Position Statement On the "Magnet Recognition Program for Nursing Services in Hospitals" and Other Consultant-Driven Quality Improvement Projects that Claim to Improve Care
MNA opposes this strategy to avoid safe RN-to-patient limits
CANTON, Mass.—A vast amount of research has accumulated over the past decade-plus which documents the patient harm resulting from deplorable RN staffing conditions in hospitals. There has been a massive exodus from nursing of well trained professionals who refuse to work under such conditions, in violation of their nursing ethics and the Massachusetts Nurse Practice Act, which calls for nurses to be advocates for their patients above all. To circumvent the demands by nurses, patients and the public for the imposition of mandated RN-to-patient limits to correct these deficiencies, the hospital industry has continued to employ a voluntary process of accreditation and validation of its nursing programs, similar to that provided for hospitals by the Joint Commission on the Accreditation of Health Care Organizations (JC). This designation, known as "Magnet Recognition" has been around for years. It has been embraced by hospital and nursing administrators as a means of boosting public confidence in their nursing care, improving retention of its nursing staff and perhaps more importantly, for increasing reimbursement for services by the federal government and private insurers.
The Massachusetts Nurses Association Board of Directors, which has evaluated this program in detail, today reiterates in the position statement below its opposition to Magnet and to other consultant-driven quality improvement projects that claim to improve care yet fail to guarantee safe staffing levels and adequate working conditions for nurses. The MNA views the Magnet process as a pure marketing ploy that trades on the public’s trust in nurses as a vehicle for burnishing the hospital’s image. The MNA believes true quality of care can only be achieved when nurses and the public are guaranteed minimum, safe RN-to-patient limits as a matter of law, and when nurses are provided with the legally protected right to influence and improve their working conditions.
Full Text of Position Statement
Background
In recent years, registered nurses, health care providers, citizens, and policy makers have become alarmed over the falling level of quality and safety of nursing care in America’s hospitals. A number of influential reports and studies continue to document the medical errors, poor patient outcomes and alarming number of preventable patient deaths directly attributable to: inadequate RN staffing levels; poor RN-to-patient limits; dangerous working conditions; and dangerous administrative practices such as utilizing unlicensed personnel to provide care that only RNs should provide, ordering RNs to perform functions that are beyond their legal scope of practice, and floating of nurses to units where they are ill-prepared to practice competently and safely.
Hospital administrators are saving money in multiple ways which increase risks to patients: They are reducing their RN work force; demanding that their unlicensed and/or unskilled workers assume responsibilities for tasks that should be done by an RN, which fragments care and jeopardizes patients’ health. At the same time, hospitals are also reducing ancillary staff, which leads in other situations to RNs spending their time performing tasks which could be done by unskilled personal, diminishing the time nurses have for actual nursing care and wasting RN resources. We are also seeing a trend toward putting nurses and patients into increasingly risky, dangerous situations– reducing the numbers of staff to monitor patients in various critical care areas and observation units in particular, and forcing staff to provide coverage on units where nurses are not trained in providing the specialty nursing care required.
These conditions have stimulated intense debate within the health care community as to how to deal with this crisis. The vast majority of frontline nurses – nine of ten nurses in Massachusetts and eight of ten nationally who deliver patient care – have called for laws to regulate RN staffing limits in hospitals in the Commonwealth.
For its part, the hospital industry has fought any attempt to impose legally enforceable requirements for improving care, and instead has been promoting voluntary solutions and strategies to deal with this crisis. One of these is the Magnet Recognition Program, which is run by the American Nurses Credentialing Center (ANCC), a for-profit subsidiary of the American Nurses Association. In fact, the Magnet Recognition Program is just another in a series of consultant-driven "quality improvement" projects the industry has proposed and implemented in the last decade, including Total Quality Management (TQM), Shared Governance and Patient Focused Care. None of these programs has succeeded in their intended goal, and most resulted in fostering the conditions that have created the crisis nurses and patients continue to face.
