The Magnet journey: opportunities for librarians to partner with nurses

Librarians in hospitals seeking Magnet nursing status find that their roles and the services of the library grow and change as the organization evolves. While librarians have long functioned as content providers and as educators in their hospitals, new opportunities are provided in a Magnet hospital for consulting to researchers and becoming collaborative interdisciplinary task force members and assisting in the administrative changes that Magnet hospitals undergo. These opportunities can foster recognition of the importance of librarians and libraries, opportunities for additional library services, and new respect for librarians' roles on the health care team. While it may be possible to achieve Magnet status without a librarian, it will be extremely difficult to achieve re-designation without the services of a qualified health sciences librarian and access to resources and published literature. 
 
Numerous initiatives by MLA, NAHRS, HLS, and individual librarians have been undertaken to collaborate with ANA and the ANCC Magnet Program and support librarians serving nursing, and information about them is available for review on the respective websites as noted in Table 1. These groups should also continue to work with the Interagency Council on Information Resources in Nursing (ICIRN) [25] to identify key resources for the nursing profession, as well as ways librarians can work with nurses to improve access to published research and support EBNP.


HISTORY OF THE AMERICAN NURSES CREDENTIALING CENTER'S MAGNET RECOGNITION PROGRAM
Developed by the American Nurses Credentialing Center (ANCC), a division of the American Nurses Association, the Magnet Recognition Program represents the ''seal of approval'' for quality nursing care and aids in nurse recruitment and retention. During the 1980s, as a reaction to the growing recognition that the supply of nurses in practice was not keeping up with demand, the American Academy of Nursing (AAN) appointed the Task Force on Nursing Practice in Hospitals. This group noticed that while most hospitals were faced with severe nursing vacancies, other hospitals attracted and kept nurses. The AAN task force commissioned a study to identify these hospitals and the variables that allowed them to create an environment that successfully attracted and retained nurses. Of the hospitals studied, forty-one were selected and designated as Magnet hospitals [1].
The study found strong similarities between these hospitals, regardless of size or location. The common characteristics of these hospitals were participatory management, nursing autonomy, supportive nursing leadership, career development opportunities, and recognition in the hospital of the importance of the quality of patient care. The variables that made them attractive to nurses were called ''Forces of Magnetism' ' [2] Based on the AAN task force research, the American Nurses Association (ANA) Board of Directors approved the Magnet Recognition Program in 1990 and assigned to ANCC the responsibility of developing and maintaining the program, with the first Magnet award given in 1994. From 7 Magnet nursing programs in 2000, the program has grown to 334 organizations designated as Magnet hospitals in May of 2009, with more applications in process [3].
The goals of the Magnet Recognition Program are to identify excellence in the delivery of nursing care to patients, promote quality health care services in an environment that supports professional nursing practice, and provide a mechanism for disseminating best practices in nursing through evidence-based practice, quality improvement, and research [4].
The Magnet designation is awarded for a period of four years, after which organizations must reapply. Organizations must designate a staff member as Magnet coordinator, which may be a full-time position or a major portion of another position, such as a nursing research coordinator. Additional personnel are involved in preparing the application, planning the site visit, and monitoring activities related to continuing the Magnet designation. The activities leading up to the site visit are referred to as ''the Magnet journey to excellence,'' with numerous opportunities for librarian participation. Current Magnet hospitals are listed on the program website [3], along with scheduled site visits. The ANCC Magnet Commission solicits input from the patients, families, clients, staff, and public with whom health care organizations interact to assist Magnet program appraisers in the evaluation process [5].
Database searches for studies on Magnet program outcomes can use the keywords ''Magnet hospital'' or the CINAHL heading ''Magnet Hospital,'' as well as search terms for the specific nursing practices, interventions, and outcomes evaluated in the studies. The Resource Centers section of the ANCC Magnet Recognition Program website includes a bibliography of research connecting the Magnet environment to organizational outcomes [6]. Reports of clinical nursing research at Magnet hospitals are being presented at conferences, with some making their way into the nursing literature, which offers an opportunity for hospital librarians to assist nurses with presentations and writing for publication [7]. Sometimes opportunities and ideas for library resources and services are buried in articles about the Magnet program, such the reference to adding diversity resources found in an article about assessing readiness [8].

