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Creating a self-sustaining professional culture of quality


Like the stairs going ever upward in M.S. Escher’s optical illusion, we see our continuing Magnet® journey at John C. Lincoln North Mountain Hospital in Phoenix, Arizona, as an upward journey. When the hospital earned Magnet designation in 2004, we wondered: Did we earn the designation because our patient-care environment was truly excellent—or did we achieve excellence as a result of going through the Magnet process?

Last year, we received Magnet redesignation. How have we been able to sustain our professional culture of quality? We see four general areas as undergoing the most significant improvements as direct outcomes of our Magnet journey:

  • trust in the competence of peers
  • engaging nursing staff in patient-care issues through shared leadership
  • collegiality and respect among physicians, nurses, and other care personnel
  • improved patient care as a result of evidence-based practice.

Our experience has shown that although these areas seem to have developed concurrently, they’re actually sequential, each nurturing the development of the next.

Trust among peers

Confidence and trust among nursing peers form the base that supports everything else required for a healthy, productive work environment that delivers high-quality care. Knowing your coworkers have advanced knowledge and skills cultivates respect.

At our facility, confidence and respect are nurtured by the generous and proactive tuition reimbursement policy for continuing education and specialized nurse training, including specialty certification. The hospital reimburses up to $5,250 per year for nursing education expenses incurred by the patient-care staff. In 2009, it reimbursed nearly $770,500 in education expenses for 200 RN, BSN, and MSN students employed at both hospitals in our network.

While education and certification are ongoing, statistics tabulated at the end of 2009 showed that at North Mountain Hospital:

  • 40% of RNs who provide direct patient care had bachelor’s degrees in nursing
  • more than 31% of RNs serving in leadership positions had master’s degrees in nursing
  • one in four RNs who provide direct patient care are certified in their specialty area; among RNs in leadership positions, one-third are certified.

Shared leadership and structural empowerment

All 14 of the traditional Forces of Magnetism support nurses’ participation in the continued improvement of quality in patient care. But three of the Forces particularly encourage bedside nurses to be engaged in efforts to improve patient care:

  • Force 2: a flat organizational structure and decentralized, shared decision making
  • Force 3: leadership that is visible, accessible, and committed to effective communication with staff and encourages and values feedback from bedside nurses
  • Force 5: models of care that give nurses responsibility, authority, and resources for the bedside care they provide, so care is tailored to the patient’s unique needs and has the capacity to accomplish desired outcomes.

Under the new vision and model for Magnet recognition, the same participation is encouraged within the concept of structural empowerment, in which influential leadership establishes the systems and processes wherein the organizational mission, vision, and values are put to work to improve patient outcomes. As a prerequisite for implementing these concepts in daily practice, nursing peers must have trust and confidence in each other. An environment of mutual respect and support makes it much easier to establish and maintain a management system of shared leadership that sustains and improves patient care on an ongoing basis.

Reversing changes that don’t work out

When nurses throughout the patient-care continuum share leadership and participate in decision making, not only can changes promoting better care be made; these changes can be reversed if practice proves they don’t produce the expected outcomes. Too often, without shared leadership among all caregivers, changes are institutionalized permanently even if bedside nurses quickly realize the “improvements” are anything but.

We encountered an important example of this when implementing use of a new I.V. catheter touted as a significant improvement. The catheter required a different insertion technique, and many problems occurred that exceeded the normal expectations inherent in a learning curve. Because we were open to input from direct-care nurses, we were able to reverse course and return to our original I.V. catheters, which proved to provide better and safer care.

So while it’s important to be able to make changes that can improve patient care, it’s equally crucial to respond to and retract changes that prove to be ineffective or detrimental in practice. Welcoming observations by bedside nurses during the decision-making process and including their opinions when drawing conclusions help ensure that the decisions reflect the conditions and experiences of frontline nurses.


Peers with trust and confidence in themselves and each other are the building blocks for collegiality—the relationship of cooperative caregiving based on effective communication and mutual respect. Collegiality levels the playing field between physicians and RNs and creates a healthy environment that fosters the best patient care.

Collegial interactions are an important component of job satisfaction. When true job satisfaction is the norm, employment ceases to be a job and becomes a calling. Our hospital administration has long encouraged a respectful relationship between physicians and nurses. The organizational and individual performance improvements and confidence-building associated with our Magnet journey have turned respect into true collegiality. Our patients have reaped positive outcomes from that evolution.

Evidence-based practice

Passion is important in the ongoing effort to improve the quality of care. Unless nurses and other healthcare professionals are passionately committed to the improvement process, quality stagnates even if it doesn’t diminish. But as we learned from our Magnet journey, passion alone isn’t enough. It needs the scientific support of evidence-based practice to make it an effective purveyor of positive change.

Almost a decade ago, intensive care unit (ICU) charge nurse Pat Jordan, RN, became angry when she saw pressure ulcers developing in patients. She believed the ulcers weren’t inevitable and that something could and should be done to stop them. With leaders’ support, she launched a campaign to fight pressure ulcers and experienced some small successes, incrementally reducing pressure ulcer incidence in the ICU.

During our Magnet journey, Jordan learned about evidence-based practice (EBP) and how to apply the results of clinical research and best practices established elsewhere to the challenges confronting our ICU patients. Once appropriate evidence-based practices were implemented, the incidence of hospital-acquired pressure ulcers in our ICU patients diminished steadily. By the beginning of 2009, they occurred in just 9% of patients. At that time, Jordan’s team kicked their efforts into high gear to apply EBP to reducing pressure ulcers. Using the theme “Skin is prime,” they shared information about best practices to combat skin breakdown.

It worked. By the second quarter of 2009, pressure ulcers were occurring in just 4% of patients; by the third quarter, only 2%. Although the rate rose fractionally to 3% in the fourth quarter, by the end of the year it had dropped back to 2%.

In a similar burst of professional passion, a nursing staff member launched a campaign to battle ventilator-associated pneumonia (VAP)—with favorable results. (See Evidence-based practice reduces VAP incidence by clicking on the PDF icon above.)

A family spirit

Trust in peers, shared leadership, collegiality, and application of evidence-based practice work together to create a climate of professional passion, enthusiasm for our calling, and empathetic support for each other. These qualities are self-sustaining and self-regenerating; they don’t depend on a single leader, no matter how charismatic. At our hospital, we’ve created an environment where members of our patient-care staff truly care about and value each other. We feel like we’re part of the same family, and that spirit extends to our patients.

Susan Kelley is Vice President for Patient Care Services at John C. Lincoln North Mountain Hospital in Phoenix, Arizona.

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