Introduction
The Magnet Model (MM) is a tool that was developed to “provide a framework for nursing practice and research” and offer some guidance to the organizations that intend to achieve Magnet recognition (American Nurses Credentialing Center [ANCC], n.d.d). Magnet recognition refers to a program that awards the Magnet status to the healthcare facilities that correspond to a set of requirements. The requirements are mostly concerned with the specifics of the eligible organization, the qualification of employed nurses, the standards used, regulatory compliance, and some other features (American Nurses Credentialing Center, n.d.a). Overall, Magnet Recognition is used to as a proof of nursing excellence in an organization (Gonzalez, Wolf, Dudjak, & Jordan, 2015; Friese, Xia, Ghaferi, Birkmeyer, & Banerjee, 2015). It is believed to indicate the highest quality of nursing (Lovering, 2013). In turn, MM is the pathway that is used to advance nursing care in specific settings to achieve said recognition. Thus, MM is one of the frameworks that are currently employed to improve the quality of nursing.
The present paper will review MM to characterize it from the perspective of its utility for the advancement of care delivery. In particular, the topic of key contexts and the most important features will be considered. Apart from that, the strengths and weaknesses of MM will be reviewed. Finally, the paper will report the principal benefits and outcomes that the model offers and conclude its use in nursing. Based on the robust literature that has been devoted to MM in the past few years, this model is capable of improving the quality of care in a given organization due to its strengths and the positive outcomes, with which it is associated.
Contexts for the Adoption of MM
MM was developed by ANCC (n.d.d), and, at the beginning of its development, it was predominantly adopted by American healthcare organizations that intended to improve the quality of nursing in them (Lovering, 2013). As time passed, MM became internationally used (ANCC, n.d.d). Regarding the types of institutions that can employ MM, it is meant for healthcare organizations and their elements, as well as the systems of healthcare organizations (American Nurses Credentialing Center, n.d.c). Thus, it can be suggested that healthcare is the primary context in which MM is adopted.
While there is not much information about this fact, MM is used in Saudi Arabia, which is the country of interest of the investigator. The present review managed to find one relatively recent article that could provide some general information about the adoption of MM by the King Faisal Specialist Hospital and Research Centre in Jeddah. In particular, Lovering (2013) reports that the Centre’s journey started in 2005, and in 2013, the hospital was recognized as “the first Magnet hospital in Saudi Arabia” (p. 619). Lovering (2013) ends her discussion with a report on the attitudes of the nurses from other Saudi facilities, which demonstrate that MM is likely to be adopted in other Saudi hospitals due to the strong approval of the initiative.
The process of adopting MM in Saudi Arabia was complicated since the King Faisal Specialist Hospital and Research Centre discovered that some of the American approaches might be inapplicable to Saudi Arabia. Apart from that, the nursing workforce in Saudi Arabia differs from that in the US. As a result, the project involved the adaptation of MM to its Saudi context, as well as the formation of a specific, culturally-appropriate Saudi nursing model (Lovering, 2013, p. 620). However, Lovering (2013) points out that MM became a template for nursing excellence in the country and suggests that the experience of King Faisal Specialist Hospital and Research Centre indicates that MM can be adapted to varied healthcare contexts and systems.
Key Features of MM
MM is a five-element framework that strives to encompass all the major factors that can help with the advancement of nursing practice. ANCC (n.d.d) reports that MM is based on the previously developed Framework of the Forces of Magnetism, which includes 14 Forces. MM reassesses and rearranges the 14 elements into five Components, eliminating the redundant forces and highlighting the particularly important ones.
The first element of MM is transformational leadership, which, as suggested by ANCC (n.d.d) is particularly well-suited for the modern turbulent environment that requires changes and flexibility from a healthcare organization. MM also includes guidance on high-quality leadership, emphasizing its key features (aspects like visual communication, feedback solicitation, employee empowerment, and so on). The first MM component incorporates the forces of high-quality leadership and management style, which are admittedly crucial for advancing care delivery.
Indeed, leadership is evidenced to be very important for nursing to the point that it might be associated with improved patient outcomes (Wong, 2015). Apart from that, transformational leadership is effective in nursing environments, in particular, concerning the safety outcomes for nurses and patients (Boamah, Laschinger, Wong, & Clarke, 2017). Therefore, it can be suggested that MM’s assessment of transformational leadership is evidence-based, and MM’s first component is valid.
