Leveraging Magnet^® principles

Abstract

Read about how one nursing team utilized Magnet tenets in their daily operations to achieve not only positive patient outcomes, but also a resilient workforce.

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Global health crises present with a unique set of circumstances, an unknown trajectory, and an array of variables that impact the evolution of the system's response to achieve the best possible outcome. Leaders on the front line must have a robust theoretical framework and a strong foundational constitution to positively navigate a dynamic situation. The COVID-19 pandemic has been an all-encompassing threat to the stability of worldwide healthcare, pushing resources to the brink of collapse, with ongoing lockdowns in various countries as we combat emerging variants, race to vaccinate, and research new treatments. As we move past the 1-year mark since the start of the pandemic, the interconnectedness of global healthcare is evident in the ever-increasing positive outcomes that have been realized.

This article highlights how one nursing team leveraged Magnet^® principles in their daily operations to achieve not only positive patient outcomes, but also a resilient workforce.

Living the Magnet culture

A medical-surgical telemetry step-down nursing unit in a Magnet-recognized tertiary medical center has been the designated COVID-19 unit since February 2020. As with all hospitals at the height of the pandemic, this high-acuity adult inpatient unit became a bridge between the ED and critical care. Advanced physical assessment, care team collaboration, emergency use authorization of medications, clinical trials, lifesaving treatments, and care bundles were developed to improve patients' morbidity and mortality as the pandemic progressed.

In the words of one clinical nurse, “The fear was real. We sought answers and partnership from our leaders. People were telling us daily that we were heroes, yet we actively didn't digest these accolades. In retrospect, this was in order to cope and continue. We saw friends and family members quarantine, and we kept working. We lived a different life, driving to work with little to no traffic, just flashing DOT signs that reminded us of quarantine.”

Shared decision-making is foundational to the organization's nursing professional practice model. In 2016, the organization conducted research to measure shared decision-making using the Index of Professional Nursing Governance. As a result of lessons learned, the nursing leadership structure was transformed to include unit-based councils, which are chaired by a unit clinical nurse and the unit nurse manager; a night council to address concerns unique to the off shifts; and a monthly network nursing council day to engage frontline nurses in decisions that affect bedside nursing care.1 These committees continued and were switched to virtual forums at the start of the pandemic to scale back large indoor gatherings. This high level of engagement was critical to the success of interventions put in place on the unit as the pandemic evolved.

The deeply rooted Magnet culture and its principles of transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovation, and improvements; and empirical outcomes were also identified by the nurse manager, frontline nurse leaders, and clinical staff as a key force in helping them navigate the pandemic. (See Forces of Magnetism.)

Transformational leadership

According to the Magnet model, “the transformational leader must lead people to where they need to be in order to meet the demands of the future. This requires vision, influence, clinical knowledge, and a strong expertise relating to professional nursing practice. It also acknowledges that transformation may create turbulence and involve atypical approaches to solutions.”2 As decisions were made in the command center, nursing unit leader coverage moved to a 24/7 operation to ensure that there was leadership support and visibility at all times. This allowed leaders to immediately respond to command center communication and enhance bidirectional flow of information with input from frontline nurses. Clear communication was instrumental in maintaining the established culture of excellence and facilitating operations.1,3

The unit's assistant nurse manager described the tone, “I realized that the mindset needed to be one that matched and met the quickly developing and changing CDC guidelines as the team was faced with the possibility of working without enough supplies and lifesaving equipment, such as ventilators, which could force the system to ration care.”

The unit's nurse manager was able to enhance the cohesiveness of the unit by focusing on key principles of shared decision-making, which include upholding professional accountability at all levels and providing structure that supports nursing autonomy.4 The nurse manager remarked, “I needed to take ownership of what I could control, first of which was effective, real-time communication through huddles, written updates from the command center, and transparency of where we were with COVID-19 cases [in addition to] availability of resources such as PPE and timely response to the needs of the staff. Early in the first few weeks of the pandemic, our unit had a total of 17 members of the nursing staff develop COVID-19. The emotional toll on the rest of the staff was palpable. We also had new nurse residents freshly off orientation who needed to be mentored and pandemic nurses who needed to be quickly acclimated to the unit. This required an all-hands-on deck approach to collectively pool our knowledge and skills and draw on our caring nursing philosophy to ensure that we were providing the best care during a time when the learning curve was sharp and intense.”

