Whether or not you have any interest in applying for ANCC Magnet Recognition Program® (MRP) designation, most organizations still strive for nursing excellence and try to become an organization that "epitomize(s) quality and professionalism" (Preface 2008 ANCC MRP Manual). As such, the MRP standards can be an extremely useful blueprint to follow and move your nursing culture from complacency to excellence.
You can start with a few nurses who have a passion for excellence. Ideally these nurses would include bedside, advanced practice, management, and administration (CNO would be perfect). Familiarize yourself with the MRP, talk with a couple of MRP program directors/ CNOs at MRP-designated hospitals, attend a conference or workshop if finances allow, and become knowledgeable about the standards. You'll soon see that there are aspects you do well and others that you may not have in place at all or need some work. You don't have to complete a formal gap analysis to determine what you need to do next.
Select those program components that will provide an infrastructure for excellence and will result in positive outcomes for patients and nurses alike. Create a vision for your nursing culture and work environment. Talk with all levels of nurses about their frustrations and dreams and what they would like to accomplish. Engage your CNO and administration in a dialogue about their vision for patients and nursing care and what resources they are willing to commit. Just time and support should be sufficient to begin. Consider what will make a difference in your organization. Select a small number of components and elements of performance that:
- Can be readily achieved
- Will set the stage for cultural transformation.
You choose; there's no right or wrong way to proceed. I would recommend addressing some standard in each component. Following are examples of places to start.
1. Build transformational leadership
Is your CNO visible and a well-known patient and nurse advocate? Does she/he have a defined relationship to all nursing care areas? Work with your CNO to see how visibility and advocacy can be achieved. Below are some ideas that have worked well for other CNOs:
- Gain a seat, presence, or voice on top administrative and board committees.
- Interview your CNO and publish his/her philosophy in a nursing newsletter or bulletin. Be sure to include his/her thoughts about patient care and nursing practice and positive feelings about nursing in your organization. He/she can also begin a tradition of weekly or monthly blogs to share experiences and dreams for the organization.
- Develop an internal nursing website to share nursing stories of excellence.
- Attend staff meetings on a regular basis, being sure to include both inpatient and ambulatory/procedural settings.
- Host breakfasts, lunches, and town hall meetings.
- Begin to celebrate unit successes with patient satisfaction and outcomes, nursing achievements, and the like. Your CNO and nurse leaders can be upfront and center, lending their support and an ear to nurse concerns.
- Participate in all new nurse orientations.
- Walk around, unannounced, stopping, and listening.
- If you have shared governance, attend meetings to listen and support.
- Include bedside nurses in all key patient care initiatives. Deliberately construct committees and task forces to include all levels of nurses.
- Liberally use interviews, focus groups, and surveys to engage staff and listen to the feedback, being willing to make mid-course corrections based on input.
- Admit when you're wrong.
- Don't be afraid to be involved and engaged and act silly. The message is clearly "CNOs are nurses and human, too"
2. Establish structural empowerment
You have a range of choices here. You can focus on professional development, striving to increase the certification, continuing and formal education, and membership in professional organizations. You can emphasize nursing's role in the community toward improvement and partnership. Or, you can take the long view and establish shared governance.
If you already have education, quality, and/or practice committees in place, you can pay attention to membership issues and ensure bedside nurses comprise more than 50% of members and that a bedside nurse is being groomed to assume the chair. Over time, managers should shift to advisory vs. membership roles as nurses accept fundamental decision making roles related to patient care and nursing practice.
There are excellent resources available online and in the literature to help you establish governance. Robert Hess and Tim Porter-O'Grady are two big-name authors with extremely useful books. Again, calling a couple of MRP hospitals to discuss shared governance's effect, barriers, key enablers, and infrastructure can be very helpful. I would recommend picking hospitals that have been re-designated at least once, since they will be able to discuss maturation of shared governance.
3. Maintain an exemplary professional practice
A great way to start is by defining your professional practice and care delivery models. While you can begin by selecting a theorist to model, I personally favor the approach of observation, experience, and dialogue with nurses in your facility. That way, you can find out what is currently being practiced. This may require group meetings or workdays to truly dig deep into all elements of your models, but it's a super way to engage your nurses while engendering excitement and pride.
For example in our hospital, leaders initially created a model with overlapping and concentric circles to describe our model.
Nurses asked, "Why can't the model be easier to understand and be more relevant?" So, we asked the nurses to draw what they had in mind. They came up with a house. Since our hospital is located in the South, it is an antebellum house. They configured meaningful construction for the rooms, steps, pillars, windows, and doors that made sense to them.
Then, we had a graphic artist make it "prettier" and the nurses took the model out to their coworkers. Three versions later, we have a model they are both proud to call their own and are able to apply to case studies as they explain excellence in care. The House, as it is called, is easy to update and revise and applies to all settings. We also built a wood house that we can use in teaching.
4. Develop new knowledge and innovations
Be sure policies and procedures are referenced with recent literature and "best practices," encourage nurses to try new things, and involve nurses in design of new units and the electronic medical record are being done in many organizations. So few hospitals have an on-sight nurse researcher and have little research activity, so this is a logical focus. Collaboration is the key here. Whether online, by phone, or in person, collaboration with a doctorate or master's prepared nurse who is well versed in quantitative and qualitative research methodology and analysis, as well as publishing, is key.
A good place to start is with your affiliated school of nursing, since you already have established relationships. Nurses from the school can serve as mentors and consultants in establishing a nurse research council, developing policies and educating interested nurses from all levels.
Once a beginning infrastructure is in place to provide knowledge and support, talk with nurses about what bothers them, what practices they question, and what patient care outcomes they'd like to see improved. This can be done in small groups, at change of shift huddles or staff meetings, or one-on-one. Some hospitals have "Ask a research question" contests, or "Lunches and learns."
For example, at our organization, a question was asked by a neonatal nurse, "What can we do to reduce crying in our 32-36 week old babies?" These babies were not able to be feed and had up to seven crying episodes a day, lasting 30 minutes. Traditional methods of cuddling and swaddling were not effective; however, nurses noticed that when mom or dad sang to the babies, crying was reduced. With the help of a school of nursing mentor and the research council, a simple research design was created and all nurses in the unit engaged. They were able to reduce the crying episodes to an average of four per day, lasting five minutes each, by playing a CD—all from asking a simple question. Moms, dads, nurses, and babies were thrilled.
5. Stress empirical outcomes
Investigate what nurse-sensitive indicators are being monitored in what departments by whom. An inventory is especially helpful in determining optimal resources, support structure, accountability, and gaps. Whether you utilize an existing committee or create a nurse quality council, an over-arching team is important to analyze, trend, educate bedside nurses, decide how to simplify and report the data, and determine need for performance improvement projects or research. You will also need to include benchmark data sources at the highest possible level on your inventory and establish goals that will position you to out-perform the mean at the 50th percentile.
Find out what databases are available for RN satisfaction surveys and patient quality indicators; prices and value vary greatly among them. As you begin new services or programs, change practices, or institute innovation, always be thinking of outcomes, goals, and benchmarks.
The journey toward becoming a MRP-designated hospital is amazing and recognizes the excellence embedded within an organization. Since less than 5% of all U.S. hospitals are designated, the MRP can still serve as a blueprint for striving for excellence in patient care and nursing practice. Along the way, champions for the journey generally arise and value becomes clear. Whatever you choose to do, whatever inroads you choose to make, you will make a difference for your patients and for your nurses.
Meryl Montgomery, RN, MSN, is director of the Learning Center at the Medical Center of Central Georgia, in Macon, GA.