The second element is the direct result of the first one: structural empowerment is supposed to be a primary outcome of transformational leadership (ANCC, n.d.d). This component incorporates the organizational structure, policies, and programs, as well as the relationships with the community and other organizations, that are supposed to constitute an environment that promotes empowerment. The latter is expected by ANCC (n.d.d) to result in professional development, nursing excellence, and innovation. These ideas are also supported by research. In particular, employee empowerment is one of the features of transformational leadership, and some evidence to it resulting in innovation (Sok & O’Cass, 2015), as well as nursing excellence (Sok & O’Cass, 2015; Wilson et al., 2015), can be found in modern literature.
Following the first two elements, the third one is exemplary professional practice (ANCC, n.d.d), which can indeed result from high-quality leadership and nurse empowerment (Wilson et al., 2015). This component centers around the understanding of the role of a nurse (or, rather, the multiple roles that nurses can play), but it also incorporates aspects like professional care models, interdisciplinary communication, and other aspects of practice. Given the above-presented evidence, it can be suggested that this component is also valid.
The fourth element follows from the previous ones, and it consists of “new knowledge, innovation, and improvements” (ANCC, n.d.d, par. 9). Indeed, ANCC (n.d.d) expects the first three components to create an environment, in which innovation would be promoted, new knowledge would be generated, and improvements would be achieved. This assumption is supported by literature: leadership and employee empowerment are shown to be associated with quality improvements and innovation (Boamah et al., 2017; Sok & O’Cass, 2015). This component also loops back to the first one: the new knowledge and innovations are required for the transformations that should be achieved with the help of nursing leadership for the improved chances of flourishing in the modern environment. The fourth MM component is also directly connected to quality improvement, which is a major Force of Magnetism.
Finally, the fifth element of MM consists of empirical quality results. It should be pointed out that MM does not offer its benchmarks (ANCC, n.d.d), and individual hospitals have to come up with their goals. For example, Lovering (2013) reports that the King Faisal Specialist Hospital and Research Centre employed international benchmarks, aiming to surpass them. On the other hand, Harris, and Cohn (2014) discuss the experience of the use of national benchmarks complemented with some specifically-developed goals. Thus, the lack of MM benchmarks can be rectified with the help of other sources of comparison. However, ANCC (n.d.d) offers some guidance concerning the last MM component. In particular, it recommends focusing on quantitative data and categorizing outcomes. It specifically suggests the following categories: “clinical outcomes related to nursing; workforce outcomes; patient and consumer outcomes; and organizational outcomes” (ANCC, n.d.d, par. 12). Thus, the final element of MM requires monitoring the organization’s achievements, and even though said achievements do not have to be connected to MM, this step can be used, among other things, to determine the outcomes of adopting MM.
In summary, MM is a model that rearranges the 14 Forces of Magnetism into five multicomponent elements that describe the activities, structures, policies, and other phenomena that should be able to advance nursing practice. Most of the elements are the logical outcomes of the previous ones with the final one describing the aim of MM, which consists of improved quality outcomes. In general, all the elements are interconnected and support each other, and they are geared towards the same goal of nursing practice advancement.
Strengths, Weaknesses, and Issues of MM
MM has multiple strengths. As shown above, it is a rather comprehensive model that acknowledges various components that have been proven to be crucial for nursing. Indeed, MM is based on a previously established model of nursing, which was enhanced and improved in the process of MM development (ANCC, n.d.d). MM also discusses the components in notable detail, highlighting the interrelationships between them. Said interrelationships are also supported by evidence (Boamah et al., 2017; Sok & O’Cass, 2015). Moreover, the presence of interconnections between the components demonstrates that MM is logically organized and well-aligned; its elements support the development of each other (Gonzalez et al., 2015), which makes their application a comprehensive endeavor.
