Magnet Status: A Floor, Not a Ceiling
The Magnet program, whose goal is to identify hospitals where nursing care is strong, has great promise. As advocates for nurses, we applaud the 414 institutions that have become Magnet certified by the American Nurses Credentialing Center (ANCC), and we urge all hospitals and health institutions to pursue the laudable goals that Magnet establishes. Research shows care delivered at Magnet hospitals is generally better than at non-Magnet hospitals. Many Magnet nurses report that as their hospitals undergo the transition to Magnet, the nurses feel more pride and respect, a sense that they will be able to approach their profession's true potential.
But many nurses have also reported that once their hospitals attain Magnet status, progress slows. In some cases there seems to be a reversion to a prior atmosphere in which nurses did not enjoy much respect and patients were at risk. And even in hospitals determined to be worthy of their Magnet status every day, too often the standards are treated as a maximum possible achievement instead of a continuing journey toward nursing excellence.
In the era of evidence-based practice, it is important that nurses constantly incorporate findings from research and clinical experience to improve care, even if the findings are not yet part of the Magnet framework. Although Magnet has achieved a good deal, there is room for improvement. Specific areas that are worth more effort include improving transparency as to program standards, ensuring adequate nurse-to-patient ratios, creating nurse-led hospitals, moving aggressively to promote safe care models, and promoting the Magnet program itself to the public.
One easy way in which the Magnet program could improve would be to increase transparency about what it seeks to accomplish. Recognition of nursing excellence would increase if the ANCC made public specifics about what it takes to achieve Magnet certification. In response to numerous requests for a Magnet application, we were told that no application would be forthcoming unless we first forfeited $300 to the ANCC. Why should interested nurses, the media, or the public have to pay so much money to find out what Magnet is measuring? With greater transparency for the program's process and standards, interested persons would be able to examine the program and contribute to improvements. The media cannot cover the story of the Magnet program if it is going to be kept secret. Perhaps there is concern that nurses or their representatives, armed with the specific Magnet standards, would fault their institutions for failing to meet them on a day-to-day basis. But wouldn't it be good policy to encourage such discussion? If the ANCC wants the public to recognize the value of the Magnet program, they should encourage understanding of the program. A pdf file of the Magnet application should be free for anyone who wants a copy.
Ensuring Adequate Nurse Staffing
One of the Magnet program's general standards for certification is for nurses to "explore the safest and best [evidence-based] practices for their patients and practice environment and to generate new knowledge." This is an excellent goal. Nursing care has improved since we became more closely focused on scientific research.
That is why it is distressing that the Magnet program does not include one of the most important standards that any hospital should have to meet--ensuring safe nurse-to-patient ratios. It is clear that many hospitals are not providing adequate staffing now, as Alexandra Robbins, author of the new book The Nurses, recently confirmed in a powerful op-ed in the New York Times. And that is true even of Magnet hospitals. Many nurses have contacted us over the years to express concerns about their Magnet hospitals, and one common refrain is that nurse-to-patient ratios are too high. Reported ratios have included one nurse to six ventilated patients on a med-surg floor, seven telemetry patients, and ten patients in postpartum (5 mothers, 5 babies).
Research shows that short-staffing harms patients, yet it continues, driven by short-sighted cost concerns. In 2002, Linda Aiken and colleagues published a landmark study finding that when a nurse's workload is doubled from 4 patients to 8, patient mortality increases by 31%. In 2012 Aiken and colleagues repeated the study across nine European countries, with very similar results.
When staffing ratios are poor it leads to missed nursing care, as found by Bea Kalisch and colleagues. Physicians, patients, and nurses all know if physician-prescribed care goes undone. But because only nurses generally hold themselves accountable for doing nurse-prescribed care, it is the first work to be ditched when staffing is inadequate. Understaffed nurses cannot perform adequate surveillance and intervention, catch and prevent errors, or fully educate or advocate for patients.
The Magnet program has a great deal of influence, so setting reasonable minimum nurse-to-patient ratios as a standard for certification would be a game changer. For the program to maintain credibility, it must follow evidence-based practice and require adequate nurse-to-patient ratios.
Gaining Institutional Power to Ensure Strong Nursing Care
Magnet standards hold that "nurses throughout the organization should perceive their voices are heard, their input is valued, and their practice is supported." Those goals are important but difficult to achieve unless nurses occupy higher levels of the organizational structure. Increasing nurses' say in top-level decision-making has rightly been a major recent theme of the Nurses on Boards Coalition founded by the American Academy of Nurses, AARP and the Robert Wood Johnson Foundation.
Sadly, today nurses barely exist at top hospital leadership levels. Our 2012 research on the top 17 hospitals as identified by US News and World Report found that the average hospital in that group had zero nurses on its board of trustees. We found only three hospitals that listed any nurses--one each--among the dozens of members usually found on each board.
Hospitals are nursing institutions. Patients go to hospitals because they need 24/7 nursing care. Therefore, nurses should be directing and running hospitals. More than half of the board should be nurses, and most should be direct care nurses to keep nursing real. The CEO of the hospital should be a nurse. Discharged patients should be enrolled in health homes (not medical homes) where a nurse-led team provides closely coordinated care. In accord with nurses' greater power in these institutions, insurance companies should be billed separately for nursing care to reflect that nursing is an autonomous profession providing life-saving professional services. Nursing must be better represented at high levels, and Magnet should adopt a standard that requires hospitals seeking certification to demonstrate that representation on their boards and executive teams.
Ensuring Safe Health Care Facilities
The Magnet program calls for facilities to show that "professional practice is grounded in a culture of safety." That is a great start, but it's very general. Here are some specific standards the program might consider to promote safety.
Communicating the value of the Magnet program itself to the public
Patients at Magnet hospitals are 14% less likely to die, and the program pays for itself through decreased nurse turnover. Yet only two of the 13 hospitals on the US News 2015 list of top hospitals that have Magnet status tout that status on their websites where patients are likely to see it. Magnet should require that hospitals take steps to promote their certification to the public and, more generally, establish that at least one public relations professional be dedicated to promoting nursing. The only hospital where we know of such a position is Massachusetts General Hospital. Magnet should explain the value of nursing to the general public.
The Magnet program has already improved care and it holds great promise. Providing a framework for stronger nursing is better than the alternative, with no clear path to such transformation. But those who lead the pack ought to flex some muscle and challenge those who follow. After all, simply building a stronger nursing profession isn't the end goal. We should strengthen nursing because our patients deserve better care. Magnet can help us get there--especially if it puts away the pocket flashlight and starts brandishing a torch.
Sandy Summers and Harry Jacobs Summers are authors of Saving Lives: Why the Media's Portrayal of Nursing Puts Us All at Risk, published by Oxford University Press (2015), and leaders of The Truth About Nursing, www.truthaboutnursing.org.