Introduction

The first reference to the concept of a Magnet hospital in the United States arose in response to the nursing shortage in the 1980s. The term was introduced by the American Nursing Academy (ANA), which conducted an analysis of the organizational structures of 183 hospitals, identifying 41 institutions that were notable for their ability to attract and retain highly qualified nursing professionals. These hospitals were subsequently designated as Magnets, and the characteristics of these institutions were grouped together and referred to as the 14 Forces of Magnetism.(¹, ², ³)

A few years later, the ANA gave rise to the American Nursing Credentialing Center (ANCC). The ANCC is a non-profit organization that offers accreditation programs and developed the Magnet Recognition Program to recognize excellence in nursing practice in healthcare institutions. In 1994, the University of Washington Medical Center was the first hospital to be designated by the organization. A few years later, in 2000, the program was extended to designate hospitals outside the United States.(⁴, ⁵)

In 2008, ANCC brought a new vision to the program, proposing a model that would encompass the 14 Forces of Magnetism through five core components: transformational leadership; empowerment framework; exemplary professional practice; new knowledge, innovations and improvements; and empirical results.(², ³, ⁴, ⁶)

Worldwide, having Magnet designation (MD) is the highest recognition of nursing that a healthcare institution can have. In addition to obtaining greater distinction for improving market share and elucidating the commitment and quality of care, MD is able to map hospitals that have excellent nursing practices, represented not only by good clinical practices, but also by better working conditions for the team.(⁷, ⁸, ⁹)

The United States contributes the largest number of Magnet-designated hospitals, and there is a continuous movement to expand designation to other countries around the world. Currently, there are 597 hospitals covered, 14 of which are outside the United States. In this scenario, countries such as Australia, Saudi Arabia, Belgium, Canada, the United Arab Emirates, England, Japan and Lebanon have representation of Magnet-designated institutions in their territories. Recently, Brazil joined this select group of institutions that represent excellence in terms of nursing practice and organization of related services.(¹⁰, ¹¹, ¹²)

To implement Magnet culture, it is necessary to consider a quality improvement journey. To this end, knowledge of the standards described in the program manual and appropriate analysis of existing gaps before application is submitted to ANCC are essential. The manual is updated periodically, and the last one was published in 2023.(¹³, ¹⁴)

Innovation and the relevance of qualified nursing practice to the institution are factors that must be expressed by an organization during the Magnet journey. The service must present excellence in the nursing care provided, in addition to expressing indicators that are superior to national benchmarks.

Additionally, the institution must provide budgetary information, identifying how financial resources are applied to activities related to teaching, research, education, certification programs and workshops, in order to promote an environment of continuous learning. It is necessary to present evidence that demonstrates nurses’ active participation in these processes as well as the presence of the Forces of Magnetism described in the model.(¹⁴)

Obtaining Magnet recognition by Hospital Israelita Albert Einstein (HIAE) represents a milestone for Brazilian nursing. The journey to obtain MD at HIAE began in 2011 and, to this end, the institution developed and implemented a strategic action plan to achieve this goal, in addition to focusing on the development of specific activities, based on the five components proposed by the Magnet Recognition Program. The delivery of the report in the midst of the coronavirus disease 2019 (COVID-19) pandemic, in May 2021, highlights the determination and commitment of the team involved.(⁸)

In July 2022, HIAE received the prestigious MD, being recognized internationally for excellence in nursing practices and strategies. The organization became a pioneer in Latin America and one of the few institutions outside the United States to achieve this feat.(⁸)

In addition to qualifying the nursing care practice environment, designation also has a significant impact on patients. It is known that care outcomes are better in Magnet hospitals when compared to non-Magnet hospitals.(¹⁵)

At HIAE, the structuring of a management model aligned with Magnet standards resulted in a reduction in the rate of acquired pressure injuries, surgical site infections, the rate of phlebitis in hospitalized patients, the rate of contrast media extravasation in diagnostic exams, the rate of catheter-associated bloodstream infections and the rate of hyperglycemia in intensive care patients.(⁸, ¹⁵)

The present study has the following research question: What impact does certification have on the present and future of nursing in the first designated hospital in Latin America in the perception of nurses who experienced the Magnet journey?

The recent achievement of MD in the country makes this study one of the first to be developed on the subject, being relevant for understanding the processes of the journey until its achievement.

This study aimed to identify the relationship between MD and nurses’ perceptions of the work process at the first Magnet institution in Latin America and the impact that designation has on nursing at the institution.

Methods

This is a descriptive-exploratory and qualitative study, carried out through evidence based on an individual’s perceptions about a specific phenomenon studied.(¹⁶, ¹⁷, ¹⁸)

The study was carried out in a private extra-port hospital, located in the south of the city of São Paulo (SP).

