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Organizational Overview

Organizational Overview

OO-5 | OO-9


Q - For the continuing educational assessment, do we need to provide each assessment individually or provide a summary of the information and data?

The organization must provide the completed, continuing educational assessment(s) for all RNs who influence care, in all levels and settings (e.g., inpatient care, ambulatory and medical practices).

Q - Must the continuing education assessment include a survey? Our organization uses other tools to build the assessment such as performance appraisals and quality and risk data.

The method of assessment is up to the organization. The key is to include all RNs (all levels) and all settings.


Q - Does the RN who is a member of the IRB need to be an employee of the applicant organization?

The requirement is there must be at least one nurse be a voting member of the governing body responsible for the protection of human research participants.  The nurse does not need to be an employee of the applicant organization.

Transformational Leadership

Transformational Leadership

TL3 | TL6 | TL7


Q - My organization does not have all the levels that are requested in the source of evidence for TL3. How do I respond to the required source of evidence request statement?

Two examples must be provided for TL3. In the case of a flat organizational nursing leadership structure (i.e. either only Nurse Managers or only AVP/Nurse Directors) two examples are required using the nurse levels that exist in the organization. For example, if there are no Nurse Managers then the organization will need to supply two AVP/director examples.


Q - What is the definition of mentoring?

Mentoring is providing information, advice, support and ideas to a person in their current role. Note: The term mentor and preceptor are not used interchangeably. See glossary definition of mentor pg. 152.


Q - What is the definition of succession planning?

Succession planning is preparing a nurse to move into a new role. For Magnet purposes, the succession planning activities of the individual does not have to result in entrance into the new role. However, the activities that move(d) them into the new role must have occurred. See glossary definition on pg. 161

The intent is that nurses are being prepared through succession-planning activities to move into one of the four options listed. For example, succession-planning activities for the CNO role might include activities for the Associate CNO or another nurse executive preparing to assume (or already assumed) the CNO’s responsibilities.

Q - My organization does not have all the levels that are requested in the source of evidence for TL7. How do I respond to the required source of evidence request statement?

Three examples must be provided for TL7 (one from an ambulatory setting) using the nurse levels that exist in the organization. If the applicant organization has a flat structure, the organization must provide three examples using the nurse levels that exist in the organization.

Q - Can I use a role not expressly identified in the four options listed? We have nurse educators, infection control, and other professional development specialist roles.

Only if one of these roles meets the definition of the four options provided. We recognize there are other opportunities for succession-planning but these four are the only options included in the Sources of Evidence.

Structural Empowerment

Structural Empowerment

SE2EO | SE4EO | SE4EO and SE6EO | SE9 | SE10 | SE12


Q - For SE2EO a and b what differentiates affiliation from participation?

Affiliation: Is a broad term and how it is used is based on the context of the requirements in the SOE. To be affiliated with an organization, the nurse does not need to be a member of the professional organization but must have, at a minimum, read an article or attended a professional organization’s conference.

Q - For SE2EO a, does the professional organization need to be a nursing organization?

It does not require a nursing profession organization however it may be easier to find evidence-based nursing practice changes in a nursing professional organization. The key point in this SOE is that the evidence-based (nursing practice) changes implemented must result from the affiliation with the professional organization. For example, a clinical nurse may have read research published by the American Medical Association that stimulated them to investigate a current nursing practice. An evidence-based nursing practice was discovered, implemented, and resulted in an improved patient outcome.

Collaboratives, consortiums, think-tanks, etc., that do not meet the professional organization definition are not allowed.

Q - For SE2EOb what is the definition of participation?

Participation is defined on page 29 of the Manual. “Participation in a professional organization may include membership, conference attendance, etc.” The outcome must be “associated with the application of NURSING Standards due to the participation”; therefore, the participation will almost always be related to a professional nursing organization. Participation - example: Active membership in a professional nursing organization and/or attendance at professional nursing organization’s conference.


Q - For SE4EO, what can be considered as organization level? For example, can organizational level be all clinical nurses or all nurse managers/directors or all specialty nurses?

