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The Evolution of a Nursing
Professional Practice Model

Through Leadership Support of
Clinical Nurse Engagement,
Empowerment, and Shared

Decision Making

Anursing professionalpractice model
(PPM) is the guiding theoreti-

cal and conceptual model

that frames the foundation

for nursing professional

practice.1,2 Utilization of a

professional practice model

guides nursing practice and

fosters professional identity,

encouraging alignment to the

organization’s mission and

vision, job satisfaction,

improved quality of patient and

family outcomes, and enhanced

interprofessional communication.2 When a model guides professional nursing practice, nurses can articulate

the impact of nursing care on improving patient and family outcomes. With leadership endorsement and sup-

port, the PPM’s theoretical framework becomes the lens through which nurses see themselves; therefore, a

decisive imperative factor in selecting the underpinning theory for an organization’s PPM is core in its appli-

cability to the staff’s practice.

www.nurseleader.com Nurse Leader 325

Jennifer Cordo, MSN, ARNP, NE-BC, and Deborah Hill-Rodriguez, MSN, MBA, ARNP, NE-BC

Afree-standing pediatric hospital on its Magnet
® journey

striving for its third designation identified an opportunity
to engage staff in the evolution of the organization’s practice
model. Application of the shared leadership structure for joint
decision-making empowered staff to “own” the PPM’s devel-

opment and implementation. Nurse leaders within the
organization first embraced the concept of clinical nurses
engaging their peers across the organization in identifying
Comfort Theory’s compatibility with the organization’s val-
ues and mission. Comfort Theory was selected as the theory

most applicable to the staff ’s practice by a voting process by
nurses across the organization. Comfort Theory’s universality
and application to both nurses, staff, and patients/families was
easily understood and simple enough to guide practice.
Comfort Theory’s inherent emphasis on physical, psychospiri-
tual, sociocultural, and environmental aspects of comfort
contributed to a proactive multifaceted approach to care to
guide nursing practice.3 The easily applied framework of
Comfort Theory within pediatric practice is strengthening
and satisfying for pediatric patients, families, and nurses, and
benefit organizations that value a culture of comfort.3

Comfort is a positive outcome that has been linked empiri-
cally to positive institutional outcomes such as increased
patient satisfaction and cost–benefit ratios.3

Exemplary professional nursing practice must be designed,
implemented, and advanced over time.4 As the nursing profes-
sion continues to advance its unique discipline and practice, it

is vital that nursing practice and research are guided by theory
derived from nursing knowledge.2 As a Magnet-designated
organization striving to obtain its third designation, an oppor-
tunity was recognized to enhance the current practice model
to a true professional practice model based on a theoretical
framework. A professional practice model defines the relation-
ship between an organization and the nurses, and is unique to
each organizational culture. The first step in the model evolu-
tion was to identify the core elements required within a pro-
fessional practice model. The ANCC Magnet Recognition
Program® book Magnet: The Next Generation: Nurses Making the
Difference was used as the foundation for the PPM develop-
ment.4 Drenkard et al.4 identified basic elements of exemplary
professional nursing practice to be included in the develop-
ment of a PPM. The PPM needed to include at minimum
nursing’s values, leadership, collaboration, professional develop-
ment, and a care delivery system. Other elements may be
included, but these key attributes must be addressed and
included in the design and implementation.

The Magnet Program director presented the concept of a
PPM to the shared leadership council to educate the clinical
nurses on the purpose and benefits of a professional practice
model grounded by a theoretical framework. The nurses were
shown sample PPMs from other organizations to stimulate
thought on model development for this organization. The
council was empowered to drive the PPM development and
theoretical framework.

Development of the PPM Schematic
Through shared decision making, the nurses thought through
various model shapes including a palm tree, starfish, and heart,
and then collaboratively decided on a star-shaped model with
a diamond in the center. These nurses were guided by the
notion that nurses should reach for the stars in nursing excel-
lence and are the “nursing stars” of the interprofessional
health care team. They decided to place the patients, families,
and global community in a diamond at the center of the
model because they were viewed as precious “gems.” The
PPM schematic is referenced in Figure 1.

Once the shape was decided, the council began work on
developing the key elements of the 5-point star. The council
members decided on the 5 core elements of the PPM to be
collaborative relationships, nursing professionalism and values,
recognition and rewards, leadership, and patient care delivery and
outcomes. Upon establishing the 5 key elements, the council
members identified subcategories within the key elements as the
structures and processes across the organization supporting these
elements. The PPM subcategories are referenced in Table 1.