The Magnet Recognition Program confers the designation "Magnet Nursing Services Recognition" on hospitals which are able to pass a lengthy and costly (i.e., profitable for the surveyors) credentialing inspection. The surveys are performed by a team in very similar fashion to the JC inspection and credentialing process.
Magnet evaluation criteria are based on quality indicators and standards of nursing practice as defined in the ANA’s Scope and Standards for Nurse Administrators (1996). The criteria are similar to JC standards. To obtain Magnet status, health care organizations must apply and pay a fee to the ANCC, submit extensive documentation that demonstrates their compliance with the ANA standards, and undergo an onsite evaluation to verify the information in the documentation submitted and to assess the presence of the "forces of magnetism" within the organization.
According to the ANCC, as of June, 2014, there are 401 Magnet-designated facilities in the country, a quadrupling in the past 10 years reminiscent of Minnesota folk humorist Garrison Keillor’s Lake Woebegone, where “all the children are above average.” In fact in the past decade ANCC has made eligibility requirements more liberal to allow more hospitals to claim they are Magnet-worthy. As one example, a now outdated Magnet requirement was that in the five years preceding application for Magnet, the hospital must not have committed an unfair labor practice as determined by the National Labor Relations Board (NLRB) or other grievance resolution body or reviewing federal, state or international court. That requirement is no longer.
Currently, nine of the 62 Massachusetts acute care hospitals – Baystate, Boston Children’s, Dana-Farber, Lawrence Memorial, Lowell General, Massachusetts General, Melrose-Wakefield, South Shore and Winchester Hospitals –have been designated as Magnet facilities.
Once designated a "Magnet Hospital," facilities then market themselves as a preferred employer of nurses and can use its magnet status as a "seal of approval for quality care." The industry can also use magnet status as a justification for higher rates of reimbursement from third party payers.
Here in Massachusetts interest in and applications for participation in the Magnet Recognition Program continues, causing staff nurses inside and outside of the MNA to request MNA’s position on the "Magnet" process. Here we present our position on the Magnet process as a concept, as well as provide key principles to help nurses in determining if and how they wish to participate in this or any similar process.
I. MNA Organizational Position on the Magnet Recognition Program
The Massachusetts Nurses Association Board of Directors is opposed to the concept of the Magnet Recognition Program for the following reasons:
Magnet Recognition Is Being Used as a Marketing Ploy to Increase Market Share by Trading on the Trust and Credibility Nurses Have With the Public
One of our most important reasons for opposing the magnet program is that the primary selling point of the program by the ANCC, and the key motivation for an institution’s participation in the process, is to utilize Magnet Recognition as a marketing ploy to garner greater market share, and to do so by trading on the respect and credibility of nurses (particularly staff nurses) in the eyes of the public.
The process is structured around the formation of "Nursing Councils", which give the illusion of shared governance and nurse empowerment, without granting nurses equal power with management and the ability to shape and modify the decisions made through the process. Nurses have no legally protected veto power in the process, and all decisions are still ultimately left to senior administrators. However, when the final decisions are made, because staff nurses participated in the process, the mere fact of their participation will be used to substantiate and validate the process.
Nurses have been down this road many times before. We believe Magnet Recognition is yet another, top-down process, like TQM, Patient Focus Care, and so many other high priced, consultant-driven programs that provide no real guarantee of quality patient care or for the creation of conditions that will protect nursing practice.
Excellence in Nursing Services Must be a Condition of Licensure
Providing quality nursing care and establishing standards of quality care for nursing services should not be a matter of choice by a particular institution, but should be a basic legal requirement and condition of licensure by the Department of Public Health. All hospitals should be held accountable for having positive patient outcomes. All hospitals should be accountable for providing safe staffing and a satisfactory work environment for its nurses.