Yes. An organization-level group includes nurses from all departments or divisions, e.g., all nurse managers across the applicant organization both inpatient and outpatient, or all specialty nurses.


Q - Can the goal be an annual goal, or must it be a 2-year goal?

Q - If you meet the 2-year goal in the first year, do you have to increase the goal for the 2nd year?

Improvement must be shown over time. Goals must be set by the organization to demonstrate improvement against the baseline and subsequent years.

If a 2-year goal is met in Year 1, then the second-year result is still provided in the graph and must be maintained (or improved) against the Year 1 early achievement.

Annual goal setting must demonstrate meeting the Year 1 annual goal and then meeting the Year 2 annual goal against the Year 1 result.

To illustrate, the baseline is 23%. A 1%-point annual increase from baseline goal is set = 24% but the Year 1 results are 26%. Year 2 goal is now 26+1 = 27% must be met to meet expectations. See graph example on page 31, 2019 Magnet Application manual

Q - Is a narrative required in SE4EO and/or SE6EO?

A narrative is required for mergers or acquisitions or if there are circumstances that are more clearly articulated with a narrative. If no explanation needed, the graph and data table should clearly demonstrate how these standards are met. Carefully follow the display requirements and sample graph illustrations.


Q - What New Graduate transition programs are on the list of recognized programs in the 2019 manual?

The only two national accreditation programs that meet Magnet criteria are the ANCC Practice Transition Accreditation Program (PTAP) and the College of Collegiate Nursing Education (CCNE). The ANCC PTAP program accredits RN Residency, RN Fellowship, and APRN Fellowship programs. CCNE accredits RN Residency programs. Learn more about the ANCC PTAP program:

Q - Does the evidence of participation in one of the two approved transition programs need to include more than just the New Graduate transition?

Any nurse residency or transition program can be evaluated by either ANCC or CCNE and if credentialed by either body, that certification is acceptable and fully meets SE9 (2019 manual).

During the site visit, the appraisers will validate that principles of the six elements of transition to practice programs are evident in the organization.

Q - If an organization obtains the RN residency program accreditation at a corporate level, would that meet the SE9 standard at the organization level?

Since the Practice Transition Accreditation Program (PTAP) is a programmatic credential, the entities in a System included in the PTAP accreditation are all eligible for meeting SE9 in the 2019 Magnet ® Application Manual.

The System certificate (or other documentation) needs to identify the entities within the System associated with the credential. The applicant entity must be named in the certificate to meet the requirement for SE9.


Q - I am a nurse who runs a camp for kids with medical issues, that is a part of my role and I am paid to attend (including weekends). Does this meet the intent of organizational support?

No. The intent is that the nurse is a volunteer, working for or on an initiative outside of their primary position expectations and without payment. Organizational support is related to how the organization supports the RNs who volunteer for these types of initiatives.

Examples of organizational support include marketing materials and brochures, use of equipment or supplies, time off, etc.

Q - Nurses volunteer for international outreach trips on behalf of our organization. Do international trips meet the intent for this Source of Evidence?

No. The Source of Evidence specifically references local or regional community healthcare initiative(s). Local or regional reflect geographically near the healthcare organization.


Q - I heard that organizations cannot use the Daisy award for this example.

Incorrect. The Daisy award may be used for SE12 as long as the contributions of the nurse or group of nurse’s addresses the strategic priorities of the organization.

Exemplary Professional Practice

Exemplary Professional Practice

EP6EO | EP8EO | EP9a and b | EP9b | EP11 | EP18EO International and Specialty Organizations | EP19EO


Q - What is meant by a defined patient population?

A defined patient population is group of healthcare consumers to include but not limited:

  1. Age (e.g., teens, elderly, infants)
  2. Gender (e.g., males, females, transgender)
  3. Diagnosis specific (e.g., diabetes, COPD, CHF)
  4. Care specific (e.g., ventilated patients, critical care)


Q - Is the interprofessional education activity referring to education for patients or staff?