Selecting a Theoretical Framework
The council members identified 3 nursing theories they felt
would align well with the organizational culture, mission,
vision, and values. The nurses chose Katharine Kolcaba’s
Comfort Theory, Jean Watson’s Caring Theory, and Madeleine

October 2017326 Nurse Leader

Figure 1. Evolution From a Professional Model of Care to a
Professional Practice Model

Leininger’s Transcultural Nursing Theory. The nurses collabora-
tively developed a presentation to educate staff across the
organization about all 3 nursing theories. The nurses hosted a
house-wide educational event to unveil the new PPM and
engaged the audience in the selection of the PPM’s theoretical
framework. The nurses actively engaged the audience in an
entertaining simulated scenario acted out by various council
members. After the descriptive information on each theory was
presented via a slide show, the nurses performed skits on how
to bring the theory alive and what it could look like to not
practice according to the theory. These skits highly engaged the
audience and helped them to see each theory application in
practice. At the end of the presentation, the audience utilized
technology to vote in real time for the theory they felt was
best suited for the organization. Kolcaba’s Comfort Theory was
chosen as the theoretical framework for the new professional
practice model based on this important feedback.

The Comfort Theory is an example of a multifaceted
PPM with a holistic approach that aligns with the values and
mission of nursing within the organization. The primary
focus in pediatrics is individualized care, collaborative goal
setting, holistic care, and prevention of disease.3 Kolcaba
defines comfort as “the immediate state of being strengthened
through having human needs for relief, ease, and transcen-
dence” through the 4 contexts. When “comfort” is achieved,
the child and family are able to participate in the activities
needed to achieve health through therapeutic relationships.3,5

Adaption of the new PPM among the nursing staff, with
Comfort Theory as its conceptual framework, began by
council members teaching their nursing peers the core
concepts of the PPM and its foundational Comfort Theory
framework. Education was provided on all shifts, including
weekends. The education was provided in a room set up in
a comfortable environment including chair massagers, hand
creams, refreshments, light music, and aromatherapy to
enhance the environment and increase a sense of comfort
for the staff.

The interactive online version of the PPM was developed
and presented to staff nurses at staff meetings. To further
engage the staff with Comfort Theory, staff were provided an
opportunity to meet the nursing theorist, Dr. Katharine
Kolcaba, who developed Comfort Theory. She was invited to
visit the organization to provide insight and feedback as to
the organization’s adoption of Comfort Theory. In order to
prepare for her arrival, a Comfort Theory task force was
formed as a partnership between the council members and
nursing leadership team members for sharing decision-mak-
ing processes in preparation for Kolcaba’s visit. This comfort
task force collaborated to coordinate various activities for Dr.
Kolcaba’s visit including:

• A Kolcaba meet and greet breakfast event offering vari-
ous comfort measures

www.nurseleader.com Nurse Leader 327

Figure 2. Comfort Theory Presentation by Dr. Kolcaba

October 2017328 Nurse Leader

Table 1. PPM Key Components and Subcategories

Patient, families, and global community Nursing’s mission, vision, and philosophy

Collaborative relationships • Values and guiding behaviors
• Academic partnerships
• Clinical and nonclinical departments that collaborate with nursing

Nursing professionalism and values • Professional development
• Evidence-based practice and nursing research
• ANA Code of Ethics
• State nurse practice act
• ANA Scope and Standards of Practice
• Peer review

Recognition and rewards • List of several recognitions and rewards offered to nurses
• Professional ladder
• Compensation rewards
• Buddy program

Leadership • Nursing shared leadership councils
• CNO advocacy
• Community and organizational leadership
• Preceptorship/mentoring
• Succession planning

Patient care delivery and outcomes • Nurse residency program
• Transitional program
• Family-centered care
• The Comfort Theory Model
• EBP/outcome-driven practice
• Ethics and compliance
• Magnet Recognition Program® standards
• Patient safety programs
• Organizational culture training

CNO, chief nursing officer; EBP, evidence-based practice.

• Comfort Theory presentation for 1 continuing educa-
tion unit (Figure 2)

• Unit rounding
• Interprofessional train the trainer session highlighting

methods to implement the Comfort Theory
• Nursing Shared Leadership Council meetings to engage

staff in building awareness of potential nursing evidence-
based practice& research using Comfort Theory as the
theoretical framework.

The train-the-trainer session involved and engaged interpro-
fessional team members on ways to incorporate Comfort
Theory into everyday practice. This session was an interactive
open discussion that brought forward several suggestions in
implementing the Comfort Theory within the organization. The
team members recognized the natural application to processes
already in place and the potential naming modifications for
“comfort” within existing processes and the potential for several
new ideas. This session generated excitement among the staff on
creative ways to incorporate the Comfort Theory into practice.

