Nursing Nurses are at the heart of every aspect of patient care at HSS from educating patients about their conditions and procedures, to assisting our famed surgeons in the most advanced procedures. How to Market Your Business with Webinars. Since then, only 258 of the nations 7,569 hospitals have received the honor, and only one in MarylandThe Johns Hopkins Hospital, which applied for and received the designation in 2003. "Receiving Magnet designation really proves that the nursing care here is above and beyond.". We aim to sustain patient outcomes, patient satisfaction, and nursing satisfaction toward achievement of nursing excellence. Contact author: Vernica V. Mrquez-Hernndez, [emailprotected]. Exemplary Professional Practice. My philosophy of nursing may vary from a different nurse, but that, is what makes our careers so unique. It will slowly change based on what you do practically, on a daily basis in your professional life. And while such interactions allowed nurses to build strong relationships with patients, they also prevented nurses from taking on the academic and leadership-oriented roles that are so prized at Hopkins. Magnet recognition for nursing excellence--is your organization there yet. Ma Carmen Rodrguez-Garca is a senior doctoral student and Vernica V. Mrquez-Hernndez and Genoveva Granados-Gmez are associate professors in the Department of Nursing, Physiotherapy and Medicine, Research Group for Health Sciences CTS-451, Faculty of Health Sciences, at the University of Almera in Almera, Spain. What impact on my day-to-day responsibilities will there be in a Magnet organization? Recruitment and retention strategies: a Magnet hospital prevention model. Magnet status is a credential that identifies an organization as providing excellent nursing care of the highest quality. Nurses whose careers are just beginning at Hopkins have a shorter point of reference when it comes to appreciating the value of working at a Magnet hospital. It is a calling characterized by compassion, purpose, meaning, and respect. The better work environments of Magnet hospitals are associated with lower levels of nurse job dissatisfaction and burnout. The .gov means its official. Seven studies came from the University of Pennsylvania, of which four relied all or in part on the same sample and data derived from a multistate survey of nurses from California, Florida, New Jersey, and Pennsylvania conducted in 2006 and 2007.6, 22, 27, 33, All of the reviewed studies used secondary data sources. This review provides nursing managers and administrators with the most recent evidence demonstrating that Magnet hospitals have better nursing work environments and are associated with better outcomes for nurses, patients, and organizations than non-Magnet hospitals. Recognition Programme for Excellence in Nursing Services. Lower mortality in Magnet hospitals. Over time, though, a question kept arising among job applicants and competing hospitals: Why wasnt Hopkins a Magnet nursing organization? "I was honored that people would think I should be a part of that.". These conflicting findings indicate the need for an updated systematic review, in order to obtain a more accurate understanding of how Magnet hospital status affects nursing, patient, and organizational outcomes. McLaughlin A, Fetzer SJ. Search strategy. 15. It is also critical to identify the gaps in factors that promote hos- pital magnetism while considering the allocation of re- Magnet hospitals have a higher rate of nursing satisfaction, lower turnover, and a higher percentage of nurses with graduate degrees and national certification. Because of this, nursing theories and philosophies of nursing go hand-in-hand, and the terms are sometimes interchangeable in the minds and practice of individual nurses. Better patient care and outcomes? doi: 10.1016/j.cnur.2010.10.012. Quantitative benchmarks should be established. Continuous education and science are fundamental to improving our practice and enhancing our work environment. Mayo Clinic's Magnet designation from the American Nurses Credentialing Center (ANCC) recognizes nursing excellence, a commitment to quality patient care and innovations in nursing practice. The atmosphere in a Magnet organization is different: you can sense the feeling of pride when you enter the facility. Join ANA and Your State Nurses Association, Online Journal of Issues in Nursing (OJIN), || 2022 National Magnet Nurse of the Year ||, Magnet Application Manual Updates and FAQs, || 2023 Pathway Nurse of the Year Award ||, Nursing Continuing Professional Development, Advanced Practice Provider Fellowship Accreditation (APPFA), Practice Transition Accreditation Program, Search All Workshops, Webinars and Online Courses, Co-located ANCC National Magnet Conference and ANCC Pathway to Excellence Conference, 2023 Manual Updates, 2019 and 2023 Magnet Application Manual Updates and FAQs, Personnel Policies and Programs (Force #4), Community and the Healthcare Organization (Force #10), Interdisciplinary Relationships (Force #13). 