The sample was composed through a convenience approach, with tactical nursing leaders from the institution, called champions. The champions are nurses who represent the nursing care team, who underwent a training cycle on the Magnet Recognition Program, with the objective of multiplying the actions and proposals to achieve and maintain the standards of excellence proposed by designation, thus being considered the Magnet reference at the local level. Participants were professionals who worked in the adult and pediatric emergency departments, adult Intensive Care Unit and urological medical and surgical clinic.

Nurses who had worked at the hospital for three or more years and had the opportunity to work in a specific stage of the process of obtaining MD were invited to participate. This criterion was defined based on the strategy adopted by the institution of appointing professionals who were references in each care unit and who would be responsible for disseminating Magnet culture in their place of work and coordinating the units. Nurses who were on vacation, away or on leave during the data collection period were excluded.

Data collection was carried out through semi-structured interviews, prepared and conducted by the authors of the research. The script consisted of data from nurses from different hierarchical levels and fields of activity, addressing their perceptions and experiences in the institution and characterizing the impact that Magnet certification brought to nursing practice.

Data were collected between April and October 2023, as previously scheduled with study participants. The interview took place in the work sector itself, in a private location and in person, and was guided by the following question: Tell me about your performance during the Magnet journey in this hospital and in your unit.

The number of interviews was obtained when statements became successively repetitive, i.e., when there was data saturation. The interviews were recorded in audio and then transcribed literally.

The data were analyzed using thematic content analysis, respecting the stages of pre-analysis, material exploration and data interpretation.(¹⁹)

The interviews were transcribed using Transkriptor software. The transcribed content was then adapted to the standard Portuguese language, without compromising the meaning of the statements. The analyses were conducted using the Interface de R pour les Analyse Multidimensionnelles de Textes et de Questionnaires (IRaMuTeq) software.

The champions’ transcribed perceptions were analyzed from two perspectives. The first was lexical analysis, using IRaMuTeq version 0.7 alpha 2 and R version 3.2.3. The transcribed reports composed the text corpus and, from the analysis, Text Segments (TS) and the clustering of statistically significant words were identified. The authors organized the analysis as follows: 1) Descending

Hierarchical Classification, in which words with statistical significance are organized into classes; and analysis or similitude tree, which is based on graph theory and is performed based on the occurrences of words present in TS from word cloud. Then, the names of the classes were defined through exhaustive reading of TS, correlating them with the frequency of the terms contained in the vocabulary, in order to reveal, in depth, nurses’ perceptions about the Magnet journey. Subsequently, thematic content analysis was performed, in which perceptions were read several times in a stage known as skimming. After mastering the data, extraction of meanings, coding, categorization and correlation of information collected with the research objective were performed. Lexical analysis and thematic content analysis were organized in such a way as to complement each other for better understanding of the data. Thus, the classes and categories were named in a similar way.(²⁰)

Data collection began after the research project was approved by the Faculdade Israelita de Ciências da Saúde Albert Einstein Scientific Committee and by the HIAE Research Ethics Committee, under CAAE (Certificado de Apresentação para Apreciação Etica - Certificate of Presentation for Ethical Consideration) 65850022.7.0000.0071 and Opinion 5.951.517, and also after authorization from the area managers.

Results

The study sample consisted of11 nurses who worked in the adult and pediatric emergency departments (45%), adult Intensive Care Unit (36%), and urology clinic (19%). All professionals interviewed actively participated in the Magnet journey within their work units. The interviewees’ mean age was 42.3 years. The mean length of professional experience at the institution was 15.4 years. Most participants held the position of senior nurse (55%) and were female (63%). In the analysis document, 109 records with nurses’ perceptions were identified, characterizing the general corpus of the study. These were separated into 107 TS, with 100 TS being used (93.45%). A total of 1,718 occurrences (words, forms, or vocabulary) were generated, of which 625 were distinct words and 371 had a single occurrence. The analyzed content was categorized into three classes: class 1, with 36 TS (57.73%); class 2, with 18 TS (24.81%); and class 3, with 17 TS (22.51%) (Figure 1).(²⁰)

Figure 2 shows the similarity tree, in which the relationship between the segment “people” and words that involved nurses’ perception of the Magnet journey was observed, highlighting the human factor as a strong element linked to the magnetic hospital (Einstein and Magnet).

After analyzing the initial data, eight subcategories emerged. Figure 3 presents descriptions of the categories and subcategories, with excerpts from nurses’ speeches.

Nurses’ feelings after designation

In this category, nurses’ perceptions regarding feelings related to their work in a hospital designated by Magnet and the impact attributed to designation, both for the professional and for the institution, were addressed.

Personal satisfaction

Nurses spoke about their daily work routine in a magnet hospital, highlighting the pride and satisfaction of belonging to a Magnet organization.