Furthermore, the nurse manager shared, “I remember being called in to the hospital on Sunday, March 15, 2020. We received an alert for all nursing management to report to the hospital immediately. On my way in, I stopped at a uniform store and bought five sets of scrubs. Something in my gut told me this was going to be bad. From that day forward, we were in pandemic mode. I kept a diary of key events that happened, took pictures of the team, celebrated every small and big win, cried with my nurses when we needed to. We had two new graduates who started as GNs in April and were immediately put to work. For Nurses Week in May, I held a pinning ceremony on the unit for them and all the team stood with them in solidarity and recited the Florence Nightingale pledge. One of the clear immediate needs was to create an atmosphere that supported self-care for the nursing team. We had recently launched a code lavender program, and providing the nursing team with some self-care tools and a designated space for rest and renewal were critical for maintaining a resilient staff.”

As a transformational leader, it's important to have a handle on where each team member is, not only emotionally during the crisis, but also with developing competencies and skills. Tracking each team member's performance with a look back 18 months and a look forward 18 months and keeping a log of events and milestones helps ensure that we recognize accomplishments and plan ahead.

Structural empowerment

To engage structural empowerment, which includes the flourishing of strong professional practice using the mission, vision, and values of the organization, we had to be extremely creative in the delivery of patient care to achieve the best possible outcomes. Empowerment was accomplished through a variety of structures and programs, keeping in mind that one size doesn't fit all. It became important not to use a cookie cutter mindset but rather engage each team member and treat each patient as an individual while learning about the novel virus. Decisive measures were put in place, including reducing the nurse-to-patient ratio to 3:1, adding care partners in a tiered approach to assist with 100% of the patients in isolation, and hiring agency nurses to meet surge capacity.

Onboarding of the agency nurses and new nurses on orientation by the assistant nurse manager and clinical leaders became a top priority for the unit. While this was ongoing, the core nursing team had to remain engaged and practice safely. For our core team, we built stronger, meaningful relationships by doing daily check-ins. The assistant nurse manager noted, “We found time to share our own fears as leaders and encourage them to practice safety measures while away from the job, maintain communication with loved ones, and check in on each other.”

In alignment with the nursing strategic plan, which supports structural empowerment, participation in hospital-wide committees is requisite to being an RN in the organization. The unit's frontline nurse leaders guided each RN in choosing their committees and assisted them in choosing process improvement initiatives and quality projects that could be implemented throughout the medical center.

During the pandemic, two initiatives completed by frontline nurses included:

• humanizing care for patients in isolation during the pandemic. Clinical nurses shared best practices to improve the patient experience while bundling care and limiting exposure in rooms.

• self-proning and incentive spirometry to reduce hypoxia with COVID-19 pneumonia. Clinical nurses sought out emerging evidence for best practices and implemented these interventions to prevent desaturation and progressive hypoxia, ultimately decreasing intubations.

Exemplary professional practice

Keeping the team focused on exemplary professional practice was key throughout the pandemic because quality and patient safety remain a top priority in a high-reliability organization. Unit leadership sustained momentum by ensuring that each nurse participated in the interdisciplinary teams, committees, and activities required for the clinical advancement program. Formal application to this program includes exemplars from the previous 36 months of practice and is a strong indicator of sustained team member engagement. Despite being the designated COVID-19 unit for more than a year and new application guidelines being implemented, this unit achieved 100% participation, with 41 nurses submitting their completed applications in April 2021.

The nurse manager commented, “I think the frontline nurse leader supports a culture of high reliability and exemplary professional practice by partnering with each nurse to provide coaching and mentoring as part of their professional development. The give-back to the team is invaluable and builds bonds and cohesiveness as they begin to contribute to the broader aspects of professional practice.”