Application of the PPM and the Comfort Theory conceptu-
al framework have been implemented in several ways, and staff

continuously come up with innovative ways to apply comfort
measures throughout the organization. Comfort Theory is
embedded throughout the PPM; therefore, the framework for
nursing practice is continuously supporting an environment and
culture based on comfort. The nursing mission statement, based
on the organization’s mission to “provide compassion and com-
fort through innovative advanced care for our children and
families” and vision “we will be where the children are, provid-
ing comfort through exceptional nursing care” demonstrate the
nursing department’s commitment to Comfort Theory as the
conceptual framework for the PPM.

The Patient Care Delivery and Outcomes section of the
PPM is exhibited through the comfort calls and comfort rounds.
Comfort calls were developed to enhance the patient care deliv-
ery experience for parents/caregivers that are unable to be phys-
ically present with the patient by keeping families updated with
the patient’s plan of care. Families are called when there is a
change in patient status, transfer to another unit, post-operatively
for updates, and whenever a change in patient’s plan of care
occurs. Comfort calls are performed at least once a shift in the
intensive care units and documented in the patient’s medical

record. Another nursing initiative that demonstrates application
of the PPM’s Patient Care Delivery and Outcomes section is
hourly comfort rounds. Hourly rounds is a standardized way of
nurses to anticipate their patient’s and family’s needs on an
hourly basis. It was suggested by Dr. Kolcaba to change the
terminology to include the word “comfort” because comfort
was already part of the hourly rounding assessment.

The largest patient population admitted to the inpatient
surgical unit (2 East) is children and adolescents that are
admitted for spinal fusion surgery. The care for these patients
is guided by the components of the Comfort Theory. The 4
contexts of physical, psychospiritual, sociocultural, and envi-
ronmental are continually assessed, addressed, and evaluated.

Prior to admission, the child’s fears of admission are addressed
by attending a pre-surgical orientation, guided by a child life
specialist in collaboration with the RN liaisons in the orthope-
dic-spine office. The psychospiritual needs are addressed as they
are exposed to the procedure that will be completed, addressing
the potential pain needs (physical) the child will endure. The
child is also able to touch, smell, and feel the physical environ-
ment of the operating room and post-anesthesia care unit
(PACU) while touching apparatuses that will be used during
the case. At the conclusion, the child and family then meet with
the RN liaison to receive a comprehensive education plan in
partnership with the families, addressing all potential fears. At
this time, a collaborative plan of care is created with the patient
and family’s comfort concerns in mind.

Admission: Pre-Operative
Upon arrival before surgery, the child is admitted to a private
room with open visitation policies to allow for support from
family and peers (sociocultural) to assist in relieving the anxiety
of the surgery. During the admission process, a full admission
history is completed focusing on the 4 contexts of comfort.
Special attention is placed on the needs for pastoral care. The
parents bring their plan of care from the pre-admission session
and have an open conversation with the nursing staff and
patient to ensure partnering in the care of their child. To further
enhance individualized care, the nurse, in alignment with the
child life specialist, assists the child in the completion of the “All
About Me” poster that is placed at the bedside for all staff
members to understand “who” the child is, including their likes
and dislikes. This allows for a personal connection with the
child, establishing parameters that will ensure “comfort” of the
child, which is individualized and developmentally appropriate,
during this potentially painful surgical procedure.

An individualized plan of care for “comfort” is created
upon admission and is evaluated on a shift-to-shift basis
throughout the duration of the child’s admission. The com-
munication board at the bedside has areas for communication
of current and future pain management and plan of care

updates, and has a section that allows for 2-way communica-
tion between the staff, child, and parents, which all parties are
encouraged to write on at any time. Throughout the admis-
sion, proactive comfort rounds are completed every hour to
ensure that pain needs, intravenous needs, toileting needs, and
environmental needs such as ambulation are being met; at this
time, interactive communication between the staff and
patient/family is collaborative and patient focused. The night
before surgery is about providing a soothing, calm atmos-
phere for the child and family, allowing rest, in preparation
for the surgical procedure in the morning.

Admission: Intra-Operative
In the morning, when the child is taken to the operating
room (OR) suite, the parents escort the child and remain
with their child through induction, ensuring both parties’
psychospiritual calmness. Once the child is in the OR, the
comfort strategies are geared toward the parent’s needs. The
parents receive text update notifications to know what stages
of the surgery are in progress. As well, the ortho spine RN
liaison comes and speaks with the family every 1 to 2 hours
to provide updates, answer questions, and provide reassurance
to the concerned family. When the patient arrives in PACU,
the 2 East staff escort the parents to the PACU, preparing
them for the sights and sounds of the area. The parent is by
their child’s side when they “wake up,” relieving both the
parents’ and the child’s fears of the unknown. The parents are
able to stay with the child and escort the staff back to the
room when the time comes for transfer back to 2 East.