Furthermore, some of the mentioned elements can also be viewed as change facilitators, which is helpful since MM adoption presupposes some change. Given the fact that change is a notably complex process (Anders & Cassidy, 2014; Hanrahan et al., 2015; Harris & Cohn, 2014), the presence of such facilitators is a positive feature. For instance, MM includes a component that is concerned with the evaluation of the quality of care, as well as other aspects of nursing (ANCC, n.d.d), which is a major part of any change model (Anders & Cassidy, 2014). Similarly, the first component, leadership, is crucial for change (Anders & Cassidy, 2014), and transformative leadership is supportive of changes (ANCC, n.d.d; Harris & Cohn, 2014; Voet, 2014). Therefore, the establishment of transformative leadership should be helpful for the adoption of MM. Employee empowerment can also be conducive to change, especially since it facilitates engagement and promotes innovative behaviors (ANCC, n.d.d; Sok & O’Cass, 2015). Thus, it can be suggested that the process of MM adoption should be facilitated because its components are supportive of change.
Apart from that, some of MM’s strengths can be noted in connection to its predecessor, the Forces of Magnetism. ANCC (n.d.d) believes that MM is simpler than the Forces since it is shorter and cuts down the redundant Forces, which appears to be a valid argument. Apart from that, MM places a special emphasis on the outcomes and their measurement and provides the framework for streamlined documentation, which the Forces lacked. These features illustrate the fact that MM is an improved, refined version of the Forces and that it is noticeably focused on practice and practical issues experienced by nurses when striving for excellence.
It should also be noted that MM is continuously developed and reviewed (ANCC, n.d.d; Graystone, 2017), which is the most significant feature and a major strength that implies the potential for ongoing improvement. For example, the most recent manual on Magnet covers better-clarified leadership roles, includes more standards for outpatient settings, and demonstrates greater attention to the transition to practice, along with some other changes (Graystone, 2017). MM is also relatively flexible and adaptable to various contexts (ANCC, n.d.d; Lovering, 2013), which is an important strength. Finally, MM offers some advice regarding the process of evaluation, which is also a positive feature of the model, but it is connected to a major weakness.
Indeed, can be suggested that MM prioritizes structure and processes at the expense of outcomes (ANCC, n.d.d). In particular, the fact that MM does not have direct expected outcomes, goals, and benchmarks can be viewed as an issue or weakness although organizations can obtain benchmarks elsewhere (ANCC, n.d.d). Indeed, reporting the results is important for multiple reasons, including the need to assess the outcomes, plan future action, and demonstrate achievements to motivate nurses and support their commitment to excellence (Anders & Cassidy, 2014; Auditore, Karsten, Rolston, & McMillan-Coddington, 2017; Hanrahan et al., 2015; Harris & Cohn, 2014). Consequently, the lack of a specific mechanism for assessing and reporting the outcomes seems to be a major issue.
However, the lack of benchmarks can also be justified to an extent. Benchmarks are contextual; for instance, the outcomes that can be achieved by American hospitals might not apply to Saudi Arabia and vice versa (Lovering, 2013). As a result, the absence of benchmarks may be viewed as another sign of the model’s flexibility. Furthermore, ANCC (n.d.d) highlights the fact that the lack of Magnet benchmarking is connected to the lack of data that would allow comparing Magnet performance and practices. Therefore, the issue is the result of MM’s intent to offer only evidence-based guidelines. Moreover, the problem can be rectified.
Indeed, it can be inferred that the development of Magnet benchmarks is an endeavor that might improve MM with the help of the entire Magnet community, which can contribute data for MM use in different contexts (countries, regions, and so on). As shown by some studies, the Magnet community has already been engaged in common research endeavors; for example, Auditore et al. (2017) describe a project which involved assembling Magnet champions to develop a report on the state of nursing. In general, ANCC (n.d.d) admits that MM needs some form of benchmarks that would provide additional guidance for the hospitals that are willing to participate while also making Magnet recognition more specific and indicative of explicitly recorded positive outcomes. For the time being, however, this feature is lacking in MM.