Professional engagement

In addition to the feeling of pride, nurses highlighted the importance of MD as a promoter of team engagement. The Magnet journey was able to motivate nursing professionals in carrying out the daily work process, being associated with the feeling of professional and personal satisfaction.

Engagement and motivation came from pride in belonging to the institution, but also inspired by the way the journey was designed. In addition to this, professionals perceived individual gains in their careers and for the organization.

In several speeches, the Magnet journey was linked to the need for constant team improvement, being a motivator for participation in continuing education actions, for instance.

Professional class valorization

Regarding the impact of MD on the professional category, nurses pointed out the appreciation and recognition of nursing as important achievements linked to obtaining it. The recognition of the institution towards the nursing service was highlighted as well as of patients, other healthcare professionals and other organizations.

Other nurses made a contrast between the atmosphere prior to designation and how they perceived the service’s current situation in relation to nursing appreciation and empowerment.

Differences were also highlighted between nursing at the Magnet institution and others that did not have designation.

Opportunities for career growth

In their speeches, nurses highlighted the opportunities that the institution provides for professional growth. On the other hand, some stressed that, although the institution provides support for development, there should also be individual commitment to achieving the excellence required by the position.

The benefits granted by the institution for individual improvement and career plan development in nursing were highlighted. It was also mentioned that these investments originated even before the institution opted for the Magnet seal.

Reflecting on the challenges after designation

This category groups together two central ideas. The first was related to the challenge of maintaining good practices and engaged professionals. The second presented the challenge of establishing a long-lasting Magnet culture in the institution and the purpose of influencing other organizations with designation.

Maintaining excellence

Some professionals pointed out in their speeches the challenge of being reassigned and sustaining nursing excellence within the institution, highlighting the difficulties faced in keeping professionals involved and engaged, with a focus on results.

Another connection that emerged from the speeches as a challenge was maintaining excellence in a complex hospital system of large proportions in terms of the volume of professionals working there.

Establishment of Magnet culture

Taking into account the fact that Hospital Albert Einstein was the first in Latin America to be recognized with MD, it was a challenge to establish and perpetuate this culture in the institution.

Understanding the relevance of working in a Magnet hospital in Brazil

In this category, two subcategories were grouped together, which included the perceptions of the nurses interviewed about how MD could impact other healthcare services and Brazilian nursing.

Model hospital for other institutions in the country

The hospital was a pioneer on several fronts when it came to accreditations in Brazil. In this context, Magnet put the institution in the spotlight, being the first hospital in the country to obtain designation. Professionals recognized this pioneering spirit and compared MD with other quality certifications that the institution had and that, in their perspectives, influenced the health system.

National nursing valorization

The interviewees discussed how MD could be important in bringing visibility and appreciation to Brazilian nursing. Nurses reported that MD is capable of recognizing them from an organizational point of view, but they also highlighted the importance of designation in obtaining recognition of nursing by patients.

Discussion

The 11 study participants highlighted their pride in working at an institution of excellence for nursing practice and demonstrated satisfaction in having contributed to achieving MD at HIAE. It was possible to verify that nurses considered themselves active agents in the journey to achieve designation. They also recognized the potential impact of designation for national nursing by influencing other institutions that aim for the same level of quality defined by accreditation standards.

Although nursing is essential at all levels of healthcare, there are several challenges in managing healthcare work in Brazil and around the world, a fact that has become even more evident since the COVID-19 pandemic. Some sensitive issues have been debated for years, such as low pay, lack of professional motivation, precarious employment relationships, and difficulties in implementing strategies to reduce employee turnover. Thus, achieving MD highlights actions that aim to attract, retain, empower, and value nursing professionals.(²¹, ²², ²³)

When compared to those in non-designated hospitals, nurses working in Magnet institutions are more likely to report job satisfaction and lower risk of burnout, in addition to expressing a desire to remain at the institution. Furthermore, it is possible to identify that these professionals have greater autonomy, more opportunities for professional development and collaborative multidisciplinary relationships.(²²) In this study, nurses compared their experience at HIAE with what they could experience in other healthcare institutions in the country, placing the institution as a reference in terms of professional recognition and appreciation. They highlighted nursing autonomy as a determining factor for professional engagement as well as strategies for developing the human factor that the nursing team can benefit from in the institution.

In parallel to this, even though magnetic hospitals have subsidies to empower and increase nursing professionals’ satisfaction, sustaining engagement and motivating the team continue to be challenges to be addressed by leaders.(⁸) This perspective was highlighted by the nurses interviewed and considered a future challenge to be faced by the institution’s strategic leaders.