Interprofessional education is education for patients led or co-led by a nurse and inclusive of other professions (e.g., occupational therapy, medicine, surgery, physical therapy)

EP9a and b

Q - My organization does not have all the levels that are requested in the source of evidence for EP9a and EP9b How do I respond to the required source of evidence request statement?

The applicant organization must provide two examples, one for EP9a and one for EP9b. In the case of a flat organizational nursing leadership structure (i.e. either Nurse Manager or AVP/Nurse Director) two examples are required using the nurse level that exists in the organization.


Q - I am not clear what is meant by an operational need?

An operational need is an identified gap that inhibits the ability to perform work in an efficient and effective level, e.g., equipment needs, time, or other needs related to the items needed for nurses to perform their jobs. This does not include examples of a work force (staffing) related needs.


Q - How do we handle peer feedback (or data collection) when there is only one nurse in the care setting?

There is no difference in expectations based on the number of RNs in a setting. They are expected to participate and be supported. (please see specifics for patient satisfaction data collection, p. 57) The organization is responsible for ensuring peer feedback occurs in settings that have very few RNs and/or RNs practicing in remote (off-site) settings.

EP18EO International and Specialty Organizations

Q - What data needs to be submitted for EP18EO for an International or Specialty Organization?

International or specialty organizations must submit 4 Nurse Sensitive Indicators (NSI’s) to an external vendor and be nationally benchmarked. If the organization cannot submit any of the options on page 51 then they must vet their selected, nationally-benchmarked Nurse Sensitive Clinical Indicator(s) with the Magnet Program Office.

International and Specialty organizations must present NSI data that is:

  • Nationally benchmarked
  • Nurse sensitive and
  • A Patient outcome measure

Q - My organization has no ambulatory areas, what is my requirement for EP19EO and EP21EO?

Organizations without ambulatory areas do not need to submit substitute data for EP19EO or EP21EO. Note, the Magnet Recognition Program considers the Emergency Department an ambulatory area.

Q - I am in an organization with no inpatient units, what is my requirement for EP18EO and EP 20EO?

Organizations without inpatient units do not need to submit substitute data for EP18EO or EP20EO.


Q - Both nurse sensitive indicators we have chosen are from the suggested list on p. 53. Do I still need to include narrative as to how the indicators are nurse sensitive? What if I am missing some ambulatory areas that are not eligible for these indicators?

Yes. Ambulatory care settings in particular may delegate responsibilities to other care providers beyond the registered nurse. To ensure the indicators selected are nurse sensitive in your organization, please provide a brief explanation.

You may have ambulatory areas that are not eligible for the indicator(s) selected and this is acceptable. Use the Unit Level Data Crosswalk to indicate eligible settings.

New Knowledge Innovations and Improvements

New Knowledge Innovations and Improvements

NK1 | NK2 | NK6EO | NK7EO


Q - What is a “completed” study?

For Magnet purposes, a “completed study” refers to a study that has concluded to the point of analysis and from which initial implications of the findings have been determined and dissemination has occurred or will occur. The study must be completed within the 48-month timeline. The study may start prior to the 48-month timeline.


Q - For our nursing research can we use the same study for NK2 as we use for NK1?

No. The applicant organization must use a different study for NK2 than is used for NK1. Both studies (NK1 and NK2) must have been completed within the 48-month application timeframe.

Q - Must a clinical nurse be listed as an investigator (Principal or sub-investigator) on the nursing research protocol used as the example for NK2?

Clinical nurses do not have to be PI or co-PI for NK2 but they need to have a level of knowledge and understanding of the applicant organization’s study to be able disseminate to internal and external audiences.

Q - Can I use the same study for NK2 a and b?

The applicant organization may use the same study for NK2a and b. Remember NK2 studies must be a different study than presented in NK1.


Q - Two examples are required. If I do not have any ambulatory care settings how do I respond?

Two examples must be submitted. If there is not an ambulatory setting, both may be from inpatient settings.


Q - Two examples are required. If I do not have any ambulatory care settings how do I respond?

Two examples must be submitted for NK7EOa. If there is not an ambulatory setting, both may be from inpatient settings.

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