Frequently Asked Questions About ANCC’s 2019 Magnet Recognition Program® Manual
The FAQs on this page offer program information and interpretive guidance on many aspects of the Magnet Recognition Program®.
Nurse Educators (2013)
The educator that is considered a "nurse leader" is the department head or director of all clinical nurse educators. Unit-based educators are not considered nurse leaders for Magnet purposes.
Continuing Nursing Education (10/2014)
Those activities intended to build on the educational and experimental bases of an individual for the enhancement of practice, education, administration, research, or theory development, to the end of improving the health of the public.
The Nurse Leader and Nurse Manager Eligibility Tables must be sent with the application and again when written documents are submitted.
Documentation Submission Requirements for System Applications
2019 Magnet® Application Manual, page 111
Two weeks prior to a document submission date, an electronic copy of the following documents will be emailed to the Magnet Office for each organization within the System:
Demographic Data Collection Tool (DDCT)
Submitted via online portal 2 weeks prior to documentation submission date.
By a documentation submission date, an electronic copy of the following documents will be emailed to the Magnet Office for each organization with the System:
Table indicating the distribution the Sources of Evidence, by component, across each organization within the system. See page 102 of the 2014 Magnet® Application Manual for an example.
Formatting—Electronic Submission (10/2014)
- The size of electronic files is not limited, but the files must not exceed the 350-page limit for the narrative content.
- The entire document should be submitted in Arial 12-point font, including headings.
- Items scanned in as evidence, such as meeting minutes, do not need to be in Arial 12-point font.
- Narrative statements should be straightforward and concise; they should include minimal extraneous information. Organizations may write narratives in any style, but they must be easy for the appraisers to read, understand, and navigate.
- The SOE narratives are included in the 350-page limit. The content in the Organization Overview (OO) section, evidence attachments, and graphed data for EP3EO, EP22EO, and EP23EO are not included in the page limit.
Time Frame (10/2014)
Effective October 28, 2014, the 48-month period is the new time frame for 2014 Magnet® Application Manual document submission and reflects the 48 consecutive months prior to submission of Written Documentation.
- Baseline (pre) data, interventions, and outcomes must occur within the 48-month time frame prior to submission of Written Documentation.
- A typical site visit occurs 6 to 10 months after an organization submits Written Documentation.
Exceptions to the time frame include:
- EP3EO (Nurse Satisfaction) must demonstrate the most recent nurse satisfaction survey within the previous 30 months prior to documentation submission.
- EP22EO (Nurse Sensitive Clinical Indications) must demonstrate the most recent eight consecutive quarters of data.
- EP23EO (Patient Satisfaction) must demonstrate the most recent eight consecutive quarters of data.
Evidence & Sources of Evidence
Sources of Evidence (SOE) (2013)
For the 2014 Manual, the bolded Source of Evidence statement presents the “condition” that should exist in Magnet organizations. The bulleted items, under the bolded statement, serve as the requirement(s) to which a response(s) is necessary. The bulleted requirement requests information, that is, a narrative, evidence, and data that indicate the Magnet condition exists in the organization. Provide narrative information and evidence/data for the bulleted examples only.
Nurse Manager or Unit Educator (10/2014)
The nurse manager or unit educator can be used in addressing the SOEs, depending on the specific SOE. When the source specifically states a role such as clinical nurse, then the SOE response must be specifically about the clinical nurse. If the SOE indicates nurse in general, an example using any nurse from the organization, regardless of role, is fine.
Evidence for Non-EO Sources (10/2014)
As indicated on page 24 of the 2014 Magnet® Application Manual, examples of acceptable evidence include copies of policies and procedures, meeting minutes, various types of correspondence, data, rosters, and screenshots. Evidence does not include examples and testimonials.
Using Examples More Than Once (10/2014)
You may use examples or projects in more than one source, but each source has specific requirements. As long as the example or project is able to meet the different requirements of each source (different type of outcome data, for example), then you can use that example or project for those sources.