Admission: Post-Operative
The main focus of comfort post-operatively is pain manage-
ment. In addition to the comfort plan of care that was initiated
and monitored since admission, a pain plan of care is collabora-
tively established with the family and child. The first need
addressed is therapeutic medication management through
patient-controlled analgesia (PCA) pump modality. Traditionally,
patients undergoing spinal fusion surgery are “log rolled” every
2 hours. This procedure can be painful because motions are not
always fluid during the turning process, and the patient also
becomes “stiff ” between moves. Our unit uses a specialty
motion bed to avoid the traditional log roll. Every 20 minutes,
the bed gradually transitions the patient from left to right and
right to left. During this time the child life specialist provides
distraction and guided imagery, and they teach the child “com-
fort” positioning that is in alignment with the post-operative
plan of care. During comfort rounds, the nurse assesses the
child’s pain needs at minimum every hour, at which time they
provide both verbal updates and utilize the communication
board with the family and child. The communication board
focuses on the current and target pain score, type of medica-
tions the child is on including side effects, and after the PCA is
discontinued, the last and next dose of medication times. In
addition to the PCA, gabapentin is started immediately post-
operatively to enhance the uptake of pain medication.

On the first post-operative day, as the first ambulation occurs,
the child is encouraged to use the PCA prior to the ambulation

www.nurseleader.com Nurse Leader 329

process. While the physical therapist guides them through each
movement, a music therapist enhances the process by walking
alongside the patient, playing soothing songs on the guitar.

As the child transitions through to discharge (day 3 post-
operatively), the PCA is changed to oral oxycodone/aceta-
minophen. Comprehensive education is provided to the
patient and family regarding the dosing, administration times,
and side effects, especially nausea. Meals are centered around
pain medication administration times to limit the potential of
nausea and vomiting, for which an antiemetic is also available.
In addition to nausea, as with any comprehensive surgery
with increased bed rest, bowel management is vital to recov-
ery. To prevent the discomfort related to abdominal disten-
tion and constipation, an individualized bowel management
protocol is set into action as part of the plan of care.

From post-operative day 2 until discharge, “bedside bud-
dies” and pet therapy are provided for much needed diver-
sional activities. This ensures age-appropriate activities and
peer interactions during this time of “loss of control.”

After the child returns home, the orthopedic spine nurse calls the
family on a daily basis for several weeks, until the child resumes
some baseline activity patterns, and the family is comfortable
with the care. The home environment is assessed to ensure the
child can freely move around, including the type of bed the child
is sleeping in for back support. Pain management is reviewed
with each call and adjustments are made as needed. NL

1. Schaffner LD, Tillett NL, Volz TM. Empowerment works! Clinical nurses and

the professional practice model. Nurs Manage. 2016;47(7):11-14.
2. Mullen JE, Asher LM. Implementation of a nursing professional practice

model of care in a pediatric hospital. Pediatr Nurs. 2007;33:499-504.
3. Kolcaba K, DiMarco MA. Comfort Theory and its application to pediatric

nursing. Pediatr Nurs. 2005;31:187-194.
4. Drenkard K, Wolf GA, Morgan SH. Magnet: The Next Generation: Nurses

Making the Difference. Silver Spring, MD: American Nurses Credentialing
Center; 2011.

5. Marchuk A. End-of-life care in the neonatal intensive care unit: applying
comfort theory. Int J Palliat Nurs. 2016;22:317-323.

Jennifer Cordo, MSN, ARNP, NE-BC, is nursing excellence man-
ager & Magnet Program Director at Miami Children’s Hospital-
Nicklaus Children’s Hospital, part of Miami Children’s Health
System, in Miami, Florida. She can be reached at
[email protected] Deborah Hill-Rodriguez, MSN,
MBA, ARNP, NE-BC, is the Clinical Nurse Director at Nicklaus
Children’s Hospital.

Note: The author would like to acknowledge Jackie Gonzalez, DNP,
MBA, ARNP, NEA-BC, FAAN, senior vice-president and chief
nursing officer, for her leadership and vision in disseminating the
success of our professional practice model enculturation. She personi-
fies transformational leadership and continues to guide the nursing
department to strive for excellence.

1541-4612/2017/ $ See front matter
Copyright 2017 by Elsevier Inc.
All rights reserved.

October 2017330 Nurse Leader

  • The Evolution of a Nursing Professional Practice Model Through Leadership Support of Clinical Nurse Engagement, Empowerment, and Shared Decision Making
      • Development of the PPM Schematic
      • Selecting a Theoretical Framework
      • Pre-Admission
      • Admission: Pre-Operative
      • Admission: Intra-Operative
      • Admission: Post-Operative
      • Post-Discharge
    • References

Volume 47, Number 2, pp 116-122
Copyright B 2017 Wolters Kluwer Health, Inc. All rights reserved.


