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Organizational Overview

Organizational Overview

OO-1 | OO-5 | OO-6 | Download PDF

OO-1

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.

OO-5

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.

OO-6 (updated September 2019)

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.

Transformational Leadership

Transformational Leadership

TL3 | TL6 | TL6a-eTL7 | Download PDF

TL3

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.

TL6

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.

TL6a-e (updated September 2019)

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.

TL7

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 - Updated September 2019

SE3/SE5 | SE8EO | SE9 | SE10a | SE11Download PDF

SE3/SE5

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. 

SE8EO

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.

SE9

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.

SE10a

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.

SE11

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

EP1EOa/b | EP2EOEP8EO | EP10EOaEP18EO | EP18EOc and/or d | EP19EOaDownload PDF

EP1EOa/b (updated September 2019)

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.

EP2EO (updated September 2019)

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.

EP8EO

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)

EP10EOa (updated September 2019)

Q - Are cohorts accepted for the organization’s turnover rate?

No. The intention for this source is the organization’s nurse turnover rate.

EP18EO

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.

EP18EOc and/or d

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.

EP19EOa & EP19EOb (updated September 2019)

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

NK2 | NK3a/3bNK7EO | NK7EOb | Download PDF

NK2

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.

NK3a/3b

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.

NK7EO

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. 

NK7EOb

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.

Site Visit

Site Visit

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Q - What does “determining enculturation at Site Visit” mean?

Enculturation is defined in the 2019 Magnet Application Manual Glossary on pg. 149.  Additionally, Appendix F, pg. 85, explains that the site visit is “…arranged to validate, verify, and amplify compliance and enculturation of the Magnet components.”  Various elements of each of the Magnet Components, including Source of Evidence (SOE) examples, may be reviewed and validated during the Site Visit to ensure that the characteristics and process by which the values of Magnet are evident throughout the organization.

During the site visit meetings and unit visits, the Appraisers will explore enculturation of Source of Evidence examples presented in the documentation as well as inquire about the enculturation of the SOE examples that were not included in the documentation; in particular those SOEs for which options were not included in the submitted documentation (i.e.TL TL6, TL7, TL9EO, SE9, EP11).

NOTE: If evidence for enculturation is not found for any SOE example, the potential exists that the SOE example will be scored deficient in the Site Visit phase.

During the Site Visit, Appraisers will:

  • Validate and verify what has been presented in the documentation for evaluation
  • Verify the accuracy of data presented for SE4EO, SE6EO, EP2EO, EP18EO, EP19EO, EP20EO, and EP21EO
  • Review personnel records to validate nurse leader education eligibility requirements are sustained.
  • Review records to validate use of periodic formal performance review that includes self-appraisal and peer feedback process, demonstrating a plan for professional development for all levels of nursing (EP11)
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