Magnet Senior Analysts’ Tips
Gain expert insight with tips from Magnet Senior Analysts.
- Formatting Non-Eos
- Providing Evidence
Q - What is the definition of demographics?
For Magnet purposes, the population and RN statistical characteristics that are pertinent to the organization. These may include, but are not limited to, age, gender, and education of the population served and nursing (RN) staff.
Q - If the description of the history of the organization is greater than 300 words, what happens? (updated September 2019)
The appraisers evaluate the first 300 words to determine if the Organizational Overview item has been met. If it is not met in the first 300 words, a request for Additional Information will be generated.
Q - Does the continuing education assessment provided need to be completed?
Yes, the assessment must be the summary (completed, with results) of the information gathered in the most recent needs assessment.
Q - What is meant by "all RNs" and "all settings"? (updated September 2019)
A continuing educational assessment must be offered to all registered nurses, in all areas (settings) where registered nurses work in the organization. This should include the CNO, Nurse AVP/Directors, Nurse Managers, Clinical Nurses, APRNs, and any other registered nurse position.
The continuing needs assessment must demonstrate that the needs of nurses in the various settings are being addressed (i.e. inpatient, ambulatory, administration, etc.). For instance, the clinical nurses in the ICU will have very different needs assessment than ambulatory nurses in a primary care clinic.
Q - What is the meaning of the word "assessment"? (updated September 2019)
An assessment is the process the organization does to identify any potential gaps in knowledge, skills, and abilities of the registered nurses in areas where they practice. The assessment can be accomplished in numerous ways, including a self-assessment of nurses in the form of a survey or other reporting. An assessment can also be achieved with input from committees and other formal structures such as the education department, risk management, infection control and nursing leadership to identify the continuing education needs for all registered nurses. The assessment must be inclusive of all levels of nursing, including the CNO, AVP/Directors and Managers, clinical nurses, and APRNs.
Q - What is meant by "all RNs" and "all settings"? (updated September 2019)
A continuing educational assessment must be offered to all registered nurses; this should include the CNO, Nurse AVP/Directors, Nurse Managers, Clinical Nurses, APRNs, and any other registered nurse position. The continuing educational assessment must be offered in all settings where registered nurses practice (i.e. all areas where registered nurses work in the organization).
Q - Are there eligibility criteria for the individual that the CNO chooses to designate to participate in the credentialing, privileging and evaluating of APRNs?
The CNO is ultimately responsible for sustaining the standards of nursing practice throughout the organization, including APRN practice, regardless of reporting relationships. The designee must be an RN and must communicate with the CNO.
Q - What is the expectation of the CNO’s (or RN designee’s) “participation” in the credentialing, privileging, and evaluating process of all advanced practiced registered nurses (APRNs)? Do we need to describe the CNO (or designee) in every phase of credentialing?
A description of the CNO’s (or RN designee’s) participation in the credentialing and evaluation of all APRNs should be a broad description of the process. It should include the CNO’s (or designee’s) roles in credentialing, privileging, and evaluating and how the CNO (or designee) are involved/participate in the process.
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 - Does the mentor associated with a mentoring plan or program need to be a nurse?
TL6a-d: For the clinical nurse, APRN, nurse manager, and nurse AVP/Director examples, the mentor must be a registered nurse. Please refer to the definition for mentor (2019 Magnet Application Manual, pg. 152)
TL6e: For the CNO example, the mentor may be a registered nurse or a non-nurse.
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 - Updated September 2019
Q - Is it is okay for the target to be established outside the 48-month window?
If an organization has established a target outside of the 48-months, there must be narrative and supporting evidence that shows how this goal was re-established during the 48-month timeframe.
Q - Can the nursing continuing education assessment include multiple professions?
An interprofessional needs assessment is acceptable, however, the supporting evidence must demonstrate the registered nurses are a part of the need’s assessment and implementation plan. The example provided, should be specific to nursing.