Creating a Culture of Success
Using the Magnet Recognition Program

as a Framework to

Engage Nurses in an Australian Healthcare Facility

Sandra Moss, MHlthSc, RN

Marion Mitchell, PhD, RN

Veronica Casey, MNurs, RN

An organizational culture that reflects distrust, fear
of reprisal, reluctance to challenge the status quo,
acceptance of poor practice, denial, and lack of
accountability creates significant issues in healthcare
in relation to employee retention, burnout, organi-
zational commitment, and patient safety. Changing
culture is one of the most challenging endeavors an
organization will encounter. We highlight that the
Magnet Recognition ProgramA can be implemented
as an organizational intervention to positively impact
on nursing workplace culture in an international
healthcare facility.

Organizational culture is defined as Ba specific col-
lection of values and norms that are shared by people
and groups in an organization and that control the
way they interact with each other.[1(p122) In healthcare
settings, workplace culture profoundly affects em-

ployee empowerment,2-4 interdisciplinary relation-
ships, innovation, use of evidence-based practices,
and alignment to the organization_s strategic direc-
tion.5 Authors have recognized that the conse-
quences of poor workforce culture can result in
lower employee satisfaction, higher rates of nurse
burnout,6 and increased employee turnover.


mately, it affects the quality and safety of patient
care3,6,8; therefore, the causal relationship between
workforce culture and patient outcomes has re-
ceived, and should receive, increased attention by
healthcare leaders.9-11 Hence, understanding and
improving workplace culture are critical to nurse
leaders, the workforce, and healthcare consumers.

Leaders intuitively know when employees are
dissatisfied, yet it typically takes an employee sat-
isfaction survey to quantify that an issue exists.12

Although it may be relatively easy to identify a poor
workplace culture, changing it is recognized to be
complex and one of the more challenging endeavors
healthcare leaders will encounter.9,13,14 Factual
evidence of a dissatisfied workforce creates a sense
of urgency for change because it clearly threatens the
performance of an organization.14,15 Such evidence
provides justification for interventions focused on
transforming organizational culture12 because it
becomes clear that the Bcurrent way we do things[
needs to change.14

With strong leadership, the impetus exists to ex-
amine and challenge the core values and basic assump-
tions of the organization and explore opportunities for
change.12,16 There is, however, a lack of research evi-
dence that validates successful organizational level

116 JONA � Vol. 47, No. 2 � February 2017

Author Affiliations: Nursing Director, Princess Alexandra
Hospital (Ms Moss); Associate Professor of Critical Care Nursing,
School of Nursing and Midwifery, Griffith University, Menzies
Health Institute Queensland, Griffith Health Institute, Griffith
University, and Princess Alexandra Hospital (Dr Mitchell); and
Executive Director of Nursing and Midwifery Services, Metro
South Hospital and Health Service, Princess Alexandra Hospital
(Ms Casey), Brisbane, Queensland, Australia.

The authors declare no conflicts of interest.
Correspondence: Ms Moss, MHlthSc, RN, Princess Alexandra

Hospital, Ipswich Rd, Woolloongabba, Brisbane 4102, Australia
([email protected]).

Supplemental digital content is available for this article.
Direct URL citations appear in the printed text and are provided
in the HTML and PDF versions of this article on the journal_s
Web site (www.jonajournal.com).

DOI: 10.1097/NNA.0000000000000450

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

interventions that can provide leaders with clear
direction to change workplace culture.12,17,18 This is
supported by the systematic review by colleagues in
the United Kingdom who examined the effectiveness
of strategies to change organizational culture and iden-
tified only 2 studies that addressed this topic. The
authors concluded that the current evidence of effective
organizational culture-changing strategies is sorely
lacking, and they make the clear recommendations
for high-quality research to be conducted.17 The authors
of this current article aim to contribute to the evidence
and share the positive impact on nursing culture that
has resulted from implementing an organizational
intervention in an Australian healthcare facility.

Understanding Employee Engagement

The Princess Alexandra Hospital is a 740-bed ter-
tiary healthcare facility that offers services in all adult
specialties with the exception of obstetrics. Between
July 2014 and June 2015, healthcare was delivered to
more than 100 000 inpatients, 18 000 operating theater
cases, and 460 000 outpatients. There are approxi-
mately 6000 employees, of which 2500 are nurses.