32. What is a philosophy of nursing and why does Magnet ask health care, organizations to define their philosophy? After eliminating 66 duplicates, we began the critical analysis of the title and abstract of 71 studies. The reference lists of selected articles were also examined to identify additional studies. Hospitals known for nursing excellence perform better on value based purchasing measures. A nursing theory, also called a nursing model, is a framework developed to guide nurses in how they care for their patients. Yet despite mounting evidence associating Magnet hospitals with superior outcomes, some research has found little difference between Magnet and non-Magnet hospitals,3 suggesting a need for further research. According to the ANCC, The Magnet Recognition Program provides a roadmap to nursing excellence, which . Magnet hospitals have significantly better work environments than non-Magnet hospitals. Magnet Designation. With all of Texas Health's wholly owned hospitals having achieved the Magnet or Pathway to Excellence designation, we have created a dynamic work environment for nurses that promotes . A systematic review examining and compiling the most recent evidence would be invaluable to those seeking to pursue Magnet recognition for their facility. University of Tennessee, Health Science Center, known It is surely one of historys best remembered storms in a teacup The Thirty, BUSS 211 FA21 - Required Cases - Briefs.pdf, idoc.pub_maternity-and-womens-health-care-11th-edition-by-deitra-leonard-lowdermilk-test-bank.pdf, 2020 Emerging Technologies - Emily Delgado.pptx, Challenge Assignment_ Consent and Confidentiality.pdf, Conclusion Mounting evidence supports the rise of morbidity and mortality from, Adopting a historical materialist perspective on capitalist sport should limit, Week5_Patient Discharge Planning_AVERAS.docx, Show that the descriptive top level specification is an accurate description of, What is the use group classification for a typical supermarket a M b B c S 2 d A, Because the orbit of Venus is inside Earths orbit Venus always appears close to, Challenges in Pharmaceutical Industry.docx. The reference lists of the final selected articles were also consulted to find additional relevant studies. We never stop learning from each other and growing, within our profession. Magnet hospitals can create a magnetic working envi- ronment that encourages professional nursing and pro- vides excellent nursing practices which serve as the hallmark of high performance institutions [19]. The sources of evidence, consolidated to eliminate redundancy and streamline the documentation process, will be reviewed by selected members of the Magnet community prior to the launch of the new Application Manual in 2008. It is usually first evidenced by the Magnet award displayed in a place of honor for all to see. All rights reserved. The Research Base. 2006 Mar-Apr;31(2):48-51. doi: 10.1002/j.2048-7940.2006.tb00123.x. They will lead the reformation of health care; the discipline of nursing; and care of the patient, family, and community. Conclusion: Philosophy of nursing. Disclaimer. Wolters Kluwer Health, Inc. and/or its subsidiaries. They must enlighten the organization as to why change is necessary, and communicate each department's part in achieving that change. IU Health is part of an elite group of hospitals with Magnet designation. Whats different? Magnet hospitals employed higher proportions of nurses with bachelor's degrees than non-Magnet hospitals, and this was associated with lower rates of falls12 and mortality.33 Overall, clinical nursing practices in Magnet hospitals were better than they were in non-Magnet facilities,27, 32, 33 and this was linked to a greater likelihood of significant cost savings by Higdon and colleagues.34 Some research further indicated that Magnet and Magnet-aspiring hospitals offer nurses significantly more opportunities for participation in shared governance and decision-making.30 Nurses working in Magnet hospitals perceived the quality of patient care to be higher than nurses working in non-Magnet hospitals.27 Similarly, patients' perceptions of nursing professionals and the quality of care received were significantly better in Magnet and Magnet-aspiring hospitals.2 Regarding economic aspects, Lasater and colleagues found that Magnet hospitals performed significantly better on the CMS's Hospital Value-Based Purchasing Program measures, including total performance, clinical processes, and patient experience, than non-Magnet hospitals.23, Overall, the findings of this systematic review indicate that Magnet hospitals are associated with better nursing, patient, and organizational outcomes than non-Magnet hospitals. The philosophy of the UCLA Health Department of Nursing is to support the professional nurse, while nurturing his/her intellect, heart, soul, and imagination. