Massachusetts Nurse :: October 2004

Journey to Magnet status: And inside look at the experience of one MNA bargaining unit

Today the quest for Magnet status has become a major topic of discussion in many hospitals. For those of us who have been frustrated and saddened by the continued degradation of the profession as nurses have done their best to provide quality care with insufficient resources and with minimal or no support, the promises of the Magnet philosophy seem nothing short of manna from heaven.

Reading the literature about the ANA's Magnet program, the process promises a restoration of respect for the science and art of the nursing profession, with a built-in mechanism to ensure an equal seat at the table for the beleaguered nursing administrator; the emergence of the nurse clinician as a professional whose input and expertise is not only recognized but sought after;as well as the restoration of quality care and staff satisfaction as primary goals for the institution.

But how does the reality of the Magnet process measure up to its advertised promise? In this article I will relate my experience as well as the experiences of nurses at Northeast Hospital Corp. (which comprises Beverly Hospital, Addison Gilbert Hospital and the Hunt Center) over the last two years of our journey through the Magnet process.

I offer the following not as an indictment of hospitals pursuing Magnet status or the Magnet process itself. It would neither be helpful nor fair to do so. Instead, I offer the following reflections and insights in the hope that it will be helpful to those of you who are about to embark on your own journey through the Magnet process. My goal is to inspire real and meaningful dialog among nurses, their nursing administrators and their larger hospital communities in the hope that should your hospital and, as a result, you decide to engage in the process that you do so fully aware and informed of not just the potential gains but the potential pitfalls. In addition, I hope that this article will help prepare you to take a proactive role in recognizing and effectively dealing with those very real problems.

Ironically, although transparency in decision making, staff involvement and true collaboration in problem solving are major hallmarks of a Magnet hospital, these are the hardest goals to achieve because for many institutions they require a dramatic shift in the internal culture. For unionized facilities it also necessitates a commitment to different approaches to conflict management between the hospital and the union.

In my view, given the stated goals of any facility aspiring to Magnet status, the presence of the union should compliment the process—as research has shown that unionized hospitals tend to have better patient outcomes than non-unionized hospitals, primarily because those nurses are already empowered to be stronger advocates for patient care and practice standards. A review of the current hospitals with Magnet designations reveal that a number of them are unionized.

As an advocate for the profession of nursing and its dedicated practitioners, I look hopefully to new ideas and advancements that give prominence to nursing in the hospital hierarchy. When the elected leaders of the bargaining unit and I were approached about this, we were skeptical about the hospital's sincerity but hopeful that it was a signal of a positive development. Two years later it would be great to be able to say that our skepticism was unfounded. In a few instances we can, but as a whole we continue to have difficulty matching the rhetoric of Magnet to the reality on the ground.

The journey to Magnet status in this case has been confused and complicated by an apparent disconnect between nursing administrators, led by the VP of nursing, who consistently communicated and demonstrated a willingness to find collaborative ways of problem solving, and the very senior non-nursing hospital administrators led by the hospital's CEO, who have communicated and demonstrated just as consistently their disdain for the union in general and the elected bargaining unit leadership in particular. The difference between promise and reality is further highlighted by legitimate clinical practice and workplace issues raised by union leaders being consistently dismissed or ignored, while at the same time some in administration have focused an inordinate amount of time and energy on targeting the elected leaders of the bargaining unit for harassment and intimidation as a result of their outspokenness in the pursuit of quality care and protecting clinical practice.

Instead of involving the elected union leaders in conversations on key issues from the outset, we find that issues are presented after plans have been made and set in place, sometimes with negative consequences. This has left us in the position of having to correct problems instead of being in the position to lend additional insight before the problem has occurred, saving time and energy all around. It has also become apparent that in some instances the administration hand picked the staff it chose to provide information and participate. Over time the nursing staff in general has begun to express frustration and some disillusionment with the process, as from their perspective, although their input is solicited, it seems to be negated or ignored even when there appears to be consensus on the committees. This makes the request for their input appear to be disingenuous.

In introducing and encouraging a collaborative approach to problems solving, we were forced to make it absolutely clear to administrators at all levels that mandatory subjects of bargaining would not be assigned to unit counsels (unit-level working groups of nurses and managers utilized in the Magnet process) without discussion with the union. This need became especially apparent in the following example. On one unit, a critical staffing shortage was identified at different times of the year. Both the staff and their managers agreed that something needed to be done to ensure appropriate staffing for patient safety and good clinical practice. Input from the staff was solicited and based on the information the staff had—and knowing that the status quo was not acceptable—the staff came up with a plan to create a system of call to boost staffing. This ensured sufficient staff and seemed to solve the problem, except that not all of the staff wanted to participate and that, although the plan was supposed to be voluntary, all nurses were expected to participate.

