Leadership In Nursing

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T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

Creating a Culture of Success Using the Magnet Recognition Program

A as a Framework to

Engage Nurses in an Australian Healthcare Facility

Sandra Moss, MHlthSc, RN

Marion Mitchell, PhD, RN

Veronica Casey, MNurs, RN

An organizational culture that reflects distrust, fear of reprisal, reluctance to challenge the status quo, acceptance of poor practice, denial, and lack of accountability creates significant issues in healthcare in relation to employee retention, burnout, organi- zational commitment, and patient safety. Changing culture is one of the most challenging endeavors an organization will encounter. We highlight that the Magnet Recognition ProgramA can be implemented as an organizational intervention to positively impact on nursing workplace culture in an international healthcare facility.

Organizational culture is defined as Ba specific col- lection of values and norms that are shared by people and groups in an organization and that control the way they interact with each other.[1(p122) In healthcare settings, workplace culture profoundly affects em-

ployee empowerment,2-4 interdisciplinary relation- ships, innovation, use of evidence-based practices, and alignment to the organization_s strategic direc- tion.5 Authors have recognized that the conse- quences of poor workforce culture can result in lower employee satisfaction, higher rates of nurse burnout,6 and increased employee turnover.

7 Ulti-

mately, it affects the quality and safety of patient care3,6,8; therefore, the causal relationship between workforce culture and patient outcomes has re- ceived, and should receive, increased attention by healthcare leaders.9-11 Hence, understanding and improving workplace culture are critical to nurse leaders, the workforce, and healthcare consumers.

Leaders intuitively know when employees are dissatisfied, yet it typically takes an employee sat- isfaction survey to quantify that an issue exists.12

Although it may be relatively easy to identify a poor workplace culture, changing it is recognized to be complex and one of the more challenging endeavors healthcare leaders will encounter.9,13,14 Factual evidence of a dissatisfied workforce creates a sense of urgency for change because it clearly threatens the performance of an organization.14,15 Such evidence provides justification for interventions focused on transforming organizational culture12 because it becomes clear that the Bcurrent way we do things[ needs to change.14

With strong leadership, the impetus exists to ex- amine and challenge the core values and basic assump- tions of the organization and explore opportunities for change.12,16 There is, however, a lack of research evi- dence that validates successful organizational level

116 JONA � Vol. 47, No. 2 � February 2017

Author Affiliations: Nursing Director, Princess Alexandra Hospital (Ms Moss); Associate Professor of Critical Care Nursing, School of Nursing and Midwifery, Griffith University, Menzies Health Institute Queensland, Griffith Health Institute, Griffith University, and Princess Alexandra Hospital (Dr Mitchell); and Executive Director of Nursing and Midwifery Services, Metro South Hospital and Health Service, Princess Alexandra Hospital (Ms Casey), Brisbane, Queensland, Australia.

The authors declare no conflicts of interest. Correspondence: Ms Moss, MHlthSc, RN, Princess Alexandra

Hospital, Ipswich Rd, Woolloongabba, Brisbane 4102, Australia ([email protected]).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal_s Web site (www.jonajournal.com).

DOI: 10.1097/NNA.0000000000000450

http://www.jonajournal.com

interventions that can provide leaders with clear direction to change workplace culture.12,17,18 This is supported by the systematic review by colleagues in the United Kingdom who examined the effectiveness of strategies to change organizational culture and iden- tified only 2 studies that addressed this topic. The authors concluded that the current evidence of effective organizational culture-changing strategies is sorely lacking, and they make the clear recommendations for high-quality research to be conducted.17 The authors of this current article aim to contribute to the evidence and share the positive impact on nursing culture that has resulted from implementing an organizational intervention in an Australian healthcare facility.

Understanding Employee Engagement

The Princess Alexandra Hospital is a 740-bed ter- tiary healthcare facility that offers services in all adult specialties with the exception of obstetrics. Between July 2014 and June 2015, healthcare was delivered to more than 100 000 inpatients, 18 000 operating theater cases, and 460 000 outpatients. There are approxi- mately 6000 employees, of which 2500 are nurses.