MAGNET PROGRAM CHANGES
The most recent edition of the Application Manual: Magnet Recognition Program reflects the latest ''Model for Magnet,'' which places great emphasis on evi- The full version of Table 1 is available with the online version of this journal. dence-based practice and research [9,10]. The fourteen Forces of Magnetism originally mapped have been refined in the 2008 edition into five components: transformational leadership, structural empowerment, exemplary professional practice, empirical quality outcomes, and new knowledge, innovations, and improvements. The relationship of the fourteen forces to the new model is clearly documented in charts in the Magnet program's website [11] and in an article by Wolf et al. [12]. Woven throughout the 2008 Manual is a strong emphasis on evidence-based practice (EBP) to support all these endeavors. A major change is additional requirements for organizations applying for redesignation. There is a higher expectation for EBP and improved outcomes as well as more emphasis on ''new knowledge, innovations and improvements'' [9,12].

EVOLVING OPPORTUNITIES FOR LIBRARIANS
The emphasis on EBP, continuing education (CE), and nursing research creates new opportunities for library services in institutions involved in the Magnet program, as well as for library liaisons to nursing schools. In the first article published on the Magnet program's impact on hospital libraries, Silver noted that the introduction of the program had been accompanied by increased interest in nursing research and a more educated nursing staff [13]. Nurses at Magnet hospitals are more likely to be certified in specialty areas, maintain CE, and conduct research to improve patient care and outcomes. Allen also noted an increased interest in her MLA CE course, ''Finding the Best Evidence to Meet Nursing Information Needs,'' with hospital librarian participants reporting the impact of the Magnet program on their work load and increased requests from nursing staff [14]. Allen and Sherwill-Navarro conducted a survey of Magnet coordinators, documenting the librarian's role in the Magnet journey and coordinator's perceptions of medical libraries [15]. In view of the growing importance of Magnet and evidencebased nursing practice (EBNP), MLA, the MLA Hospital Libraries Section (HLS), the MLA Nursing and Allied Health Resources Section (NAHRS), and MLA CE instructor authors investigated and educated librarians and nurses about the contributions librarians can make to EBNP (Table 1). MLA CE courses with current or recent approval can be found in the MLA Continuing Education Clearinghouse database [16].
Follow-up evaluation for the 2003 ''Evidence-Based Nursing'' MLA symposium noted the synergistic value of librarians working with nursing [17]. Nurses have been invited to many of the CE offerings, and librarians have presented and exhibited at nursing conferences around the country-far too many to note here. One important outcome was a presentation by Rourke, the first MLA representative to the ANCC Magnet Recognition Program, at the 2008 National Magnet Conference in Salt Lake City [18].