It may also be mentioned that MM might be associated with increased spending (Rettiganti et al., 2018). The present investigation did not discover many comments on this topic, but this problem may be balanced out by the benefits of MM, which are going to be described in the next section. In summary, MM is a rather strong model: it covers the important elements of nursing, highlighting their interrelationships, and specifying how they can be employed to advance nursing practice. Apart from that, MM is convenient and usable, even simple. Its primary flaw, which is acknowledged by its developer organization, can be viewed as another strength since the absence of specified, rigid benchmarks are beneficial from the perspective of flexibility. Moreover, this issue can be seen as a potential for improvement, and it can be employed to unite the Magnet community to develop working nursing benchmarks for general use. Given the fact that one of the strengths of MM is its ability to evolve, it can be assumed that it is going to turn the mentioned issue into a potential improvement. Thus, the strengths of MM do not just outweigh its weaknesses; they can transform the weaknesses into opportunities.
Benefits and Outcomes of MM Adoption
MM is a model that is developed specifically to advance the quality of nursing practice, which is why its outcomes for nursing and hospitals are overwhelmingly beneficial (Stimpfel, Rosen, & McHugh, 2014). The American Nurses Credentialing Center [ANCC] (n.d.b) lists the benefits that it expects to observe in the organizations that adopt MM. They include positive outcomes for patients (in particular, improved quality of care and patient safety) and management (especially the attraction of talent and improved retention of nurses), as well as nurses themselves. MM also fosters collaboration and teamwork, and it can be beneficial for the facility’s reputation since Magnet is an acknowledged recognition system (ANCC, n.d.b). It should be pointed out that the benefits cited by ANCC (n.d.b) are supported by testimonials and case studies, even though the latter is mostly relatively outdated (published before 2010). The present investigation demonstrates that there are also more recent articles that are published in peer-reviewed journals and also indicate the mentioned outcomes.
First of all, clinical outcomes and quality of care are shown to improve in the organizations that practice MM. For example, decreased mortality rates are reported in Magnet facilities (Kutney-Lee et al., 2015). For instance, as shown by a longitudinal (13 years) study, death likelihood is 7.7% lower for the surgical patients in the facilities that are recognized by Magnet, and postoperative complications in such organizations are 8.6% less likely to result in death (Friese et al., 2015). Similarly, a reduction in falls can be witnessed (Stimpfel et al., 2014). The two quality indicators can serve as an illustration of MM-associated results.
In general, the improvements concerning nationally benchmarked clinical outcomes are reported by Magnet-recognised facilities, including, for example, the National Database of Nursing Quality Indicators and the National Patient Safety Goals (Harris & Cohn, 2014). In the case study by Harris and Cohn (2014) the reviewed institution also received some awards for the quality of care after the implementation of MM. Moreover, MM institutions tend to report increased patient satisfaction (Harris & Cohn, 2014; McCaughey, McGhan, Rathert, Williams, & Hearld, 2018). In general, it is relatively well-established that MM is associated with a better quality of care and safety of patients, which suggests that MM is beneficial for patients.
The staff of Magnet-approved facilities can also benefit from MM. Empowerment in MM organizations tends to result in staff autonomy and enhanced productivity (Gonzalez et al., 2015). Moreover, nurses in Magnet institutions report increased satisfaction and lower burnout rates (Gonzalez et al., 2015; Harris & Cohn, 2014; Kutney-Lee et al., 2015), which implies that MM is beneficial for nurses. Consequently, reduced turnover rates may be found (Gonzalez et al., 2015), which is a positive outcome from the perspective of the facilities’ managers. Moreover, there is some evidence indicating staff injuries reduction, which implies lower expenses and can be viewed as a beneficial outcome from the perspectives of both nurses and management (ANCC, n.d.b; Harris & Cohn, 2014). It is also noteworthy that physicians in MM-recognised facilities can report greater satisfaction with nurse efficiency (Harris & Cohn, 2014), and in general, there is some evidence to MM fostering teamwork and interdisciplinary collaboration (Gonzalez et al., 2015). In summary, the staff and Magnet-recognised organizations as a whole also experience positive outcomes that are associated with MM implementation.
Furthermore, ANCC (n.d.b) argues that MM advances the nursing profession, predominantly by affecting nursing standards. The improvements in nursing efficiency and care quality result in advanced standards that Magnet hospitals champion. Apart from that, a study by Wilson et al. (2015) discovers that the nurses of MM facilities reported greater willingness (and desire) to employ evidence-based practice when compared to the staff of non-magnet facilities or the facilities that work with the framework termed “Pathway for Excellence.” Moreover, the study shows that the barriers to evidence-based practice reported by Magnet nurses were less numerous than those reported by non-Magnet nurses. Therefore, it can be suggested that there is some evidence to MM being beneficial for the integration of evidence-based practice, which is also advantageous for the advancement of nursing practice.