In 2000, regularly collected facility-wide data highlighted issues that required attention. There were unacceptable nursing turnover rates of 25% and record high external nursing agency use, resulting in bed closures to maintain patient safety.19 The Executive Director of Nursing Services (EDNS), who provides strategic, professional, and operational leadership for nursing staff, commissioned an exter- nal vendor to conduct an employee engagement (EE) survey to assist with uncovering issues affecting nurs- ing workplace culture. Using an independent vendor was a strategy aimed to gain employee confidence in the anonymity of feedback and obtain high response rates with a representative sample.20,21

Gaining an understanding of nursing workplace culture through periodic EE surveys is an important step to diagnose the current state and provides lead- ers with insight into strengths and challenges.20,22-24

There are many established EE consulting firms and EE tools available, such as the Gallup 12-item Worker Engagement Index,25,26 May Scale,27-29 or various versions of the Utrecht Work Engagement Scale.30-32

Concerns regarding the validity and reliability of survey items28,29,33 and lack of criteria available to compare existing tools are well documented.34,35 It is widely recognized that there is no singular EE measurement tool that is universally accepted.35-38

Measuring EE is therefore not an exact science but aims to predict employees_ attitudes,20 commit- ment to the facility,3,39-41 and assessment of employ- ment conditions.20 It is important that the instrument includes items that measure key employee

Bengagement drivers.[20,42 Furthermore, the instru- ment needs to be able to discriminate without floor and ceiling effects to have confidence that, as the level of EE improves, so do the survey results.43,44

The Instrument

The survey instrument included 130 quantitative and 17 qualitative items under 6 categories of EE, lead- ership, values and behavior, quality and innovation, safety, and consumer outcomes. Workforce culture is measured by 10 items under the EE category and is the focus of this article.

A 6-point Likert scale was used to measure EE drivers including trust in leadership, clear strategic direction, commitment to the healthcare facility, pride in the workplace, ability to contribute, and positivity about the facility_s future. All items are theoretically linked to EE.20,23,38,45 The EE items remained the same through each survey cycle, although 2 items related to trust in leadership were not collected in 2004 and 1 item was not collected in 2006. From item responses, the vendor tallied and calculated the percentage of respondents who they classified as engaged, neutral, or disengaged. Using the level of engagement as the indicator, the vendor determined employee workplace culture, which was reported to the site_s nurse leaders.

Procedure

The external survey was administered biannually to all nursing employees from 2000 to 2015, with the exception of 2008, which was delayed and con- ducted in 2009. Paper surveys were provided to each nurse manager in charge of a ward area for dis- tribution to nursing employees at the beginning of the survey period during 2000 to 2009. An online survey was used in 2013 to 2015, enabling employees to complete the tool through a Web-based portal on a computer on-site or at home. The survey was open for a 1-month period, providing employees sufficient time to complete the survey.20,21 Before the survey period, advertising in the form of flyers, email noti- fication, and briefings during facility meetings ad- vised employees of the survey_s purpose. Nurses were informed that participation was voluntary and responses were anonymous.

Impetus for Intervention

In 2000, the survey response rate was 63% (n = 794), and results identified a culture of Bblame[ with 54% (n = 429) of nursing employees reporting that they often thought about leaving the healthcare facility.46

A culture of blame reflects a workplace culture of distrust, fear of reprisal, reluctance to challenge the

JONA � Vol. 47, No. 2 � February 2017 117

status quo, acceptance of poor practice, denial, and lack of accountability.34,47,48 The survey results coupled with the site_s nursing staff turnover became the catalyst for examining an intervention aimed to improve nursing workplace culture and associated retention rates. Understanding the engagement drivers provided valuable information for the nurse leaders to determine a vision and path forward.20,42

Intervention

A leader_s vision is critical for cultural change and provides future direction linked to strategy, structure, and systems.2,14 The EDNS_ vision was to transform nursing culture by becoming a MagnetA-designated healthcare facility.19 The Magnet Recognition ProgramA

(MRP) originated from a study conducted in 1981 that determined organizational characteristics pro- fessionally and personally rewarding for nurses.49

More than 3 decades of evidence demonstrates that Magnet-designated healthcare facilities have posi- tive nursing workplace cultures and patient out- comes,4,8,50-53 providing a rationale to commence the Magnet journey.