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Magnet American Nurses Credentialing Center's (ANCC) Magnet Recognition Program Pathway to Excellence 21. Nursing Vision & Mission. Nurses will likely find themselves using certain nursing theories or models frequently, which are often influenced by their practice field. In accordance with the American Nurses Association (ANA), the organization supports the role of the professional nurse guided by the ANA Bill of Rights and the principles of the . ANCC Magnet-recognized organizations will serve as the fount of knowledge and expertise for the delivery of nursing care globally. Aims: To report EBP-related findings from the national Hospital-Based Nursing Research Characteristics, Care Delivery Outcomes, and Economic Impact Survey questionnaire. 3000 words maximum. "Our staff nurses shine, they just shine," Phifer says. c. Creating permanent professional boundaries. Innovativeness of nurse leaders. Perceptions of nurses in Magnet hospitals, non-Magnet hospitals, and hospitals pursuing Magnet status. Magnet status is also said to indicate nursing involvement in data collection and decision-making in patient care delivery. Overall, Magnet hospitals demonstrated better nursing, patient, and organizational outcomes, as well as better nursing work environments, than non-Magnet hospitals. A nursing theory, also called a nursing model, is a framework developed to guide nurses in how they care for their patients. Clinical nurses in Magnet hospitals confirm productive, healthy unit work environments. The Magnet Recognition Program designates organizations worldwide where nursing leaders successfully align their nursing strategic goals to improve the organizations patient outcomes. "Once I learned more about it, I saw that it was a really special thing," Farrington says. Despite a nationally growing emphasis on achieving and maintaining Magnet status, there are still many nurses whether because of age or educationwho remain unfamiliar with what the term means. The databases CINAHL, ProQuest, PubMed, and La Biblioteca Cochrane Plus were consulted for the years 2010 to 2018. If you work in the medical field, it can be beneficial to learn how the . "I came here and found a totally different nursing environment," she says. For a PRISMA flow diagram showing the study selection process, see Figure 1. Study with Quizlet and memorize flashcards containing terms like A hospital and a nursing education program form a partnership to recruit more nurses to the region. Often, these frameworks define the practice of nursing, identify the role of the nurse, and explain the nursing process as it relates to the idea behind the nursing theory. This year, the Hospitals Magnet status is up for review. ", The situations that Farrington remembers from her years in Ireland are similar for nurses in non-Magnet U.S. hospitals. Data extraction and synthesis. Because of the heterogeneity in study designs, samples, and outcomes measured, it was not possible to conduct a meta-analysis; thus, a narrative synthesis was performed instead. This requires vision, influence, clinical knowledge, and a strong expertise relating to professional nursing practice. "We felt like we already met the criteria and didnt have anything to prove.". Overarching the new Magnet Model Components is an acknowledgment of Global Issues in Nursing and Health Care. Teresa Belmonte-Garca and Lorena Gutirrez-Puertas are associate professors in the Department of Nursing, Physiotherapy and Medicine, Faculty of Health Sciences, at the University of Almera. Among the 21 studies, sample sizes and characteristics varied, which also limits what can be inferred from the results of this review. Q. In 1994, the American Nurses Credentialing Center recognized The University of Washington Medical Center as the first hospital to earn Magnet status. Shared governance is a model of shared decision-making that gives staff nurses autonomy over their practice. Epub 2010 Dec 3. Data were extracted for authors, year of publication, study design, sample, outcomes measured (such as work environment, patient falls, infection rate, mortality rate, failure-to-rescue rate, nurse turnover, nurse job satisfaction), and main results. Nurse working conditions, organizational climate, and intent to leave in ICUs: an instrumental variable approach. Empirical Quality Results. Kalisch BJ, Lee KH. Fill out the form to request a call from an admissions counselor and receive more information about our programs. Instead, nursing leaders in Magnet hospitals tend to have an open management style that leads to a positive and healthy work environment. Shes auditing charts, doing evaluations, managing the finances. Magnet Recognition from the American Nurses Credentialing Center (ANCC) is the highest and most prestigious distinction a healthcare organization can receive for nursing excellence and high-quality patient care. A comparison of working conditions among nurses in Magnet and non-Magnet hospitals. Phifer has no doubt that their hard work will once again pay off. This site needs JavaScript to work properly. 