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Magnet Recognition Program has global appeal
Magnet program attracts hospitals outside of U.S.
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By Heather Stringer
EDITOR'S NOTE: Heather Stringer is a freelance writer. Freelance writer Jonathan Bilyk also contributed to this article.
Sandy Lovering, a nurse at a hospital in Saudi Arabia, knew the Magnet Recognition Program® is considered a gold standard of nursing, but she never imagined it would be something her hospital would ever consider.
But in 2005, Lovering’s CEO, Tariq Linjawi, MD, asked her a question that surprised her. “What was the highest credential in nursing?” he asked. Although the hospital had Joint Commission accreditation, he wanted to set the bar higher.
“I told him it was Magnet recognition,” said Lovering, DHSc, RN, CTN, executive director of nursing affairs at King Faisal Specialist Hospital & Research Center in Jeddah. “He asked if the hospital could achieve this recognition and if I could lead us there. I said yes, but I had no idea what was required and whether it was possible.” That day marked the beginning of what became more than a six-year journey to receive Magnet® designation from the American Nurses Credentialing Center, a subsidiary of the American Nurses Association. While Lovering’s hospital was the first to achieve Magnet status in Saudi Arabia in 2013, its sister hospital in Riyadh followed suit shortly thereafter. At present, eight hospitals outside of the U.S. have Magnet designation. They are in Belgium, Canada, Lebanon, Australia and Saudi Arabia, and more are pursuing the Magnet journey.
See a list of Magnet facilities in other countries
Why the interest in Magnet?
Persevering through the process
There has been a steady increase of interest in Magnet designation among hospitals and healthcare organizations in a number of countries as information spreads from the ANCC and other organizations about the benefits for patients and staff alike. Antwerp, Belgium, became the latest hospital outside of the U.S. — and the first in mainland Europe — completing the process in 2017. It was preceded by Mount Sinai Hospital in Toronto, which completed the process in 2015.
The ANCC has reported inquiries concerning how to implement Magnet programs from hospitals in countries that include Thailand, Japan, the Philippines, Belgium, Germany, Italy and Brazil, and expects to see increasing numbers of hospitals outside the U.S. complete the Magnet journey.
The ANCC awarded the first Magnet recognition in 1994 to the University of Washington Medical Center in Seattle. The first hospital overseas to receive the designation was Rockdale Infirmary in the United Kingdom in 2002, but it later withdrew from the program. As of July 2018, there are 478 hospitals worldwide with Magnet recognition, up from 420 just two years earlier.
Shared governance model
To earn Magnet recognition, the hospital needed to implement a shared governance structure that would empower nurses to make decisions to improve the safety and quality of patient care. Lovering and Haines started educating themselves by studying Tim Porter O’Grady’s shared governance models, as well as the ANCC’s “Guide for Established Shared Governance: A Starter’s Toolkit,” which was co-authored by George.
“The biggest challenge many hospitals face with implementing shared governance is still the change in the role of the nurse managers,” explained Bob Hess, PhD, RN, FAAN, executive vice president and chief clinical executive for OnCourse Learning. “It requires an entire nursing organizational shift that ultimately gives bedside nurses control over their clinical practice while extending their influence to areas previously controlled only by management.” Hess, who also is founder of the Forum for Shared Governance and former vice chairman of the American Nurses Credentialing Center’s Commission on Accreditation, has developed the only instruments that measure shared governance by professionals in healthcare organizations. Recently, those instruments, known as the Index of Professional Nursing Governance (IPNG), were revised and reduced from 86 to 50 items. The instruments were included in George’s ANNC guide and have been translated into 10 languages. Hess said the revisions should help organizations overcome one of the chief perceived challenges to completing the Magnet journey – the length of time needed to implement the shared governance structure. He noted some organizations have now been able to implement the structure in just two years, using the IPNG. “Education, particularly of staff and middle management, has been the key driver in reducing that implementation time,” Hess said. “In hospitals where implementation time has been shortened, and where the Magnet journey has been most effective, every time the staff would turn around, they were finding more education.”
At King Faisal, Lovering started introducing the concept of shared governance to units throughout the hospital and organized training sessions to teach unit council chairmen about their new role, how to lead a meeting and manage conflict. The hospital began distributing benchmark data to all employees rather than only managers.

If a particular unit saw a negative change in a quality indicator, the nurses discussed strategies for improvement during unit council meetings. Although some nurse managers initially were resistant to shared governance, within two years the benefits of the new structure became clear.