In 2002, the site_s official journey toward Magnet designation began with an application to the American Nurses Credentialing Center. Typically viewed as a designation process that enables healthcare facilities to confirm the existence of the Magnet characteristics within the work environment, the nurse leaders aimed to use it as an organizational intervention to transform culture by empowering, inspiring, and motivating em- ployees at every level of the healthcare facility.50,53-56

Strategies aligned to the MRP were implemented using a top-down and bottom-up approach, provid- ing direction from leaders and empowering direct care nurses of all levels to drive the change.14,34,57

Ensuring employee participation in achieving the vision increased likelihood of the intervention_s suc- cess.14,34,57 Clear strategic direction, participatory governance structures, improved access and trans- parency of data, opportunity for professional devel- opment, and increased recognition and reward are examples of changes that have been successfully im- plemented over time and evident within Magnet healthcare facilities (Table 1).58-60

Outcomes and Discussion

The site successfully gained Magnet designation in 2004, becoming the 1st in the southern hemisphere. It achieved subsequent redesignations in 2009 and 2014. Importantly, the aim to reduce nursing turn- over was achieved. Since 2004, nursing turnover averaged less than 8% and was zero in 2015.

The EE survey continued to measure the inter- vention_s impact. Employee engagement survey

response rates over time (2002-2015) ranged from 52% (n = 920) to 78% (n = 1177) (see Table, Sup- plemental Digital Content 1, http://links.lww.com/ JONA/A511). After the implementation of Magnet principles in 2002, nursing engagement culture continuously improved, with the exception of 2013. In 2013, the survey was conducted during a significant period of federal and state health reform that resulted in significant employee uncertainty. Although the nursing engagement culture declined in 2013, it remained in a culture of Bambition.[

The 2015 survey continued an upward trend with the level of EE surpassing all previous results obtained during the 14-year period. Engagement culture items improved from 23% to 42%.61 Results progressed from a culture of blame in 2002 to suc- cess in 2015, with 67% (n = 929) of nurses engaged. Importantly, the percentage of respondents classified as engaged increased (36%, n = 652), whereas those classified as Bneutral[ decreased (26%, n = 97) (Figure 1). When employees move from an engage- ment category of neutral to engaged, cultural change becomes evident, with increased staff commitment to the organizational leaders_ direction.63

Trust in management was the greatest improve- ment observed, increasing by 42% (n = 696).61 Nurses identified that there was a clear direction for the future (68%, n = 938), pride in the healthcare facility (77%, n = 1060), and commitment to continuously improve how things are done (76%, n = 1047). Com- pared against the vendor_s government public healthcare services benchmarking peer group facilities (N = 123), the site rated in the top 10%.62

Ongoing leadership and commitment are re- quired to sustain and strengthen culture.14,20 The 2015 EE survey results are currently being analyzed to identify priority items to be actioned and included in the nursing workforce plan. An evalu- ation of the professional practice model is pro- ceeding to ensure it remains contemporary and relevant. Furthermore, strategies to increase direct care nurse participation in shared governance are underway.

The MRP was introduced as an organizational intervention to improve nursing culture and nurse retention. Nurse leaders created shared ownership, commitment, and heightened accountability to achieve the vision.64 Shared ownership of the inter- vention supported nurse engagement and promoted trust and willingness to commit to change.65 Highly engaged employees care about the future of the facility; actively participate in decision making; and have autonomy, accountability, flexibility, and com- mitment to the vision.45,66 This provides evidence that this healthcare facility was able to use the MRP

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as a continuous cultural transformation framework to align practice with clearly defined goals. This is endorsed by others.50,60,67

Limitations

The EE survey response rate varied between 52% (n = 920) and 78% (n = 1177), and results may

therefore not be representative of those who did not complete the surveys. Furthermore, there are no reliability and validity data for the survey, and thus, we cannot be confident that we are measuring what we think we are measuring or that the items have internal consistency. It is evident that there is a need for further studies to be undertaken to provide

Table 1. Strategies and Actions Implemented to Align With the Magnet Recognition Program

Strategy Implementation

Strategic direction & Nursing Strategic Plan outlining key performance measures aligned to the Magnet Recognition Program outcome criteria.

