Patient care quality has become a priority for health care providers, following public demand and concerns about medical efficiency, malpractice litigation, rising competition and changes in regulation. The range of possible actions to improve patient care is long, and among the most efficient is to empower nurses and turn hospitals into great places to work. For the past few decades, a new breed of inspiring hospitals has been rethinking their organisation and management approach in light of patient-centric guiding principles. What has come of it? So-called ‘Magnet’ hospitals that increase the quality of patient experience while demonstrating an unrivalled capacity to attract and retain qualified staff.
Inspiring hospitals, on all continents
Magnet hospitals address two challenges – the difficulty to hire nursing staff and the necessity to improve patient care – with a single approach. In the 1980s, US hospitals were plagued by high nurse turnover, a situation potentially leading to dysfunction and negative impact on patient care. The American Nurses Association identified 41 hospitals that, unlike their peers, had remained fully staffed. Conducting further research, the association found that supporting nursing practices could generate excellent patient care environments while attracting and retaining caregivers. These successful establishments became known as Magnet hospitals.
Today, Magnet hospitals designate facilities where nursing care follows the standards established by the American Nurses Credentialing Center, a division of the American Nurses Association, and that are accredited through the Magnet Recognition Program®. Launched in 2010, this label evaluates the quality of nursing services across five levers: transformational leadership, structural empowerment, exemplary professional practice, innovation and quality improvement, and empirical outcomes.
Despite being resource-intensive – it may require years to complete and millions of dollars of investment – the accreditation process has proved to be very successful. Hundreds of US hospitals have been recognised as Magnet® facilities, from the Cleveland clinics to Brigham and Women’s Hospital in Boston, and the programme has been adopted by establishments in countries such as Australia, Canada, Lebanon, and Singapore. The Magnet model is also inspiring hospitals across Europe that build on the American Nurses Association’s findings to develop their own patient-centric approaches.
Nurse empowerment, patient focus
A combination of healthcare personnel empowerment and patient focus constitutes the cornerstone of Magnet hospitals. Professional empowerment of the nursing staff takes place through training, up-skilling and the co-construction of projects. By seeking the participation of medical and paramedical employees in identifying issues and finding solutions, their expertise is valued, and their leadership acknowledged. Successful collaboration ensues with doctors, executives and support function teams. In turn, positive relationships foster listening, team cohesion and social dialogue, and create fruitful environments to implement change within hospitals, thus creating a virtuous circle is in place.
The other key success factor in Magnet hospitals is the patient focus. Since improving the quality of care is the ultimate objective of the facilities adopting a Magnet approach, most of of their initiatives are designed to serve the well-being and health of the patient. For instance, the centre hospitalier universitaire (CHU) of Montreal has adopted a patient-as-partner approach and created a direction of patient partnership, where patients are part of the members. Also in Canada, the CHU Sainte-Justine – the country’s largest mother and child centre and one of the four most important paediatric centres across North America – organises frequent open kaizen events with patients, family and professionals.
Decades of research have validated the Magnet hospital approach. First, Magnet hospitals obtain better occupational health and human resources indicators: fewer accidents at work, reduced risk of employee burn-out, less medical and paramedical absenteeism, decreased staff turnover and greater employer attractiveness. These achievements result from a better quality of life at work, as demonstrated through higher job satisfaction levels among staff. Nurses feel more involved at work, appreciate a better work-life balance and consequently are less likely to consider leaving the institution. In Australia, for example, the Princess Alexandra Hospital of Brisbane has reduced nursing staff turnover from 25% in 1999 to just over 10% in two years.
Another important finding is that caregivers rank higher the quality of care in Magnet hospitals, as well as safety conditions, productivity and efficiency. This assessment is backed by significantly improved indicators of quality of care and patient experience: lowered mortality rates for identical conditions and similar risk levels; fewer care-related errors and accidents; higher patient satisfaction; fewer complaints and claims to the institutions.
Similar conclusions were reached in the UK, where a pilot initiative – the first experimentation of the applicability of Magnet standards outside the US – showed advantageous cost-benefits over a sample of 30 National Health Service Trusts. Improvements ranged from reduced pressure ulcers and patient falls to lower turnover, fewer nurse vacancies, nursing work incidents and nurse burn-out. “Magnet status isn’t about a badge, it’s about a journey to create workplace conditions that ensure nurses and midwives can lead and deliver the very best care for patients, their families and carers,” comments Nottingham University Hospitals.