Q - What New Graduate transition programs are on the list of recognized programs in the 2019 manual?
Two national accreditation programs that meet Magnet criteria are ANCC Practice Transition Accreditation Program (PTAP) and Commission of Collegiate Nursing Education (CCNE). The ANCC PTAP program accredits RN Residency, RN Fellowship, and APRN Fellowship programs. CCNE accredits entry-to-practice nurse residency programs.
Learn more about ANCC’s PTAP at: https://www.nursingworld.org/organizational-programs/accreditation/ptap/
Learn more about CCNE accreditation at www.ccneaccreditation.org
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 Practice Transition Accreditation Program (PTAP) and Commission on Collegiate Nursing Education (CCNE) accreditations are programmatic credentials, the entities in a System included in the accreditation are all eligible for meeting SE 9 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 - 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 - Does the example need to describe both culturally and socially sensitive care?
No; it is acceptable to submit an example which describes culturally and/or socially sensitive care.
Exemplary Professional Practice
Exemplary Professional Practice
Q - Should we submit a schematic of the PPM for both EP1EOa and EP1EOb?
Yes, each example should have the schematic of the PPM included. Since the PPM must align with each example; it would be helpful if the applicable part of the PPM is highlighted for the appraiser’s review.
Q - Our nurse satisfaction vendor, does not include "all nurses” (i.e. not only clinical nurses, inclusive of APRNs and nursing leaders) in the survey or in the presentation of data for nurse satisfaction. Since the SOE requires “all nurses”, how should we handle this?
It is required to “include all nursing levels collected and benchmarked by the vendor”. You must also provide an explanation in your Unit Level Data Crosswalk (ULDC) when your vendor does not survey a nursing level or area of care.
Q - Is the interprofessional education activity referring to education for patients or staff?
Interprofessional education is education for patients, inter-professionals, or nurses led or co-led by a nurse and inclusive of other professions (e.g., occupational therapy, medicine, surgery, physical therapy)
Q - Are cohorts accepted for the organization’s turnover rate?
No. The intention for this source is the organization’s nurse turnover rate.
Q - Since we must use a national benchmark for EP18EO a through d, if the vendor does not provide unit level data, but rather organization level data, would this be acceptable?
No, you must provide 8 quarters of nationally benchmarked data at the unit level, where the vendor collects the clinical indicator. If unit level data is not available, another clinical indicator should be selected. Remember, Falls with Injury and HAPI stage 2 and above are required.
Q - Can we use the core measure VTE-1 (VTE prophylaxis on admission or by Hospital day 1)?
No, the Core Measure of VTE describes process, not an outcome measure. For instance, prophylaxis or other methods to prevent VTE represent process. The outcome of that process is a decrease in the VTE.
Q - Is an explanation about how the selected indicator is nurse sensitive required for each source?
Yes, an explanation must be included for “how the selected indicator is nurse sensitive” in the organization. Nurse Sensitive Clinical Indicators for Ambulatory must be provided for each SOE for both clinics (2 examples) and/or standalone ambulatory facilities (4 examples).
New Knowledge Innovations and Improvements
New Knowledge Innovations and Improvements
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. The study used for NK2 must be disseminated within the 48-month application timeframe. The same study can be used in NK2a and NK2b to demonstrate dissemination.
Q - What does “organization” mean for NK3a and NK3b? Could this mean any one unit? Or does the new or revised practice need to take place on more than one nursing unit? Could this be anywhere within the organization?
The examples provided for NK3a and NK3b, may be at the organization-level, division-level or the unit-level.
Q - Two examples are required. If I do not have any ambulatory care settings how do I respond?
Two examples must be submitted for NK7EO. If there are not ambulatory settings in your organization, both may be from inpatient settings.
Q - NK7EOb is written different than the other sources where ambulatory is an option. Is this intentional?
Yes, this is intentional. NK7EOb must be from an ambulatory setting, while NK7EOa can be from an inpatient or an ambulatory setting.
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