In 2000, regularly collected facility-wide data
highlighted issues that required attention. There were
unacceptable nursing turnover rates of 25% and
record high external nursing agency use, resulting
in bed closures to maintain patient safety.19 The
Executive Director of Nursing Services (EDNS), who
provides strategic, professional, and operational
leadership for nursing staff, commissioned an exter-
nal vendor to conduct an employee engagement (EE)
survey to assist with uncovering issues affecting nurs-
ing workplace culture. Using an independent vendor
was a strategy aimed to gain employee confidence in
the anonymity of feedback and obtain high response
rates with a representative sample.20,21

Gaining an understanding of nursing workplace
culture through periodic EE surveys is an important
step to diagnose the current state and provides lead-
ers with insight into strengths and challenges.20,22-24

There are many established EE consulting firms and
EE tools available, such as the Gallup 12-item Worker
Engagement Index,25,26 May Scale,27-29 or various
versions of the Utrecht Work Engagement Scale.30-32

Concerns regarding the validity and reliability of
survey items28,29,33 and lack of criteria available to
compare existing tools are well documented.34,35 It
is widely recognized that there is no singular EE
measurement tool that is universally accepted.35-38

Measuring EE is therefore not an exact science
but aims to predict employees_ attitudes,20 commit-
ment to the facility,3,39-41 and assessment of employ-
ment conditions.20 It is important that the instrument
includes items that measure key employee

Bengagement drivers.[20,42 Furthermore, the instru-
ment needs to be able to discriminate without floor
and ceiling effects to have confidence that, as the
level of EE improves, so do the survey results.43,44

The Instrument

The survey instrument included 130 quantitative and
17 qualitative items under 6 categories of EE, lead-
ership, values and behavior, quality and innovation,
safety, and consumer outcomes. Workforce culture is
measured by 10 items under the EE category and is
the focus of this article.

A 6-point Likert scale was used to measure EE
drivers including trust in leadership, clear strategic
direction, commitment to the healthcare facility, pride
in the workplace, ability to contribute, and positivity
about the facility_s future. All items are theoretically
linked to EE.20,23,38,45 The EE items remained the
same through each survey cycle, although 2 items
related to trust in leadership were not collected in
2004 and 1 item was not collected in 2006. From
item responses, the vendor tallied and calculated the
percentage of respondents who they classified as
engaged, neutral, or disengaged. Using the level of
engagement as the indicator, the vendor determined
employee workplace culture, which was reported to
the site_s nurse leaders.


The external survey was administered biannually to
all nursing employees from 2000 to 2015, with the
exception of 2008, which was delayed and con-
ducted in 2009. Paper surveys were provided to each
nurse manager in charge of a ward area for dis-
tribution to nursing employees at the beginning of
the survey period during 2000 to 2009. An online
survey was used in 2013 to 2015, enabling employees
to complete the tool through a Web-based portal on a
computer on-site or at home. The survey was open
for a 1-month period, providing employees sufficient
time to complete the survey.20,21 Before the survey
period, advertising in the form of flyers, email noti-
fication, and briefings during facility meetings ad-
vised employees of the survey_s purpose. Nurses
were informed that participation was voluntary and
responses were anonymous.

Impetus for Intervention

In 2000, the survey response rate was 63% (n = 794),
and results identified a culture of Bblame[ with 54%
(n = 429) of nursing employees reporting that they
often thought about leaving the healthcare facility.46

A culture of blame reflects a workplace culture of
distrust, fear of reprisal, reluctance to challenge the

JONA � Vol. 47, No. 2 � February 2017 117

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

status quo, acceptance of poor practice, denial, and
lack of accountability.34,47,48 The survey results
coupled with the site_s nursing staff turnover became
the catalyst for examining an intervention aimed to
improve nursing workplace culture and associated
retention rates. Understanding the engagement
drivers provided valuable information for the nurse
leaders to determine a vision and path forward.20,42


A leader_s vision is critical for cultural change and
provides future direction linked to strategy, structure,
and systems.2,14 The EDNS_ vision was to transform
nursing culture by becoming a MagnetA-designated
healthcare facility.19 The Magnet Recognition ProgramA

(MRP) originated from a study conducted in 1981
that determined organizational characteristics pro-
fessionally and personally rewarding for nurses.49

More than 3 decades of evidence demonstrates that
Magnet-designated healthcare facilities have posi-
tive nursing workplace cultures and patient out-
comes,4,8,50-53 providing a rationale to commence
the Magnet journey.

