According to the Congressional Research Service (CRS, 2001), a severe nursing shortage is imminent. Due to the expected increase in the elderly population, the Bureau of Labor Statistics (BLS) forecasted an increase of 21.7% in the demand for RNs and an increase of 82.2% for home care nurses for the period 1998-2008 (BLS, 2000;CRS, 2001;National Association for Home Care [NAHC], 2001).

The demand for RNs is projected to exceed the supply in 2009, with the shortage worsening through 2020, at which time the demand for RNs could be 13% to 20% greater than the supply. Although the predicted nursing shortage will be worldwide and affect all healthcare settings, home care is expected to be critically affected (CRS, 2001).

Some agencies are already experiencing a shortage of nurses. The Balanced Budget Act (BBA) of 1997 brought dramatic reductions in home health reimbursement and new regulatory and reimbursement requirements soon followed. These costly changes greatly impacted home care agencies' ability to attract adequate nursing staff with competitive wages and benefits (NAHC, 2001).

In a survey of 400 home health agencies conducted by the NAHC in February 2000, 63% of the responding agencies reported difficulty retaining nursing staff. The shortage does not appear to be related to agency affiliation, location, or size (Ellenbecker & Cushman, 2001). A follow-up study of 196 agencies revealed that 64% had unfilled positions.

To provide needed services, more than one-quarter of the agencies have begun to substitute other staff for RNs, and more than one-third of agencies reported refusing referrals due to a lack of staff (Ellenbecker & Cushman, 2001). An agency's success in providing services to those in need will depend on its ability to attract and retain qualified nursing staff (Bennett, 2000;Ellenbecker, 2001).

Job Dissatisfaction

One of the most significant factors that contribute to the difficulty in both recruiting and retaining nurses is the practice environment (Aiken, Clarke, & Sloane, 2002;Havens & Aiken, 1999;Peterson, 2001;Scott, Sochalski, & Aiken, 1999). In a 2001 national survey, 50% of current nurses said that they have considered leaving direct care for reasons other than retirement. Almost one-half (49%) said that if they were younger they would not have become nurses at all.

Although nurses report that the most satisfying aspect of their jobs is helping patients and their families, stressful working conditions impede the ability to provide quality care and are the main reason cited for contemplating leaving direct patient care (Federation of Nurses and Health Professionals [FNHP], 2001).

Several studies have linked job dissatisfaction with inadequate staffing levels, perceived low support from management, and lack of a voice in decision making (Aiken, Clarke, & Sloane, 2002;Aiken, Clarke, Sloane, Sochalski, & Silber, 2002;FNHP, 2001;Scott et al., 1999).

Although there exists little data on nurses in home care, the literature suggests that they are dissatisfied for similar reasons, except that they rank the amount of paperwork as the worst aspect of their job (Cushman, Ellenbecker, Wilson, McNally, & Williams, 2001;FNHP, 2001). Many home health agencies estimate that nurses spend over one-half their time completing paperwork (NAHC, 2001). Home care nurses primarily leave their jobs due to stress and the increasing regulatory and time demands of the job as well as lack of appreciation (Cushman et al.).

The home care industry has changed significantly during the last decade resulting in clinicians caring for sicker patients while working under new regulatory requirements such as OASIS, OBQI, and HIPAA. Additionally, the Prospective Payment System (PPS) has placed even greater external and internal pressures to provide efficient and cost-effective care (Widmer, 2002).

As the reality of PPS demands that home care providers do more with less, the importance of retaining experienced staff becomes more critical. However, unless the working environment is supportive, strategies to recruit and retain nurses are unlikely to be successful (Peterson, 2001).

Magnet Recognition

In 1982, the American Academy of Nursing (AAN) Task Force on Nursing Practice in Hospitals conducted a study of 41 hospitals in the United States that were able to attract and retain professional nurses during a national nursing shortage in the early 1980s. The study sought to identify and describe characteristics that distinguished these "magnet" hospitals (American Nurses Credentialing Center [ANCC], 2002). Three major categories of magnet characteristics were identified:

1. leadership attributes of the nursing administration;

2. professional attributes of the staff; and

3. the supportive professional environment (Scott et al., 1999).

An effective leader was described as one who is visionary, supportive, and knowledgeable, and who values education and professional development of all nurses within the organization. Nursing administrators of magnet hospitals were able to create an organizational culture that encouraged professional growth and enhanced staff satisfaction. The important attributes of professional nursing practice included:

[black small square]Therapeutic relationships with patients. The nurse's ability to establish and maintain therapeutic relationships with their patients.

[black small square]Nurse autonomy and control. The practice environment included a flat organizational structure with few supervisory personnel where decision making was decentralized, allowing the staff nurses to organize and deliver patient care (Havens & Aiken, 1999).

[black small square]Collaborative nurse-physician relationships. These relationships were based on mutual respect for each other's knowledge and competence, and a mutual concern for the provision of quality care (Scott et al., 1999).