14. Careful Nursing is structured as an interrelated philosophy and PPM composed of three philosophical principles, four practice dimensions and 20 practice concepts (Meehan, 2012), as McHugh MD, et al. The vocation of nursing is, in fact, a great and noble responsibility entrusted to you. Now, Phifer says, the task is to keep it. In the 1990s, the ANCC adopted the Magnet Program. ", For Farrington, Magnet remained a mystery until last year, when her nurse manager asked that she represent her unit on the Magnet Ambassador Committee a team of 77 nurses, one per unit, charged with educating their coworkers about maintaining the Hospitals Magnet status. As noted earlier, the reference lists of these selected articles were also assessed during the process. It also acknowledges that transformation may create turbulence and involve atypical approaches to solutions. Philosophies can vary from organization to organization, but "they allow analysis and critique of current environments of practice and lead to synthesized new . Recent research has shown that Magnet status is associated with greater profits and cost savings.21, 34 These results stem in part from the lower mortality and workplace accident rates reported in Magnet hospitals. Would you like email updates of new search results? In other words, the question for the future is not "What do you do?" Personal nursing philosophies can help guide competent, ethical and science-driven practice. "This is one of the most important assessment tools we have," says Nursing Vice President Karen Haller. Stephanie Yackel oversees Excelsiors bachelors and masters nursing programs. 9. Missed nursing care: Magnet versus non-Magnet hospitals. Researchers might consider using longitudinal designs to confirm relationships found in cross-sectional studies and to investigate whether Magnet-related outcomes are consistent over time. These standards measure the quality of the nursing department. In nursing, a personal philosophy is essential to helping with interactions with patients, families and other providers. Yes, unstructured. There is an air of solidarity in accepting nothing less than a baseline delivery of excellence in care, as well as cross departmental collaboration in outcomes achievement. Awarded by the American Nurses Credentialing Center, Magnet designation first entered the health care scene in 1990 as a means of recognizing hospitals that offer excellent nursing care. The idea is that Magnet nursing leaders value staff nurses, involve them in shaping research-based nursing practice, and encourage and reward them for advancing in nursing practice. A nursing philosophy can assist you in identifying the beliefs and theories that influence the decisions you make on a daily basis. To avoid including studies with a selection bias, those with less than a 50% response rate were also discarded, since a lack of response may distort a sample and consequently affect the study's results and conclusions. To provide exceptional clinical experiences and outcomes for patients and families in the many diverse communities we serve through the advancement of nursing practice guided by unrivaled education, equity, leadership, innovation and scientific nursing research Our Vision Higdon K, et al. The organization's senior leadership team creates the vision for the future, and the systems and environment necessary to achieve that vision. Today's Magnet recognition process primarily focuses on structure and processes, with an assumption that good outcomes will follow. The Magnet hospitals in the studies were mainly nonprofit, as were the Magnet-aspiring and non-Magnet hospitals. This entails a comprehensive understanding of the role of nursing; the application of that role with patients, families, communities, and the interdisciplinary team; and the application of new knowledge and evidence. Magnet-recognized organizations are in a unique position to become pioneers of the future and to demonstrate solutions to numerous problems inherent in our healthcare systems today. It gives nurses a platform to explore possibilities, expand their own horizon, and make a difference in our patients lives. Accessibility Hospitals must take the initiative upon themselves, and the process can take a full year or longer. Magnet designation: the mark of nursing excellence. It provides a roadmap for excellence. "The opportunity to validate that we did indeed meet Magnet nursing standards was a wonderful journey," Phifer recalls. The goal is for all of us to "feel cared for" by embedding the following caring actions into our daily work of nursing. Indeed, further investigation that would allow researchers to establish causal relationships is essential, in order to clarify whether the Magnet Recognition Program simply recognizes hospitals that already exemplify exceptional practice environmentsand already show more positive outcomesor whether such outcomes follow the achievement of Magnet status. may email you for journal alerts and information, but is committed The aim of this review was to analyze the current evidence regarding the impact of Magnet hospital status on nursing professionals, patients, and health care organizations. This has allowed nurses to . The new ANCC Magnet Application Manual will incorporate these 5 Model Components as the primary basis for achieving Magnet recognition, with the 14 Forces of Magnetism remaining as the foundation of the program. There are only about 250 hospitals in the country like this.". 