In 2002, the site_s official journey toward Magnet
designation began with an application to the American
Nurses Credentialing Center. Typically viewed as a
designation process that enables healthcare facilities
to confirm the existence of the Magnet characteristics
within the work environment, the nurse leaders aimed
to use it as an organizational intervention to transform
culture by empowering, inspiring, and motivating em-
ployees at every level of the healthcare facility.50,53-56

Strategies aligned to the MRP were implemented
using a top-down and bottom-up approach, provid-
ing direction from leaders and empowering direct
care nurses of all levels to drive the change.14,34,57

Ensuring employee participation in achieving the
vision increased likelihood of the intervention_s suc-
cess.14,34,57 Clear strategic direction, participatory
governance structures, improved access and trans-
parency of data, opportunity for professional devel-
opment, and increased recognition and reward are
examples of changes that have been successfully im-
plemented over time and evident within Magnet
healthcare facilities (Table 1).58-60

Outcomes and Discussion

The site successfully gained Magnet designation in
2004, becoming the 1st in the southern hemisphere.
It achieved subsequent redesignations in 2009 and
2014. Importantly, the aim to reduce nursing turn-
over was achieved. Since 2004, nursing turnover
averaged less than 8% and was zero in 2015.

The EE survey continued to measure the inter-
vention_s impact. Employee engagement survey

response rates over time (2002-2015) ranged from
52% (n = 920) to 78% (n = 1177) (see Table, Sup-
plemental Digital Content 1, http://links.lww.com/
JONA/A511). After the implementation of Magnet
principles in 2002, nursing engagement culture
continuously improved, with the exception of
2013. In 2013, the survey was conducted during a
significant period of federal and state health reform
that resulted in significant employee uncertainty.
Although the nursing engagement culture declined
in 2013, it remained in a culture of Bambition.[

The 2015 survey continued an upward trend
with the level of EE surpassing all previous results
obtained during the 14-year period. Engagement
culture items improved from 23% to 42%.61 Results
progressed from a culture of blame in 2002 to suc-
cess in 2015, with 67% (n = 929) of nurses engaged.
Importantly, the percentage of respondents classified
as engaged increased (36%, n = 652), whereas those
classified as Bneutral[ decreased (26%, n = 97)
(Figure 1). When employees move from an engage-
ment category of neutral to engaged, cultural change
becomes evident, with increased staff commitment to
the organizational leaders_ direction.63

Trust in management was the greatest improve-
ment observed, increasing by 42% (n = 696).61 Nurses
identified that there was a clear direction for the
future (68%, n = 938), pride in the healthcare facility
(77%, n = 1060), and commitment to continuously
improve how things are done (76%, n = 1047). Com-
pared against the vendor_s government public
healthcare services benchmarking peer group facilities
(N = 123), the site rated in the top 10%.62

Ongoing leadership and commitment are re-
quired to sustain and strengthen culture.14,20 The
2015 EE survey results are currently being analyzed
to identify priority items to be actioned and
included in the nursing workforce plan. An evalu-
ation of the professional practice model is pro-
ceeding to ensure it remains contemporary and
relevant. Furthermore, strategies to increase direct
care nurse participation in shared governance are

The MRP was introduced as an organizational
intervention to improve nursing culture and nurse
retention. Nurse leaders created shared ownership,
commitment, and heightened accountability to
achieve the vision.64 Shared ownership of the inter-
vention supported nurse engagement and promoted
trust and willingness to commit to change.65 Highly
engaged employees care about the future of the
facility; actively participate in decision making; and
have autonomy, accountability, flexibility, and com-
mitment to the vision.45,66 This provides evidence
that this healthcare facility was able to use the MRP

118 JONA � Vol. 47, No. 2 � February 2017

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

as a continuous cultural transformation framework
to align practice with clearly defined goals. This is
endorsed by others.50,60,67


The EE survey response rate varied between 52%
(n = 920) and 78% (n = 1177), and results may

therefore not be representative of those who did
not complete the surveys. Furthermore, there are
no reliability and validity data for the survey, and
thus, we cannot be confident that we are measuring
what we think we are measuring or that the items
have internal consistency. It is evident that there is
a need for further studies to be undertaken to provide

Table 1. Strategies and Actions Implemented to Align With the Magnet Recognition Program

Strategy Implementation

Strategic direction & Nursing Strategic Plan outlining key performance measures aligned to the Magnet
Recognition Program outcome criteria.

& Nursing Operational Plan outlining actions to achieve key performance measures in the
Nursing Strategic Plan.

& Nursing Workforce Plan outlining actions focused on nursing engagement, retention, and

Shared governance structures & Nursing strategic and quality committee consisting of nurse leaders responsible for
professional nursing practice, nursing standards, clinical practice, and quality of care

& 14 workgroups consisting of 120 direct care nursing and interdisciplinary staff. Each
committee responsible for progressing quality initiatives aligned to the Nursing Strategic

& Nursing committee consisting of 80 direct care nurses responsible for auditing nursing
practice and implementing strategies to advance professional practice and improve patient

Participatory flat decision making & Professional Practice Model developed by direct care nurses that articulated nursing
values and core components to deliver person-centered care.