Money Spent on Consultants is Better Spent on Direct Patient Care
The Magnet program is another expensive program, requiring thousands of dollars in fees to consultants, and thousands of dollars in staff time. This money would be better spent on improving staffing conditions or on nursing salaries. It is also important to understand just who is behind this program. The Magnet program was created by the American Nurses Association as a profit making venture. Not only does ANCC collect fees to conduct the Magnet evaluation, it also provides consultants, for a fee, to assist in achieving the designation. The ANA is firmly opposed to nurses’ having the right to mandatory RN-to-patient limits.
Voluntary Credentialing/Accreditation Programs Don’t Work
The nursing community has had many years of experience in evaluating the effectiveness of voluntary credentialing programs such as the JC accreditation process. The JC program is universally condemned by nurses as a farce, providing no true evaluation of the quality of care in the hospitals it surveys. In fact, this has been substantiated by two exhaustive governmental reports on the process: one as far back as 1999 by the Inspector General of the United States and another by the Government Accounting Office, which found that many JC accredited hospitals were found to have significant patient safety problems undetected by the surveyors. The Inspector General’s report criticized the JC because there was too collegial a relationship between the surveyors and the surveyed in the process. We see the same problems being duplicated by the Magnet Recognition Program.
Magnet Recognition Fails to Include any Requirement for Safe RN-to-Patient Limits
In numerous studies and in every credible survey of nurses, the most important solution to the problem of providing quality patient care and of creating conditions to retaining nursing staff is the need to establish safe, minimum RN-to-patient limits or, in the absence of minimum limits, to grant frontline nurses the right to refuse patient assignments that prevent the delivery of quality patient care.
The Magnet Recognition Program provides no specific recommendations for the establishment of safe staffing standards, nor does it grant nurses the protected right to refuse an unsafe patient assignment. The MNA cannot support a program that claims to provide a "seal of approval on quality of care for the public" that does not include a guarantee of safe staffing standards.
In the Unionized Setting, the Magnet Process Undermines the Collective Bargaining Process and True Workplace Democracy
In a hospital where nurses are unionized, the collective bargaining process conducted through the existing labor/management relationship is the established, legally protected forum for addressing all issues impacting nurses’ working conditions. Any program that purports to seek and utilize staff nurses’ input, any program that proposes changes in policies and practices to boost retention and recruitment of staff without directly dealing with the nurses’ elected union representatives undermines the collective bargaining process and nurses’ rights. Such decisions can only be decided by the union as a matter of law. Further, if the hospital is serious about working in partnership with nurses as equals to arrive at standards they are willing to stand behind and truly endorse, then they should be willing to engage in good faith negotiations over those changes and to codify them through enforceable language as part of the union contract.
II. MNA Principles of Participation for Nurses Considering Magnet Recognition
While the MNA, as an organization, is opposed to the Magnet Recognition Program for the reasons provided above, we recognize many non-unionized nurses without self-governance will have limited ability to stop their employer from seeking Magnet status. Other nurses in good faith may already be engaged in this or another process where they believe their efforts and credibility will result in better patient care.
The MNA Board of Directors wanted to provide nurses with some guidance as to key principles for participation in any institutional process that seeks to utilize nurses’ expertise and credibility with the public. We strongly urge nurses to consider these principles prior to their entering into the process. These include:
- Frontline nurses should have the power to select, among themselves, who will represent them in the Magnet or any other process.
- Front-line nurses elected or appointed by their peers to participate in the process must have the right to recommend and approve changes in the criteria for Magnet status based on the needs of their particular institution.
- In a unionized setting, any and all proposals made that impact the working conditions of nurses are subject to review, negotiation and ratification by the union.
- The result of the Magnet process should result in a written, legally binding document that guarantees nurses a voice and a real choice in all decisions impacting their work and obligating the institution to adhere to the standards arrived at for the life of the Magnet Recognition designation—which is four years.
- Nurses participating in the process should have access to all information and materials (i.e. financial documents, consultant’s studies, vendor contracts, merger or restructuring plans, etc.) that will assist them in making informed decisions.
The process recognized in the workplace that must adhere to these principles is the employee governance process authorized and protected by law – collective bargaining.
June 19, 2014
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