It should be pointed out that a recent study reviewed mortality rates of the patients in pediatric critical care, specifically, in freestanding children’s hospitals (Rettiganti et al., 2018). This article found no statistically significant mortality decreases associated with the Magnet status. The study has its limitations as a retrospective one, and it describes only a very specific setting. It also indicates that the Magnet status is associated with greater charges, which is why the authors questioned the benefit of the use of MM in the stated settings. The study was criticized for its relatively small sample (Aiken, Sloane, Lake, Agosto, & Roberts, 2018), but the authors defended their methodology in a response to the critics (Rettiganti & Gupta, 2018). In general, the study appears robust and mentions all its limitations, highlighting the fact that the results cannot be applied outside of the studied settings.
This study offers the findings that are at odds with multiple other high-quality peer-reviewed investigations that demonstrated MM-related improvements (Aiken et al., 2018). Despite being contrary to the well-established picture, these results need to be taken into account when considering the topic. Possibly, additional research in the specified settings could provide more data for more conclusive statements, but for the time being, it should be taken into account that there is some evidence that suggests that the mortality rates reduction might not be present in every institution that adopts MM. The investigation of the reasons for this issue could be exceptionally helpful.
Also, as pointed out by Rettiganti and Gupta (2018), the fact that Magnet institutions show improved mortality outcomes is mostly supported by observational studies, which cannot prove the causational relationship between Magnet status and the listed results. Still, the mentioned associations tend to be repeated from study to study (Aiken et al., 2018). Overall, MM is a relatively well-researched model with an active community that produces new data for investigation. Future research should help to settle the found discrepancy in the mortality outcomes.
In summary, the ANCC (n.d.d) approach to outcomes classification can be used to report that all the required categories have been evidenced to be improved after the introduction of MM. In particular, clinical, nurse, patient, and organizational outcomes were witnessed (Gonzalez et al., 2015; Harris & Cohn, 2014; Kutney-Lee et al., 2015). It is also noteworthy that the outcomes which ANCC (n.d.d) reports as anticipated are supported by recent research. While some discrepancies in the literature can be found, the majority of studies, which are high-quality and peer-reviewed, prove the idea that MM has multiple benefits for the healthcare organizations that choose to adopt it. The only potential negative outcome is increased charges, and it appears to be overwhelmed by the positive ones.
Conclusion
ANCC (n.d.d) has developed a robust model for the advancement of nursing care delivery, and, having reviewed its key contexts, features, strengths, issues, and outcomes, the present paper can offer the following conclusions. MM can be implemented in a wide variety of contexts; it was developed in the US, but nowadays, it is used internationally and has been successfully adapted to completely different cultural settings. MM is a model for nursing excellence, which further specifies its content. It incorporates five key elements that are meant for the improvement of nursing care delivery, and they are evidenced to be capable of contributing to this outcome. In particular, MM includes leadership, empowerment, exemplary practice, innovation, and improvement, and quality results that are empirically supported (ANCC, n.d.d). Guiding these components, MM exists to help healthcare organizations in achieving Magnet-recognised excellence.
MM has multiple strengths, including its content, flexibility, ability to evolve, logical structure, the presence of change-facilitating components, and some other beneficial features. The primary issue of MM is the lack of benchmarks, but this problem is acknowledged by ANCC (n.d.d), which implies that it should be rectified in the future. Also, some evidence indicates that MM may be associated with higher charges, but the benefits that have been attributed to it seem to outweigh this issue. In particular, MM is beneficial for patients (through improved quality of care and safety), nurses (through reduced burnout and greater satisfaction), and organizations (through enhanced nurse retention). There is some controversy related to a recent study, which found no impact of MM on mortality rates in specific settings, but additional investigation is required to establish the causes of this observation. In general, the benefits of the model are proven by multiple high-quality studies. Said benefits, along with its strengths, adaptability to various contexts, and potential for improvement, suggest that MM is a feasible and helpful model that can indeed advance nursing care delivery in the workplace.
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