“Now all the nurses love it,” Lovering said. “They could see it making a difference. All of our clinical outcomes started hitting benchmarks and nurse satisfaction improved. Eventually we started seeing better-than-benchmark results.”
Positive points in the process
Another Magnet requirement that has proven challenging for hospitals overseas relates to educational training. Magnet hospitals are expected to create an action plan to reach the Institute of Medicine’s goal to increase the proportion of nurses with a baccalaureate degree to 80% by 2020. In 2017, the Magnet Recognition Program office partnered exclusively with CGFNS International, Inc., to pilot a new education comparability evaluation for all four ANCC programs that require baccalaureate in nursing or higher eligibility standards.
Many countries do not have RN-to-BSN programs, and international nurses who are interested in enrolling in one of the American programs often must have a U.S. nursing license to be eligible, said Julia Aucoin, DNS, RN-BC, CNE, a consultant with Magnet expertise at the Nursing Knowledge Center, who has worked with hospitals in Lebanon, Qatar and Jordan. It can be expensive to take the American licensure exam and maintain it, in addition to paying for a U.S. education, she said. Although this poses a challenge, sometimes employers will help by covering a portion of the cost of education.
Aucoin has realized there are advantages to being overseas for some aspects of the Magnet journey. Magnet hospitals are required to show examples of successful implementation in areas such as space design and acquisition of technology, but the governmental regulations in the U.S. can delay this process, she said. “The hospitals I have worked with overseas are very innovative and sometimes have an easier time implementing new technology because their countries do not have the equivalent of the FDA,” Aucoin said.
Magnet hospitals also must display exemplary patient outcomes, and the cultural attitudes in different countries can impact the ability of the patient and caregiver to work as partners to improve outcomes, Aucoin said. In the Middle East, patients are highly respectful and cooperative with caregivers because they see healthcare as a privilege, while in the U.S. there is a value on independence and freedom of choice, Aucoin said.
Lovering began the journey by learning what was required, which prompted her to fly to the U.S. for the annual Magnet conference more than a decade ago. She and Fiona Haines, MCur, RN, King Faisal hospital’s Magnet coordinator, began reading everything they could find about the program, including the work of Ada Sue Hinshaw, author of “Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses.”

Although Lovering knew about the Magnet program, she was keenly aware that this was not the case for the vast majority of the hospital’s nurses, who represented more than 30 countries. To introduce them to the value of the program, the hospital invited Hinshaw to speak at a nursing conference in 2007. Lovering also discovered organizations could hire a nurse consultant through the ANA’s Nursing Knowledge Center. The consultant is trained to help hospitals working toward the Magnet goal. Nurse consultants have held nursing leadership roles as CNOs or Magnet program directors, for instance. They can request translators when working with overseas facilities. Lovering’s facility hired consultant Vicki George, PhD, RN, FAAN, a managing partner with Nurse Consulting Partners based in Wisconsin, to perform a gap analysis.

The analysis revealed the hospital needed to start benchmarking nurse-sensitive indicators, such as bloodstream infections, urinary tract infections, fall rates and ventilator-associated pneumonia. They quickly encountered a significant hurdle: There were no international benchmarking databases available.
Lovering contacted the National Database of Nursing Quality Indicators, based in the U.S., to explore whether the organization would consider allowing non-U.S. hospitals to join the database, and in 2007 King Faisal became the first to do so. The database allows the hospital to compare its nursing quality measures to other nursing units and hospitals in the U.S. and throughout the world in areas such as patient outcomes, nurse satisfaction with the work environment and nurse staffing levels.
Future of Magnet overseas
Although there are only eight countries outside the U.S. with Magnet hospitals, nurses are hearing the Magnet message at conferences around the world. George recently spoke at a conference in South Korea and Marsha Hughes-Rease, MSOD, MSN, RN, did the same in Singapore at an event attended by nurses from Malaysia and other countries in Southeast Asia.

“These countries are interested because Magnet recognition is no longer a U.S. phenomenon,” said Hughes-Rease, a Nursing Knowledge Center consultant who has worked with hospitals in Japan. “Nursing is a worldwide profession and nurses have become global citizens, and it does not take long for the word to get out in terms of the best practices of nursing.”
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Contents
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Understand Magnet nursing
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Interim director discusses past and future of the Magnet program.
Magnet hospitals - nurse giving thumbs up sign
The Magnet difference
Experts discuss some of the unique characteristics of Magnet hospitals.
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Find your Magnet hospital
A breakdown by state of all the Magnet hospitals in the U.S.
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Magnet has global appeal
Hospitals in other countries are seeking Magnet recognition.
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Frontline nurses take the lead
Nurses are taking on leadership roles as Magnet Champions.
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Free CE: From Novice to expert
Build your expertise by adding to your skills and experience.
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Magnet can be a lifesaver
Read first-hand account of how Magnet hospitals saves lives.
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Seeking Magnet: Pros and cons
A look at some of the benefits and costs of pursuing Magnet status.
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Improve patient care
Research suggests Magnet status can improve patient outcomes.
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Nurses battle Hurricane Harvey
Nurses at Magnet hospitals in Houston stepped up during crisis.
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Achieve accreditation
Key steps hospitals can take to help them in the Magnet process.
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Lifelong learning in nursing
Magnet program places a strong emphasis on continuing education.
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continuing education catalog
Continuing education catalog
A look at courses that can help nurses on the Magnet journey.
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APRNs and Magnet nursing
Magnet status can elevate nurse educational standards.
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When you get the Magnet call
Read testimonial from CNO of one of the newest Magnet hospitals.
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What being Magnet means
Learn about the continuing journey of the nation's first Magnet hospital.
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Achieve nursing excellence
Read stories of recent Magnet Nurses of the Year winners.
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It takes a special leader
Find out how transformational leadership leads to satisfaction.
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RNs gain support
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The Magnet culture dictates fitting education into nurses' routine.
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IOM goals are top of mind
Magnet supports education targets for 2020.
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RNs are at the helm
Transformational leadership plays big role in Magnet process.
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