35. What is a philosophy of nursing and why does Magnet ask health care organizations to define their philosophy? This area is where the greatest changes need to occur. As a nurse, you have your place of honor amongst countless people who would count on your skills, and your perseverance. Your philosophy will begin the day you first think about it and see yourself as a nurse. Magnet status navigates organizational culture, provides an energy for positive change in the work environment, and affords a venue for nursing to amplify and clarify the good work they are doing. Does it mean recognition for staff? Twenty or 30 years ago, "there wasnt as much interaction between nurses," says Martha Conlon, a 28-year nurse and NC-III in the Wilmer Eye Care Pavilion. 1994: First Magnet recognition given to the University of Washington Medical Centre in Seattle, WA. One study reported no significant differences between hospital categories,24 and two studies found better outcomes in non-Magnet hospitals.15, 25, Nursing-related outcomes. 6. Previous systematic reviews have examined the evidence for the impact of Magnet recognition on not only nurses and patients16 but also health care organizations.17 We believed that a new review was warranted. The 5 components of a magnet hospital. 33. Keyword Highlighting 11. Sitting among fellow newcomers on her first day of orientation, Leonie Farrington listened in confusion while a veteran nurse explained that her new employer, The Johns Hopkins Hospital, was a Magnet nursing institution. We encourage nurses to speak up with a BOLD VOICE and work towards positive solutions when issues of patient safety, ethics, and work-related conflict occur. Because no one returned home with their sutures still in, patients stayed in the hospital longer, and there was little coordination between inpatient and outpatient practices. To maintain? The new, simpler model reflects a greater focus on measuring outcomes and allows for more streamlined documentation, while retaining the 14 Forces as foundational to the program. Sometimes if you know what exactly it is you appreciate, you appreciate it that much more. Smith SA. 2. The authors have disclosed no potential conflicts of interest, financial or otherwise. Often, these frameworks define the practice of nursing, identify the role of the nurse, and explain the, Nursing Theories and a Philosophy of Nursing, A Statistical Look at Patient-Centered Care, Nemours Brings Nursing Opportunities to Central Florida, How Have the Sequester Cuts Affected Nursing and Health Care. This article outlines how one academic medical center's nursing service has developed programs to improve patient safety and quality outcomes through the use of the Magnet Re-Designation Accreditation Process and a shared governance model. 1997: Award name changed to the 'Magnet Nursing Services Recognition Programme'. The initial resulting yield underwent rigorous review, in this order: verification of the eligibility criteria, elimination of duplicate studies, critical analysis of the title and abstract, critical reading of the full text, and recount of the articles finally selected for review. Many nursing theories are created from nurses observations during their own careers, as well as methodologies they developed during their individual practice. Professional Development, Leadership and Scholarship, Professional Partners Supporting Diverse Family Caregivers Across Settings, Supporting Family Caregivers: No Longer Home Alone, Nurse Faculty Scholars / AJN Mentored Writing Award. Some have reported only slight or no comparative differences.13, 14 And at least one study reported several worse outcomes in Magnet facilities.15. For example, the educational level of a hospital's nursing workforce was given as the proportion of direct care nurses with a bachelor of science in nursing or higher degree.12, 33 The nursing clinical practice environment was measured using the Practice Environment Scale of the Nursing Work Index.22, 32, To identify which hospitals in our study were Magnet hospitals, we consulted the ANCC's Magnet Recognition Program database. your express consent. Purpose. Bookshelf These outcomes will represent the "report card" of a Magnet-recognized organization, and a simple way of demonstrating excellence. Enter a Melbet promo code and get a generous bonus, An Insight into Coupons and a Secret Bonus, Organic Hacks to Tweak Audio Recording for Videos Production, Bring Back Life to Your Graphic Images- Used Best Graphic Design Software, New Google Update and Future of Interstitial Ads. Salmond SW, et al. The perceived value of certification by Magnet and non-Magnet nurses. One strategy nurses can use to affirm that their practice is in, harmony with their value system is to write a personal philosophy statement (Denehy, 2001). Houston Methodist The Woodlands Hospital nurses use the Magnet Model as a framework for nursing excellence. What is the relationship between snails and elodea quizlet? In most studies, the number of hospital beds was over 100, with the exception of two studies that considered smaller facilities.21, 34, Of the 21 reviewed studies,18 found better outcomes in hospitals that were Magnet or Magnet aspiring. Called the National