The key to success: more inclusive work practices
Participative management and ongoing training account for the biggest difference between Magnet and non-Magnet hospitals. “The staff was intensively involved at all levels during our application process and real participation in this experience profoundly affected their commitment to the profession and to the organisation,” reports Catherine Lyons, University of Rochester-Strong Memorial Hospital, US. “Magnet® hospitals impact patient outcomes by investing in the ongoing nursing education and career development needed to provide safe, high quality patient care,” agrees Janice Nuuhiwa, Children's Memorial Hospital, Chicago, US.
As part of an Attraction, Retention, Involvement of nurses and Quality of care (ARIQ) project, Clinic Pasteur in Toulouse, France, based its participative approach on a steering committee comprised of a nurse and a nursing assistant from each service (medicine/surgery/obstetrics wards, as well as home-based hospitalisation) and health executives. Thanks to their recommendations, Clinic Pasteur has ensured the development of research activities and facilitated the up-skilling of nurses. This became a continuous process through the annual evaluation of professional practices on multiple criteria – autonomy at work, value of work, professional relations, professional fulfilment. The results are shared with the entire medical-healthcare community to allow anyone to act on the key learnings.
Employer branding has become an integral part of the improvement strategies deployed by an increasing number of homes and institutions for health and social care. A good example is the hospital of Valenciennes, France, permeated by a Magnet-hospital culture and with closely correlated nurse and patient satisfaction. The institution worked hard on improving staff onboarding, identifying skills, fostering professional mobility and designing a career path for nursing executives while aiming at reducing psychosocial risks further. Project coordination increased as well as transparency. Being an attractive employer and retaining trained medical staff is no longer just nice to have. Hospitals are now aware that taking care of staff first allows to better deliver on their core mission – taking care of patients.
Embarking on a Magnet hospital journey
More projects inspired by Magnet hospitals are being implemented across the world at the hospital and country level. In Australia, for example, Magnet hospitals have inspired a nursing and midwifery leadership initiative, the Essentials of Care, that has gained significant traction in the country. A team in Belgium has adapted the Magnet® methodology into a European framework, ARIQ. The initiative aims to help participating healthcare institutions launch a process of self-evaluation and continuous improvement around their mission statement, staff support and community outreach development. In France, the national health authority (HAS) has found very conclusive the results of benchmarks comparing 850 North American institutions – some Magnet, others not. In the UK, obtaining the Magnet® accreditation became a recommendation in the 2015 Shape of Caring review and several UK hospitals embraced it, including Nottingham University Hospitals, Oxford Health and NHS Grampian.
Whatever the label, these initiatives follow common principles such as co-construction of projects, interprofessional approaches, end of silos, a culture of caring, quality of life at work, focus on the patient experience, managerial innovation, performance and quality.
Such projects typically start with workshops including staff executives, medical executives and directors to raise awareness on managerial and organisational innovations, share benchmarks and explore ideas for improvement. The outcomes are complemented by an external assessment of areas most in need of transformation, as well as recommendations on project scope and design. This is followed by a new series of inclusive collaborative workshops to mobilise all stakeholders (especially caregivers, nurses) and develop actionable solutions, which pilot teams then put to the test in real-life conditions. Teams are trained and executives coached on Magnet hospital project management. Finally, monitoring progress requires the implementation of tracking indicators and using them with a mindset of continuous improvement.
Beyond the common credo that staff and patient experience are closely intertwined, initiatives inspired by Magnet hospitals need to consider the context and the specific needs, missions or identities in the project design and deployment. A tailor-made approach is necessary at all stages.
Magnet hospitals response to the Covid-19 pandemic
A recent publication* about Covid-19 patients care has shown the effectiveness and relevance of the Magnet hospital model:
- Management ideas of Magnet hospitals: establishing a sustainable support echelon
- Empowerment of head nurses: staff qualifications standards, unified and dynamic personnel deployment, and coordinated training arrangements
By transforming organisation and management into Magnet Hospital, hospitals effectively improved the “coping capacity of the nursing team and played a positive role in the prevention and treatment of Covid-19” said the publication. In light of the health crisis, it is still too early to learn the necessary lessons and other publications are expected on the subject.
* Y. Liu, H. Wang, J. Chen, X. Zhang, X. Yue, J. Ke, et al. Emergency management of nursing human resources and supplies to respond to coronavirus disease 2019 epidemic, Int J Nurs Sci, 7 (2) (2020 Apr 4), pp. 135-138, 10 April 2020