The solution also became more of a problem when what seemed to be a temporary fix to a temporary problem began to be discussed in a more permanent manner. It was only at that point that the union was made aware of the situation. In presenting the issue to the union for consideration, we were informed that the plan was staff created and staff endorsed. However, upon contacting the staff, it became clear that they did not actually want to "have to sign up for call" and would prefer not to accept—but they felt that they had no choice. If they did nothing they believed that the patients and the people working shorthanded would be at risk. Furthermore, in discussions with the staff about how they would choose to solve the problem if all options were open to them, they unanimously believed that what was needed was additional staff assigned for the critical times.

Given this additional information, the union representatives returned to the managers and made an additional request for information regarding the situation, including occurrences and staffing. We were able to tackle the problem with a broader scope than the unit staff could because we had access to more information. With the help and input of the staff, we were actually able to negotiate a more comprehensive fix to the problem addressing the needs of both management and the staff without compromising care and forcing staff to work more than they wanted to.

This example actually highlights one of our key areas of concern: how does staff ensure that solutions requiring best practice and the best patient outcomes get serious consideration and implementation? The assumption is that, through the Magnet process of staff-nurse empowerment and an institutional commitment to key nursing issues affecting clinical practice and patient care, safe staffing will be a natural outgrowth. The problem with this assumption is that it relies completely on the will of the management in charge. A Magnet designation comes with no built-in enforcement mechanism⎯much like JCAHO and its self policing.

We began to find areas of true collaboration and areas where we could build trust. This change was credited to the behavior being modeled by the VP of nursing, Janice Bishop, who had begun to explore, create and communicate tangible ways of interacting in a more positive and productive manner despite continued negativity and hostility from others in the hospital hierarchy. Unfortunately, just as we began to believe that nursing administration could and would be empowered to be an equal power at that table, we experienced an abrupt and unexpected change in the hospital's nursing administration. Unfortunately, since beginning this article and the Magnet journey, the VP of nursing who was key to the process and our involvement resigned her position. Since that time we have experienced an unprecedented increase in attacks on the elected bargaining unit leaders, as well as a shift in the forward momentum of collaborative communication and problem solving and a return to an unproductive, adversarial and hostile atmosphere. The result of this is a growing mistrust of the administration and increased skepticism of the effectiveness of the nursing administration.

It also highlights one of our major areas of concern with respect to the Magnet system, which appears to be totally based on the "good will" of an "enlightened" manager to work. What happens when the manager changes? Or the leaders who are committed to the process leave or change their mind? What guarantee is there that the culture created will be maintained? Again we do not need to look too far back in nursing history to see examples of great initiatives spearheaded by innovative nursing leaders that were completely wiped out when the more "budget minded" in the hospital hierarchy felt that innovation and ideals did not serve the bottom line.

Interestingly, this quest has had an unexpected yet positive side effect for the bargaining unit. It has actually motivated the nurses to become more organized and has empowered the membership to become more involved, even if it is to serve as a watchdog over the process. It has also done a lot to shed light on the differences between "perceived participation and power" and "real participation and power." And it has also reinforced the very tangible benefits of the union.

In addition, this pursuit of Magnet status has forced us as a bargaining unit to look at ourselves and our own shortcomings as a group and, as we continue to work, to empower the members to take an active role in shaping their work environment, their clinical practice and their professional development. On the level of labor and management interactions, it has also created more opportunities for interaction. Even if they have not always been positive, they still offer the potential to create opportunities for positive change.

While our particular experience has not been ideal, we have not dismissed out of hand the potential for transformation and change with an administration truly committed to the ideals demonstrated in Magnet institutions. The bargaining unit has taken the position that we will keep an open mind and act in good faith to create a hospital where the ideals of the Magnet system are more than just catchy slogans on posters, banners, billboards or commercials for the hospital to use as part of a marketing campaign.

We believe that we are far from the ideal at this time, but we hold out hope that transformation can come and that we can find more proactive and collaborative ways of reaching our common goals of quality patient care, an informed and empowered nursing professional and a healthy and thriving healthcare institution. Although it is unfortunate that in order to achieve this, hospitals must pay hundreds of thousands of dollars to an outside agency only to learn that the goal was always within their grasp for free and that all it ever required was the will to change and insight enough to see their staff as true partners for success.

We promise to keep you posted.