New knowledge, innovation, and improvements

Having an unwavering commitment to patient safety through evidence-based practice and clinical practice guidelines was challenged by the uncharted territory of COVID-19, driving the worldwide medical community to come together to find innovative treatments and interventions. Nurse leaders of COVID-19 units needed to be adaptive and flexible, as well as foster resiliency in the care team.5

Clinical nurses on the unit were directly involved in the creation of nurse-driven proning protocols and partnered with research teams to provide emergency use authorization treatments and clinical trials. The culmination of this work was the creation of a COVID-19 best practices bundle. Established in January 2021, this bundle includes a medical-surgical patient care protocol and a proning protocol.

Another innovation that was unique to the pandemic was the widespread use of virtual family visitation. As soon as the doors of the hospital were shut, nurses found themselves acting as a proxy for family members who desperately wanted to be with their loved ones. The nurses used smartphone and tablet technology to facilitate family visits during critical times and help patients cope with isolation.

Empirical outcomes

Frontline nursing leadership must maintain accountability for all quality outcomes throughout the course of the pandemic. Metrics for patient safety, such as nursing-sensitive indicators; nurse engagement, such as RN turnover and satisfaction; and patient experience outcomes, such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, are strong indicators of the success of processes put in place in response to the challenges brought on by the pandemic.

From a patient safety perspective, emerging evidence in the literature revealed that emergency practices, including placing I.V. poles outside of rooms to conserve personal protective equipment and having doors closed at all times, led to increased risk of central line-associated bloodstream infection (CLABSI) and falls. Comparative data from 2019 and 2020 for this unit showed that the CLABSI rate increased from .44 (1 case) in 2019 to 1.56 (2 cases). The catheter-associated urinary tract infection (CAUTI) rate increased from .50 (1 case) in 2019 to 2.78 (3 cases) in 2020. Although this was an unexpected outcome, it wasn't statistically significant compared with national benchmarks. The fall rate remained unchanged from 2019 to 2020 and falls with injury were 0 for 2020.

Fear of the unknown posed a great risk of increased RN turnover. And stretched resources from tangibles, such as continuous pulse oximetry monitors and advanced oxygen delivery systems, to human resources, such as hospital staff and guest relations capabilities, seriously impacted the patient experience. Despite these challenges, as of June 2021, the unit achieved an 89th percentile ranking for “would recommend hospital” and a 91st percentile ranking for “communication with nurses” in the national HCAHPS survey ranking.

From the perspective of one clinical nurse, “The stress was palpable, constant, and with the potential to do damage to morale and confidence. What I saw instead was the power of the nursing spirit come to life tenfold. Senior unit nurse leaders, who are already familiar with emergent situations, served as extended resources, responding to codes often several times per shift. The demand and emergent situations caused extreme fatigue and burnout. The novice nurse role was accelerated to fill the gaps created by sheer need and the desire and determination to provide patient-centered care. It's my opinion that the gap created by the intensity of COVID-19 was filled by strong leadership and shared decision-making, which encouraged team unity and governance.”

Resiliency amidst uncertainty

By leveraging Magnet principles, frontline nurse leaders can successfully navigate through the uncertainty of disaster situations without sacrificing quality. This unit maintained statistically stable CLABSI, CAUTI, and fall/fall with injury rates throughout the pandemic, achieving HCAHPS survey scores in the 90th percentile. The unit also fostered a resilient nursing staff, having all 17 nursing team members who developed COVID-19 early in the pandemic return to work and sustaining a low turnover/vacancy rate.

Forces of Magnetism

Two of the Forces of Magnetism—nurses as teachers and utilization of consultation and resources—were key during this pandemic. Following emerging research, nurses, in consultation with the hospital-based infectious disease department and using CDC guidelines, disseminated vital and updated information to staff, patients, and families. For example, in the community, there were issues of some patients having no place to go after discharge because families were fearful of bringing the virus into the home. Shifting and sometimes inconsistent information as more was learned about the novel virus during the early part of the pandemic created distrust among not only the general population, but also some in the medical community. Using nurses as teachers allowed leaders to be transparent and committed to sharing knowledge. Frontline leaders needed to be the face of integrity and remain open with dialogue as patients and team members became visibly shaken, afraid, and outright angry at times. Leading by example and continuing to maintain a positive atmosphere in the workplace showed the team and the community the true meaning of exemplary professional practice.