HIAE had already adopted a set of policies and practices that translated into professional appreciation - even before it envisioned achieving Magnet. The foundation built at the institution to meet the requirements of the other accreditations that the organization holds certainly contributed to a differentiated organizational environment and workforce management indicators consistent with Magnet’s demanding standards. The nurses themselves recognized the crucial role of the Joint Commission International (JCI) and the Person-Centered Care certification (Planetree) in achieving this result at Magnet.

At the hospital, from the beginning of their professional career as a nurse, employees can benefit from career growth programs and receive different forms of support and investment. This structure contributes to greater employee engagement and helps the hospital attract and retain nursing talent.(⁸)

However, it is still difficult to determine all the impacts that Magnet can bring. The results may vary according to each institution, making the experience of being designated unique. Therefore, the processes for designation should be seen as the sum of efforts to achieve standards of excellence, bringing improvements to the institution and better working conditions for nursing professionals.(¹⁶)

It is worth noting that, in this research, it was not possible to explore reports that expressed what changes were arising from Magnet in relation to nurses’ work process in the institution to meet designation standards, just as the increase in terms of care quality after achieving designation was not highlighted.

In the context of Magnet recognition, hospitals are encouraged to adopt nursing Professional Practice Models, which are theoretical frameworks that outline nursing values and processes. Implementing these Professional Practice Models can demonstrate improvements in several aspects, including nurses’ perceptions of quality of care and patient satisfaction, (1) which can be translated into excellent care delivery, resulting in a positive reputation for nursing.

Establishing a new culture is slow, since it is associated with principles and values that are built over time and are more difficult to change. Thus, when we consider that Magnet only arrived in Brazil a year ago, it will take time to establish this culture. Even with knowledge of the attributes imposed by designation, the construction of a new culture is not yet guaranteed, given that designation has been present in the United States for over 30 years and only 10% of hospitals in the country are designated.(¹¹, ²⁴, ²⁵, ²⁶)

The presence of a Magnet hospital in Brazil, the first in Latin America, puts Brazilian nursing in the spotlight, contributing to the visibility of the profession in terms of its excellence and successful management models. Moreover, other hospitals that are on the Magnet journey can benefit from this achievement, since the sharing of insights, experiences, knowledge and perceptions throughout designation process can help in the growth and development of institutions that seek to enter the journey or those that are already on the journey and aim to be designated.(²²)

Having a designated Magnet institution brings with it the responsibility for the hospital and local nursing to remain at the forefront. Indeed, maintaining and promoting autonomy, good working conditions, better teaching conditions and professional satisfaction, linked to better outcomes, seems to be a concern for champions.(²⁷, ²⁸)

It was possible to identify that achieving MD influenced nursing’s status quo in the hospital. Magnet culture was strengthened throughout the process of achieving designation in this service.(⁸) Some studies have shown that Magnet has a positive impact on organizational culture, especially for nurses. However, the lack of standardized assessment tools used to assess the organizational culture associated with designation has limited the comparison of studies.(²⁶)

The research was conducted with nurses from different hierarchical levels and different departments. Furthermore, there was homogeneity in the content of speeches, showing that participants had a uniform view regarding the processes of the journey to Magnet. It is important to highlight that the sample consisted of champions, i.e., nurses trained in the premises of Magnet and who, therefore, had knowledge about designation. Furthermore, they experienced the journey in practice, being responsible for implementing in their units policies and practices defined by the leaders of the pillars. Thus, the perception of these nurses may differ when compared to that of nurses from the same hospital who did not actively work during the Magnet journey.

The interview analysis methods made it possible to highlight the human factor’s contribution to the Magnet journey. The dendrogram of the hierarchical classification of nurses’ perceptions about the Magnet journey and the word similarity tree highlighted “people” and “population”. The champions represent the human factor of the strategy adopted by the hospital’s Magnet implementation team.

In Brazil, most of literature produced on MD consists of case studies and integrative reviews, and further research on the topic using other methodologies is needed. Furthermore, the fact that this hospital was designated recently makes this one of the first studies conducted after designation was obtained.

It is expected that the results of this study will provide support to sustain Magnet culture in the institution and throughout the Latin American scenario, demonstrating the importance of the forces of magnetism and the impact they can have on the healthcare institution.(²⁸)

Conclusion

The results of this study made it possible to identify the perception of nurses who experienced the Magnet journey until achieving designation in the first hospital in Latin America. Nurses’ perceptions were linked to the feelings that emerged from obtaining Magnet designation, with emphasis on the pride and satisfaction of belonging to a Magnet organization, the future challenges of maintaining the standard of excellence in nursing, and the representativeness of the achievement for the professional category at a national level. Moreover, nurses understood that the success achieved in achieving designation can inspire other institutions that seek designation. Regarding the impact, nurses highlighted that, although designation was attributed to one institution, it highlighted the quality of Brazilian nursing, contributing to its greater appreciation and recognition.

References

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