status in 2002, beginning with HUP. The hospital executive team fully supported the Magnet process. Everyone realized that creating a culture of Magnetism would improve recruitment and retention rates; but most importantly, create a culture of world-class patient care. The average RN vacancy rate at Magnet hospitals is 4.1 percent, according to American Nurses Association (ANA).

Health system executives began readying HUP for the Magnet process by making sure the hospital had the necessary nursing leadership and financial infrastructure in place. The HUP executive team supported 10 additional RN FTEs to the budget each year so that clinical nurses are able to participate on unit council meetings. The Magnet program espouses a shared governance model in which nurse leaders and clinical nurses work together to make decisions about patient care and administrative issues.

The hospital also budgeted for the additional costs associated with the Magnet application process, including preparing the necessary documents. “These additional costs totaled $1.5 million for the one year prior to the granting of the recognition,” says Rich, who is also the assistant dean of clinical nursing practice for the University of Pennsylvania School of Nursing.

In addition, before applying for Magnet, HUP began participating in ANA’s National Database of Nursing Quality Indicators, a proprietary database that consists of unit-specific, nurse-sensitive data, such as patient fall rates and nosocomial infections rates, from U.S. hospitals. Magnet applicants are required to collect patient outcomes and satisfaction data for each nursing unit within the organization for at least two years before applying to the program.

Improving Patient Care

Magnet applicants must comply with the program’s 14 Forces of Magnetism, which are “attributes or outcomes that exemplify excellence in nursing.” (Forces of Magnetism, ANCC.) In addition, for each Magnet Force, there are sources of evidence that applicants are required to fulfill. (To learn about the 14 Forces of Magnetism, visit the ANCC web site.

After conducting a gap analysis, HUP nurse leaders identified several areas that needed extra support and enhancement. One identified gap centered on promoting a safe and healthy work environment (which is related to Magnet Force 4 and source of evidence 2).

“The gap in this standard was to address workplace injuries due to the lifting of patients, combined with concerns of an aging workforce and physical challenges,” says Rich. A team of senior executives and nurse leaders designed a patient lift team in collaboration with the hospital’s transport department. However, HUP leaders did not stop there: $2.8 million was allocated from the capital budget to equip 542 patient rooms, including emergency and radiology rooms with automated ceiling lifts. To date, nurse satisfaction is at an all time high, and worker’s compensation injuries are diminishing, says Rich.

HUP also needed to work on improving patient satisfaction scores. Rich used the National Database of Nursing Quality Indicators (NDNQI) to affect change in areas that scored low on satisfaction. For instance, both perioperative and ED nurse-physician collaboration measured in below average ranges. Rich engaged a consultant group for about one year, which facilitated dialogue and assisted interdisciplinary work teams in each department to transform a disrespectful work environment into a world-class, best practice, interprofessional culture. The following year NDNQI scores markedly improved in both units and continue to do so.

“The purpose of obtaining Magnet status,” says Rich, “is about providing nurses with an evidence-based practice environment and the voice of empowerment, which allows clinical nurses to deliver outstanding patient care. “When patients walk out of here, they know that their clinical nurses had the ability, not only by knowledge but by resources to deliver world-class patient care,” says Rich.

Building Nurse Pride

“I wanted us to believe that we actually ‘lived’ what Magnet espoused,” says Rich. “I wanted our nurses to truly feel that they were autonomous, they had professional growth, and that they were supported as a partner with doctors and the other members of the team.” However, getting nurses to truly “live” what the Magnet program espoused didn’t happen so easily. In the beginning, Rich needed to do a lot of education and communication. She sat in on committee meetings, participated in daily rounds, and communicated via email with her nurses to get an idea of what Magnet status meant to them and how to achieve it. One key challenge was convincing nurses that the hospital just wasn’t trying to win an award. “They thought, ‘Is this just about getting a symbol? If that is all this about, then it doesn’t mean anything to me,’” says Rich.

Ironically, the challenging process of preparing documentation for the Magnet application was what caused many HUP nurses to recognize the true value of the Magnet award. Rich and eight other PhD nurses at University of Pennsylvania took on the laborious task of writing detailed narratives about how HUP adhered to the 14 Magnet Forces, which required answering more than 300 questions. The nurse leaders wrote the narratives based on input from the staff nurses.

Once completed, the narratives were posted online for the staff to read. “That,” says Rich, “is when something clicked.” For the nurses, the process of writing down what they do every day and then reading what their colleagues do enlivened them and struck a chord of pride, says Rich. She clearly recalls that there was an actual tipping point one day when she felt a sense of change, a realization among the nurses of the true purpose of Magnet and how they fit into reaching that goal. “People came alive with, ‘I get it. Now, I see what this is about, it is about excellence in nursing practice and patient outcomes.”

Vacancy Rates Decline Dramatically

Reaching for and achieving Magnet designation has helped reduce the nursing vacancy rate at HUP, says Rich. When she arrived six years ago, the vacancy rate in the nursing department was 25 percent. Now, it’s 3.8 percent, she says. The remarkable improvement in vacancy has resulted in the ability to increase the RN-to-patient ratios on medical-surgical units to 1:4-5 and on intermediate units to 1:3 ratios. Dollars saved from reducing turnover were used to improve the ratios.

The improved ratios also enabled Rich to support the American Organization of Nurse Executive’s paper on hiring only baccalaureate prepared nurses. HUP currently only hires BSN graduates and 85 percent of bedside clinical nurses at HUP have at least a BSN.

Rich is not surprised that her staff did so well on the Magnet application and site visit, when Magnet appraisers spent five days talking with nurses and other hospital staff to evaluate whether the hospital met Magnet standards. Rich has grown accustomed to excellence from her nursing staff. “I know I sound like a proud mama, but I have the best nurses in the world, and I tell them that.”

Victoria Rich, PhD, RN, FAAN, Chief Nurse Executive for the University of Pennsylvania Medical Center in Philadelphia (victoria.rich@uphs.upenn.edu).

This article originally appeared in The Business of Caring, a newsletter dedicated to helping nurse managers develop business and leadership skills. Learn more.