Models of good practice for promoting staff autonomy: The Magnet Recognition Program  Karen B. Haller, PhD, RN Vice President for Nursing & Patient Care Services The Johns Hopkins Hospital Baltimore, Maryland, USA

Objectives ● Review Magnet Program’s goals. ● Relate to HPH strategies. ● Discuss implementation.

Magnet designation is the highest level of recognition given to health care organizations that provide the services of professional registered nurses. - American Nurses Credentialing Center (ANCC)

Magnet Recognition Program Goals 1.Promote quality in a milieu that supports professional practice. 2.Identify excellence in the delivery of nursing services. 3.Provide for the dissemination of “best practices” in nursing.

Hospitals can use the Magnet Program ● To assess and improve their processes for achieving quality outcomes. ● To acknowledge nursing staff for contributions to positive care outcomes. ● To achieve greater recognition within the community for nursing.

Origins of the Magnet Program 1981 – American Nurses Association commissions a study of hospitals that maintained competent nursing workforces during a time of shortage – Researchers (McClure et al., 1983) publish characteristics of model hospitals and coin the term “Magnet hospitals.”

Creation of Magnet Award 1990 – Accreditation program began through the ANCC – University of Washington Medical Center, Seattle, received the first award – Rochdale Trust, U.K., became the first non  U.S. healthcare organization to receive a Magnet award.

AMERICAN NURSES CREDENTIALING CENTER ANCC MAGNET RECOGNITION M Magnet hospitals must meet stringent qualitative and quantitative standards that define the highest level of nursing practice and patient care.

Forces of Magnetism 1.Quality of Nursing Leadership (visionary, knowledgeable, staff advocacy) 2.Organizational Structure (flat, decentralized, unit-based decision-making) 3.Management Style (participatory, valuing staff nurse input) 4.Personnel Policies and Programs (employee-friendly) 5.Professional Model of Care (staff nurses given authority and accountability)

Forces of Magnetism 6. Quality of Care (an organizational priority) 7. Quality Improvement (educational, with staff nurses) 8. Consultation and Resources (availability of expertise, adequate staffing) 9. Autonomy (within scope of Nurse Practice Act) 10. Community and the Hospital (hospital as corporate citizen)

Forces of Magnetism 11. Nurses as Teachers (of peers as well as patients and families) 12. Image of Nursing ( RN is integral member of team) 13. Interdisciplinary Relationships (mutual respect, collegial RN s - MD s) 14. Professional Development (education, competency)

Co-ordinated by: World Health Organization European Office for Integrated Health Care Services, Barcelona Technically supported by: WHO Collaborating Centre for Health Promotion in Hospitals and Health Care At the Ludwig Boltzmann Institute for the Sociology of Health and Medicine at the Institute for Sociology, University of Vienna Sponsored by Federal Ministry for Health and Women Health Promoting Hospitals Italian National Conference on HPH Torino, Italy, November 2003 Six Principal Health Promotion Strategies for Staff Quality developmentStrategic positioning Staff as persons STA-1: Enabling staff for healthy living at the workplace STA-5: Enabling staff for lifestyle development Staff in their professional roles STA-2: Enabling staff for healthy working in the hospital STA-4: Enabling staff for management of work related health problems Hospital / community setting STA-3 : Developing the hospital into a health supportive setting for staff STA-6 : Developing the community into a health supportive setting for specific needs of staff Pelikan et al., 2003

Magnet research shows…  Improved recruitment  Improved retention  Less agency usage  More control of practice environment  Greater autonomy  Better relationships with physicians  Fewer needlesticks  Lower mortality rate (CMI-adjusted Medicare mortality rate)  Lower disease- specific mortality rate  Higher patient satisfaction  Decrease in falls

Summary of the Research Study Job Satisfaction & Burnout Nurse- Patient Ratios Autonomy and Empowerment Education Levels of Nurses Patient Outcomes Patient Satisfaction Kramer & Schmalenberg (1991, 2002, 2003) ++ Aiken, Smith, & Lake (1994) + Aiken, Sloane, & Lake (1997) ++ Aiken, Sloane, Lake, Sochalski, & Weber (1999) + Aiken, Havens, & Sloane (2000) +++ Upenieks (2003) ++ + indicates the study variables.

Lower Medicare Mortality Among a Set of Hospitals Known for Good Nursing Care  4.6% lower mortality rate  0.9 to 9.4 fewer deaths per 1,000 (95% confidence interval) Aiken, Smith, & Lake, 1994 Aiken, Smith, & Lake, 1994

“ – a greater proportion of nursing service personnel being registered nurses – is not the sole explanation for their lower mortality. This finding reinforces our belief that the mortality effect derives from the greater status, autonomy, and control afforded in the Magnet hospitals...” Aiken, Smith, & Lake, 1994, p. 783 Aiken, Smith, & Lake, 1994, p. 783

“ The practical importance of our findings is influenced by the extent to which the organizational characteristics of Magnet hospitals can be replicated elsewhere.” Aiken, Smith, & Lake, 1994, p. 783 Aiken, Smith, & Lake, 1994, p. 783

Relationship between the practice of nursing and the mortality rates in hospitals  Aiken et al., 2002  Blegen, Goode, & Reed, 1998  Czaplinski & Diers, 1998  Kovner & Gergen, 1998  Mitchell & Shortell, 1997

Hospital Organization, Nurse Staffing, and Patient Outcomes Hospital organization Nurse patient ratios / nursing skill mix Nurse autonomy Nurse control Nurse intra- organizational status Surveillance / early detection of complications Patient outcome Medical staff organization and qualifications Nurse-physician relations Rapid institutional response Aiken, 1999

Implementing the Magnet approach StructureProcess Outcome

Characteristics of Effective Nursing  Organizational structure  Quality of nursing leadership  Personnel policies and programs  Professional models of care  Levels of autonomy Source: ANCC ( Source: ANCC (

 Organizational structure 1.Chief Nursing Officer is at the executive level. 2.Decentralized departmental structures allow strong nursing involvement in the committee structure across departments. 3.Equal attention is given to the quality of staff and the quantity of staff.

 Quality of nursing leadership 1.Leaders are knowledgeable and strong risk-takers who convey a sense of advocacy and support for the staff. 2.The nursing directors and managers are pivotal to the success of the organization.

 Personnel policies and programs 1.Salaries and benefits are competitive. 2.Shift rotation is minimized. 3.Significant administrative and clinical promotions reward expertise with both title and salary changes.

 Professional models of care 1.The model of care gives the nurse the responsibility and related authority for patient care. 2.Nurses are accountable for their own practice and are coordinators of care. 3.Nursing management is responsible for developing an environment where care can flourish. 4.Nurses are involved in the development, implementation, and evaluation of nursing care.

 Level of autonomy 1.Nurses exercise independent judgment. 2.Autonomy is viewed as self- determination. 3.Interdisciplinary decision- making is essential.

Conclusion ● The Magnet Program provides a good framework for granting high levels of staff autonomy (empowerment). ● ancc/magnet.html