& Nursing Operational Plan outlining actions to achieve key performance measures in the Nursing Strategic Plan.

& Nursing Workforce Plan outlining actions focused on nursing engagement, retention, and recruitment.

Shared governance structures & Nursing strategic and quality committee consisting of nurse leaders responsible for professional nursing practice, nursing standards, clinical practice, and quality of care delivery.

& 14 workgroups consisting of 120 direct care nursing and interdisciplinary staff. Each committee responsible for progressing quality initiatives aligned to the Nursing Strategic Plan.

& Nursing committee consisting of 80 direct care nurses responsible for auditing nursing practice and implementing strategies to advance professional practice and improve patient care.

Participatory flat decision making & Professional Practice Model developed by direct care nurses that articulated nursing values and core components to deliver person-centered care.

& Annual nursing retreat for direct care nursing staff focused on identifying improvement opportunities related to practice environment, clinical practice, and patient outcomes.

& Magnet evaluation conducted after the achievement of Magnet Designation to determine opportunities to improve structures and processes that support the Magnet journey.

& 360 Magnet Champions consisting of direct care nurses from all units throughout the healthcare facility.

Access and transparency of data & Monthly unit-level nursing scorecard report provided to each nurse manager for distribution to direct care nurses. Nursing scorecard report included data on patient outcomes, staffing resources, unit activity, and budget.

& Web-based data repository for nursing projects, quality initiatives, and research, accessible to all nursing staff.

& Increased monitoring, benchmarking, and reporting of patient outcomes including quarterly inpatient and ambulatory patient satisfaction; quarterly pressure injury prevalence; and monthly incidents for patient falls, healthcare-associated infections, medication administration incidents, catheter-associated urinary tract infection, and ventilator-associated pneumonia.

Professional development & Monthly Magnet Champion forums that showcased nurse-led innovation, research, and outcomes.

& Magnet Champion half-day workshops designed for Magnet Champions to learn about the Magnet Recognition Program and understand their roles and responsibilities.

& 3-day workshop for all nurses to learn skills in management, leadership, and change management.

& 360-degree feedback process established to enable nurses to receive feedback about professional performance from colleagues.

& Scholarship funding for direct care nurses to attend state, national, and international conferences.

Recognition and reward & Annual Recognition and Reward Plan outlining methods to formally showcase nursing staff who have significantly contributed to the nursing profession, patient outcomes, and community.

& Nursing annual review. & Monthly nursing newsletter. & International, national, and state nursing forums held on-site to showcase and share

innovation. & Staff lifestyle program consisting of health promotion initiatives including on-site group

or personal fitness classes, nutrition program, weight management program, meditation, and massage.

& Internal marketing campaign to promote image of nursing and recognize nursing contributions to healthcare facility, patient outcomes, and the community.

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these data. However, from a practical viewpoint from within the organization, we have confidence that the nurses_ results clearly reflected reality.

Conclusions

Employee engagement is critical in healthcare, yet it remains an ongoing challenge for many. With vision, leadership, and empowerment of staff, nursing workforce culture can improve. The MRP provided a framework to guide a clear path forward for nurse leaders in a non-US healthcare facility. This high-

lights opportunities for nurse leaders globally who are examining ways to transform culture of the nursing workforce and meet future healthcare challenges.

Acknowledgments

The authors thank Joy Vickerstaff, Former Executive Director of Nursing Services, Princess Alexandra Hospital; Richard Ashby, Chief Executive Officer, Metro South; Nursing Executive Committee, Prin- cess Alexandra Hospital; Magnet Champions; and Nursing Services, Princess Alexandra Hospital.

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