OPPORTUNITIES FOR LIBRARIANS ON THE MAGNET JOURNEY
The increased opportunities for new or expanded roles for librarians and for the library under the Magnet expectations are obvious. While the library and librarian are not specifically mentioned in the 2008 Manual, the need for access to the latest knowledge and literature is apparent in the sections related to EBNP [9]. For example, a thorough review of the literature for any evidence-based change requires skilled searching and even mining of the Internet and bibliographic databases to locate the latest knowledge and research to support all the expectations of the Magnet program. A comprehensive collection of the latest literature or timely access to interlibrary loan is needed to gather all the needed evidence. Research has shown that the evidencebased approach to nursing works best when nurses have access to libraries near clinical settings, current databases and research journals, and the Internet for use in clinical practice [19,20]. Areas where the librarian can contribute include collection development to support evidence-based practice and the education of nurses and other professionals in the hospital to effectively use the search tools and available literature.
In addition to evidence-based practice, other initiatives of the Magnet program offer opportunities for librarians working with nursing. Interdisciplinary collaboration is encouraged under the requirement for Magnet nursing programs to demonstrate ''exemplary professional practice.'' The development of comprehensive care plans necessitates that nurses work in partnership with the disciplines of medicine, pharmacy, nutrition, rehabilitation, social work, and psychology and with other professions. These interdisciplinary collaborations and the resulting care plans must rely on the latest evidence from the literature. To foster autonomous nursing practice under the ''professional practice model'' mentioned in the manual requires a nurse to make judgments about how to provide care based on the unique needs of patients and their families. The knowledge, skills, and resources previously identified as necessary to practice must be consistently available in the practice environment. Nurses must make decisions about care based on current evidence about safe and ethical practice. This type of model of nursing care places great emphasis on not only collaborative care, but also on the education of nurses, on patient education, and on the availability of current literature, professional standards, and other data sources to support autonomous practice. The role of the librarian in providing professional literature and ensuring the availability of current standards and data is a natural outgrowth of the Magnet program.
Nurses at all levels are encouraged to contribute to the organization and the community, and the Magnet hospital must demonstrate that it uses multiple strategies to support lifelong professional learning and role development. The advantages of access to a The Magnet journey The Magnet journey library and the assistance of a librarian in this endeavor should be obvious to a busy health care professional. While libraries at academic medical centers have long had responsibilities for providing assistance to researchers, community hospital libraries have not focused on these services. One of the changes that the quest for Magnet status engenders in a hospital is a new focus on identifying opportunities for research that can advance the practice environment. When research on a nursing practice is not available, the Magnet initiative encourages nurses to undertake their own research projects to establish the most effective nursing practices for their institution. They are then urged to publish the results of their research so that it can advance the practice of nursing. This emphasis on research provides opportunities for hospital librarians to assist nurses not only in reviewing their practices against the evidence, but also in creating new evidence. The added expectations for improving outcomes as a requirement for redesignation require greater dedication to EBP and benchmarking with other organizations. This ongoing commitment should demonstrate increased use of published resources and library services, not just access to resources. This creates the opportunity for Magnet hospital librarians to participate in programs and research demonstrating the use of patient education resources and application of published research to patient care. Linking literature to the electronic health record is just one example of where librarians can serve on interdisciplinary teams.
Academic librarians serving nursing schools are seeing a parallel interest among nursing faculty in EBNP and health information literacy [21]. In addition to teaching students to work in evidencebased practice environments, nursing faculty need library support when serving as consultants to hospitals seeking Magnet status. Also, many bachelor of science in nursing, master of science, and doctoral nursing students work at hospitals on the Magnet journey and use their practice environment as the basis for their papers, graduate research projects, and dissertations. Serving hospital staff as well as students is a significant role noted in the NAHRS surveys of Magnet coordinators [15,21] and librarians [22]. Magnet programs are creating new opportunities for academic-health care collaboration, which should extend to the libraries serving these programs.
With its emphasis on specialty certification and nursing research, the Magnet program is working in collaboration with other nursing organizations. Most notable is the partnership with the Sigma Theta Tau International Virginia Henderson International Nursing Library (VHL) [23] to include Magnet program research in the Library's Registry of Nursing Research, as noted on the Magnet program website [24]. Abstracts and ''practice innovations'' from the ANCC 2008 National Magnet Conference are linked from the VHL home page [23].

SUMMARY
Librarians in hospitals seeking Magnet nursing status find that their roles and the services of the library grow and change as the organization evolves. While librarians have long functioned as content providers and as educators in their hospitals, new opportunities are provided in a Magnet hospital for consulting to researchers and becoming collaborative interdisciplinary task force members and assisting in the administrative changes that Magnet hospitals undergo. These opportunities can foster recognition of the importance of librarians and libraries, opportunities for additional library services, and new respect for librarians' roles on the health care team. While it may be possible to achieve Magnet status without a librarian, it will be extremely difficult to achieve redesignation without the services of a qualified health sciences librarian and access to resources and published literature.
Numerous initiatives by MLA, NAHRS, HLS, and individual librarians have been undertaken to collaborate with ANA and the ANCC Magnet Program and support librarians serving nursing, and information about them is available for review on the respective websites as noted in Table 1. These groups should also continue to work with the Interagency Council on Information Resources in Nursing (ICIRN) [25] to identify key resources for the nursing profession, as well as ways librarians can work with nurses to improve access to published research and support EBNP.