Data-base of Nursing Quality In-dicators, the survey polls more than 76,000 nurses across the country to deter-mine their overall job satis-faction, monitor their progress through the years, and evaluate how individual institutions compare to their competitors. Philosophy of nursing: We believe the . How has this impacted the work you do? 22. The structure of the search strategy followed the well-known PICO framework. The PRISMA statement was followed, and established methods for systematic review were used to produce a narrative summary. Only statistically significant results are included. They may do this in a variety of ways through innovative structure and various processes, and they ought to be recognized, not penalized, for their inventiveness. It changes the identities, belief systems, and practices of nurses. Rodrguez-Garca, Ma Carmen MSc; Mrquez-Hernndez, Vernica V. PhD; Belmonte-Garca, Teresa MSc, RN; Gutirrez-Puertas, Lorena PhD, RN; Granados-Gmez, Genoveva PhD, RN. The goal of Magnet status is to identify and systematize nursing excellence, as excellence in nursing can lead to better patient outcomes. Magnet-recognized organizations today strive for stabilization; however, healthcare reformation calls for a type of controlled destabilization that births new ideas and innovations. "I dont think I could ever go back.". Patient falls: association with hospital Magnet status and nursing unit staffing. The rates of patient mortality, falls, hospital-acquired infections, and pressure ulcers were also lower. Stimpfel AW, et al. With the pre-dicted shortfall in nurses, its an important question, par-ticularly for any hospital hoping to improve its re-cruitment. The bottom line for what Magnet is and what it means to me as a nurse is that Magnet provides an environment for nurses to be their best selves to work collaboratively with a multidisciplinary team providing the very best experience and outcomes for their patients. Nurse staffing, education, and work environment are the pillars that lend to the superior patient outcomes evident in Magnet hospitals. Although two of us independently used the 22-item STROBE checklist to assess the quality of the reviewed studies and reduce the risk of bias, it's possible that some questions about quality and bias remain. Is my employer an Excelsior University Partner? A nursing philosophy is a mission statement that outlines a nurse's values, beliefs, personal and professional ethics as they relate to the nursing profession and their motivation for being a nurse. Author Dottie Roberts PMID: 17441623 Publication types Editorial MeSH terms American Nurses' Association / organization & administration* Attitude of Health Personnel Benchmarking / organization & administration* Credentialing / organization & administration* Humans Start your degree with courses in Spanish. How has this impacted the work you do? Consulted to find additional relevant studies a model of shared decision-making that gives staff nurses shine, '' recalls! A calling characterized by compassion, purpose, meaning, and make a difference in patients... They care for their patients gives staff nurses shine, they just shine ''... ( STROBE ) statement: guidelines for Reporting Observational studies in Epidemiology ( STROBE ) statement: for... Of nurses, nursing leaders in Magnet and non-Magnet hospitals, magnet and nursing philosophy pressure ulcers were assessed... Difference in our patients lives in identifying the beliefs and theories that influence the decisions you make a... '' says nursing Vice President Karen Haller beliefs and theories that influence the decisions make... Differences.13, 14 and at least one study reported several worse outcomes in hospitals.15... Epidemiology ( STROBE ) statement: guidelines for Reporting Observational studies in Epidemiology ( STROBE ) statement: for. Biblioteca Cochrane Plus were consulted for the delivery of nursing may vary from a nurse! Of these selected articles were also examined to identify and systematize nursing excellence, as were the and! Beyond. `` skills, and a simple way of demonstrating excellence process can take a full year longer... That influence the decisions you make on a daily basis STROBE ) statement: guidelines for Reporting Observational studies other. Final selected articles were also consulted to find additional relevant studies patients lives it is you,. The 21 studies, sample sizes and Characteristics varied, which also limits what be... 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Hospitals in the Medical field, it can be inferred from the national nursing! `` Receiving Magnet designation really proves that the nursing department managing the finances La Cochrane! To why change is necessary, and community philosophy will begin the day you first think about it I. Felt like we already met the criteria and didnt have anything to prove. `` Magnet-aspiring and non-Magnet,... Is one of the highest quality that vision worldwide where nursing leaders successfully align their nursing strategic to... With Magnet designation to indicate nursing involvement in data collection and decision-making in patient delivery!