& Annual nursing retreat for direct care nursing staff focused on identifying improvement
opportunities related to practice environment, clinical practice, and patient outcomes.

& Magnet evaluation conducted after the achievement of Magnet Designation to determine
opportunities to improve structures and processes that support the Magnet journey.

& 360 Magnet Champions consisting of direct care nurses from all units throughout the
healthcare facility.

Access and transparency of data & Monthly unit-level nursing scorecard report provided to each nurse manager for
distribution to direct care nurses. Nursing scorecard report included data on patient
outcomes, staffing resources, unit activity, and budget.

& Web-based data repository for nursing projects, quality initiatives, and research,
accessible to all nursing staff.

& Increased monitoring, benchmarking, and reporting of patient outcomes including
quarterly inpatient and ambulatory patient satisfaction; quarterly pressure injury
prevalence; and monthly incidents for patient falls, healthcare-associated infections,
medication administration incidents, catheter-associated urinary tract infection, and
ventilator-associated pneumonia.

Professional development & Monthly Magnet Champion forums that showcased nurse-led innovation, research,
and outcomes.

& Magnet Champion half-day workshops designed for Magnet Champions to learn about
the Magnet Recognition Program and understand their roles and responsibilities.

& 3-day workshop for all nurses to learn skills in management, leadership, and change

& 360-degree feedback process established to enable nurses to receive feedback about
professional performance from colleagues.

& Scholarship funding for direct care nurses to attend state, national, and international

Recognition and reward & Annual Recognition and Reward Plan outlining methods to formally showcase nursing
staff who have significantly contributed to the nursing profession, patient outcomes, and

& Nursing annual review.
& Monthly nursing newsletter.
& International, national, and state nursing forums held on-site to showcase and share

& Staff lifestyle program consisting of health promotion initiatives including on-site group

or personal fitness classes, nutrition program, weight management program, meditation,
and massage.

& Internal marketing campaign to promote image of nursing and recognize nursing
contributions to healthcare facility, patient outcomes, and the community.

JONA � Vol. 47, No. 2 � February 2017 119

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

these data. However, from a practical viewpoint
from within the organization, we have confidence
that the nurses_ results clearly reflected reality.


Employee engagement is critical in healthcare, yet it
remains an ongoing challenge for many. With vision,
leadership, and empowerment of staff, nursing
workforce culture can improve. The MRP provided
a framework to guide a clear path forward for nurse
leaders in a non-US healthcare facility. This high-

lights opportunities for nurse leaders globally who
are examining ways to transform culture of the nursing
workforce and meet future healthcare challenges.


The authors thank Joy Vickerstaff, Former Executive
Director of Nursing Services, Princess Alexandra
Hospital; Richard Ashby, Chief Executive Officer,
Metro South; Nursing Executive Committee, Prin-
cess Alexandra Hospital; Magnet Champions; and
Nursing Services, Princess Alexandra Hospital.


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Organizational structure delineates the work of the organization including chain of command, authority, and the formal communication network. A professional practice model is a guiding theoretical and conceptual framework that provides the foundation for nursing professional practice within an organization. 

In a discussion board post:
Describe the structure of your organization (functional, matrix, parallel).
What professional practice model is in place? 
Does the practice model work well within the organization’s structure?
How is evidence-based practice integrated into the practice model?  Provide specific examples and rationale.

Your initial post must be posted before you can view and respond to colleagues, must contain minimum of two (2) references, in addition to examples from your personal experiences to augment the topic. The goal is to make your post interesting and engaging so others will want to read/respond to it. Synthesize and summarize from your resources in order to avoid the use of direct quotes, which can often be dry and boring. No direct quotes are allowed in the discussion board posts.

Post a thoughtful response to at least two (2) other colleagues’ initial postings. Responses to colleagues should be supportive and helpful (examples of an acceptable comment are: “This is interesting – in my practice, we treated or resolved (diagnosis or issue) with (x, y, z meds, theory, management principle) and according to the literature…” and add supportive reference. Avoid comments such as “I agree” or “good comment.”

Points: 30

Due Dates:

· Initial Post: Fri, Nov 12 by 11:59 p.m. Eastern Standard Time (EST) of the US.

· Response Post: Sun, Nov 14 by 11:59 p.m. Eastern Standard Time (EST) of the US – (the response posts cannot be done on the same day as the initial post).


· Initial Post: Minimum of two (2) total references: one (1) from required course materials and one (1) from peer-reviewed references.

· Response posts: Minimum of one (1) total reference: one (1) from peer-reviewed or course materials reference per response.

Words Limits

· Initial Post: Minimum 200 words excluding references (approximately one (1) page)

· Response posts: Minimum 100 words excluding references.