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Some nurses charge the program has strayed from its original mission
Like many nurses, Alene Nitzky, PhD, RN, went into nursing because she wanted to help people. She had moved through the U.S. healthcare system as both a patient and an advocate, and wanted to draw from her experience to deliver quality, compassionate care to others.
She joined a Magnet hospital in her hometown that was recognized for “nursing excellence” and high-quality patient care.
But the longer she worked there, the more she felt that Magnet status was less about supporting nurses and providing the best care, and more about hospital marketing and profits.
“I felt like all they wanted from me was to hang bags of chemo and keep my mouth shut,” Nitzky told MedPage Today. “I felt I had no future there, that my skills and abilities beyond that were not valued.”
Nitzky acknowledged clashing with management and eventually leaving the hospital, but her concerns about Magnet status were shared by several nurses contacted by MedPage Today. Many similarly acknowledged a lack of autonomy, excessive documentation, and understaffing issues that detracted from the original intentions of Magnet. But some also felt that the program’s value depended on its execution by management — thus varying widely from hospital to hospital.
Principles of Magnetism
Magnet status is awarded to hospitals that meet a set of criteria designed to measure nursing quality by the American Nurses’ Credentialing Center (ANCC), a part of the American Nurses Association (ANA).
It was developed in the early 90s to help hospitals attract and retain nurses during a nursing shortage spurred by poor working conditions, partially due to the introduction of managed care organizations. In response to increasing pressure about the cost of care, hospitals reduced staffing and implemented mandatory overtime. For bedside nurses, this meant an increased workload and less control over scheduling, without a bump in pay.
To combat those challenges and boost the nursing profession’s image, ANCC developed the Magnet designation program, based on a 1983 ANA survey of 163 hospitals, deriving its key principles from the hospitals that had the best nursing performance. The prime intention was to help hospitals and healthcare facilities attract and retain top nursing talent, foster a collaborative culture, and empower nurses to deliver better patient care — ultimately improving clinical outcomes.
Pursuing Magnet status varies from hospital to hospital, but on average it takes a little more than 4 years to achieve, and it needs to be renewed every 4 years.
As of 2016, a total of 445 hospitals had achieved Magnet status, an increase from 387 five years earlier. Notably, U.S. News & World Report‘s top five hospitals of 2017 — the Mayo Clinic, Cleveland Clinic, Massachusetts General Hospital, Johns Hopkins Hospital, and UCLA Medical Center — have all pursued Magnet designation.
Repulsed by Magnet
But several nurses told MedPage Today that the program has strayed from its original mission.
“I think that the original intent of Magnet was good, but that intention is completely lost,” said Sara Koeller, RN, BSN, a California-based nurse who has worked at both Magnet and non-Magnet hospitals. “The overall thing is to get a banner in front of hospital which says we are Magnet status and no one really knows what it means — even the nurses in the hospital.”
Chief among their concerns was that Magnet limited nurses’ independence and flexibility in practice. Nitzky said bedside nurses at Magnet hospitals often don’t have time to think; instead they go through the motions, doing the minimum in hands-on care.
“Nurses do not have autonomy,” she said. “They are railroaded into yes-men and yes-women, ‘Stepford’ nurses who simply function according to the mandates and requirements put on them by the administration.”
Koeller agreed that nurse happiness and critical thinking skills aren’t paramount. She said her hospital often focuses less on patient-centered care and more on technology.
A recent column by MedPage Today contributor Milton Packer, MD, echoed those frustrations with the Magnet system, which Packer experienced first-hand during a relative’s 5-day stay in a Magnet hospital. He said nurses did everything by the book, regardless of whether it made sense.
From taking vital signs to responding to personal needs, he noted that “every movement had been dictated in advance. Every word used in communications had been pre-approved. Forms needed to be checked, whether or not they had relevance. But the really important questions were never asked.”
“Instead of spending time with patients, nurses sit in front of computers,” Packer wrote. “Instead of interacting with patients according to their needs, nurses simply ask formulaic questions that are dictated by the Magnet program. The process takes up all of their time. And their compliance with the process is the only thing that matters.”
While Magnet status is supposed to symbolize better working conditions, nurses still work 12-hour shifts and are expected to take on a huge burden of electronic documentation for the program, Nitzky said. And since hospitals frequently understaff their nursing, the extra burden often leads to not having enough time for real lunch breaks or regrouping during hectic rounds, she said.
Gerard Brogan, lead nursing practice representative for National Nurses United (NNU), the nation’s largest union and professional association of registered nurses, called Magnet designation a “commercial product,” and argued that it’s part of a strategic effort to deregulate the profession.
“The ANA has decided to back the healthcare industry over the bedside nurse,” Brogan told MedPage Today, adding that Magnet promotes short-term financial incentives that drive hospitals to cut costs and skimp on nursing requirements.
Many nurses contacted by MedPage Today complained that hospitals viewed Magnet merely as a marketing tool. Though they went through the certification process, they ultimately did little to support a thriving nursing culture.
“They hire a team of people to go through the program and make the changes in the hospital, to check a box and please the Magnet people, but as soon as they get it, the chief nursing officer is fired,” said Sandy Summers, RN, MSN, MPH, founder and executive director of the Truth About Nursing, a nonprofit organization that raises awareness about the role of nurses in modern healthcare.
“All the changes that the hospital went through to increase professionalism, performance, and vision are reduced and it becomes clear that it was all window dressing and they weren’t interested in changes,” she said.
Nitzky said when Magnet inspectors left her hospital, it would go “back to business as usual, finding workarounds for any promises of nurse/patient staffing ratios, gutting committees where direct-care nurses had a voice.”
Hospitals shell out about $2 million for initial Magnet certification, and pay nearly the same amount for re-certification every 4 years — an obvious money-maker for the ANCC and the ANA. The organizations did not respond to a MedPage Today query about total annual revenue from Magnet.
Magnet status is also a good return-on-investment for hospitals. A study by the Robert Wood Johnson Foundation found that achieving Magnet status not only pays for itself, but actually increases hospital revenue down the line. On average, Magnet hospitals received an adjusted net increase in inpatient income of about $104 to $127 per discharge after earning Magnet status, amounting to about $1.2 million in revenue each year.
Jeff Doucette, DNP, RN, vice president of the Magnet Recognition Program at ANCC, spoke with MedPage Today about the Magnet program, but declined to comment about nurses’ aforementioned complaints.
He had previously sent Packer an email in response to his column noting that patients and nurses should “share these concerns directly with executive leaders at the organization and allow them to investigate. Then they will be given the opportunity to make the necessary changes to ensure the service breakdowns can be corrected.”
Still an Attractor
Doucette’s comments parallel the sentiments of other nurses who said the program’s execution varies widely by hospital.
Susan O’Brien, MS, RN, PCCN, has 41 years of hospital experience and has worked at both Magnet and non-Magnet hospitals. One Magnet hospital where she worked was keenly focused on exceptional patient care and had been recognized with national awards.
“The employees and leadership lived the mission,” O’Brien told MedPage Today. “The leadership in the hospital was committed to staffing ratios that allowed the patient to receive the care that the patient should and the [nurse] wanted to deliver.”
Data about quality were prominently displayed in the hospital for all to see, including patients, their families, and staff, O’Brien said. And the hospital was committed to ensuring staff had the education and equipment to do their job well.
Summers agreed that delivering on the mission of Magnet depends on the institution.
“When going through the program with good intentions, it is a way to transform the hospital to one where nurses are stronger and more included in decision making,” she said. “Those nurses are much happier and confident, and the care they deliver is better. When people feel like respected professionals, they act like respected professionals.”
What Do the Data Say?
There’s no consensus in the literature as to whether Magnet status has an impact on nurse retention or on clinical outcomes.
Last month, a study of a single hospital found that nurses who worked there 2 years after it lost its Magnet designation reported significantly lower work engagement than those who worked there under Magnet status. Similarly, a 6-year-old study found that Magnet hospitals provide better work environments and a more highly educated nursing workforce than non-Magnet hospitals.
A 2010 study, however, found no significant difference in working conditions between Magnet and non-Magnet hospitals.
The clinical outcomes literature is similarly equivocal: one study from 2013 found that Magnet hospitals have 14% lower mortality and 12% lower failure-to-rescue rates than non-Magnet hospitals. But a 2011 study showed that non-Magnet hospitals generally had better patient outcomes than Magnet hospitals.
Regardless of whether they work at a Magnet hospital or not, nurses are likely to face continued pressure as hospital administrators focus on keeping costs down, Summers said.
But Nitzky still channeled the blame on Magnet: “What we really need is a massive sit-down strike of all physicians and nurses who work under these oppressive conditions to band together and say, enough. This is not healthcare. This is a profit-generating scheme that preys on direct caregivers and the uninformed public.”
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