In 1994, the Magnet Hospital Recognition Program was established to build upon the AAN study; it is administered by the ANCC. The overall goals of the program are to identify excellence in the provision of nursing services, to recognize those institutions that act as a "magnet" by creating a work environment that recognizes and rewards professional nursing, and to provide a method for the dissemination of successful nursing practices and strategies among healthcare institutions (ANCC, 2002).

Studies have supported that ANCC's magnet designation process successfully identifies hospitals that provide a magnet environment. Nurses in ANCC-certified hospitals are even more satisfied with their jobs and rate the quality of patient care significantly higher than the original magnet hospitals (Aiken, Havens, & Sloane, 2000;Scott et al., 1999). Although differences exist between the original magnet hospitals and the ANCC-certified hospitals, in both cases "a magnet hospital is one that attracts and retains nurses who have high job satisfaction because they can give quality care" (Kramer & Schmalenberg, 2002, p. 26).

Progress of the Magnet Program

* In 1998 the program was expanded to recognize nursing excellence in long-term care facilities (ANCC, 2002).

* In 2000 the program expanded again to include international healthcare organizations and any setting in which nurses practiced (Urden & Monarch, 2002).

* In 2002 the program was renamed the Magnet Recognition Program (ANCC).

Although there were only 16 ANCC-certified magnet hospitals in 2000 (Aiken, Havens, & Sloane, 2000), the rate of facilities applying for magnet recognition has increased in the past 2 years due to evidence that magnet recognition is a proven way to recruit and retain nurses (Aiken, 2002). Currently, 67 healthcare organizations are designated as magnet facilities (ANCC).

Magnet facilities provide the elements that nurses in any setting require to be satisfied in their positions. Home care nurses, like their hospital counterparts, want a supportive environment so that they can give quality care and be recognized for their efforts. Magnet designation has been available to home care agencies since 2000, yet according to Mary Moon Allison, Assistant Director of Accreditation and Magnet Recognition Programs, "to date, there have been no home care applicants" (personal communication, January 16, 2003).

Benefits of Magnet Recognition for Home Care Agencies

Home care agencies, their employees, and patients all stand to benefit from magnet recognition.

Benefits for the Organization:

* Magnet designation may be publicized and used for marketing the agency to consumers and potential nursing personnel.

* Home care agencies affiliated with magnet hospitals should have administrative support to expand magnet designation.

* Recognition as a magnet organization should lead to an increase in referrals from all payment sources (ANCC, 2002).

* Magnet designation is a major factor in nursing recruitment and retention (Aiken, 2002;ANCC, 2002).

* The number of unfilled nursing positions is one-half the national average in magnet hospitals (Kramer & Schmalenberg, 2002).

* Although magnet hospitals pay higher nurse labor costs, they save money by reducing costs related to nurse turnover (ANCC;Hinshaw, 2002).

* Magnet hospitals are also able to recruit and retain nurse administrators, who typically have had a relatively high turnover rate (McClure & Hinshaw, 2002).

Benefits for the Professional Nurse:

A nurse in a magnet facility has the opportunity to work in an exciting, stimulating, and supportive environment that offers:

* higher nurse-patient ratios,

* competent coworkers and higher staff retention,

* control over practice,

* educational and promotional opportunities (Hinshaw, 2002),

* recognition of the importance of nurses to the success of an entire organization (which increases staff morale).

All employees, not just nurses, benefit from the excellent management and practice environment of magnet facilities (McClure & Hinshaw, 2002).

Benefits for the Consumer:

The excellent nursing care provided in magnet facilities improves patient outcomes such as decreasing mortality and enhancing patient satisfaction (Aiken, 2002;Aiken, Clarke, Sloane, Sochalski, & Silber, 2002;ANCC, 2002;Havens & Aiken, 1999;Hinshaw, 2002).

Because magnet hospitals have lower mortality rates, shorter average length of stay, and higher patient satisfaction, consumers are able to use magnet designation as a reliable way to choose good hospitals (Aiken, 2002).

Although the research supporting magnet designation has been done in the hospital setting, the concept of magnetism can be applied to any healthcare setting where nurses practice (Aiken, 2002). "The standards and criteria used are appropriate regardless of the setting...because we are talking about a work environment" (M. M. Allison, personal communication, January 16, 2003). The "Magnet Culture" is described as "dynamic and positive milieu for professional nurses [with] core values of empowerment, pride, mentoring, nurturing, integrity, and teamwork..." (ANCC, Benefits Section, paragraph 8, 2002).

Why Hasn't the Home Care Industry Taken Advantage of Magnet Recognition?

Although there is no research on why home care agencies have not taken advantage of the magnet program, the following list suggests several possible reasons:

1. There may be a lack of awareness about magnet status and its availability to home care agencies. ANCC's Web site (http://nursingworld.org/ancc/magnet/magnet.htm) makes no specific mention of home care and appears to be referring only to hospitals and long-term care facilities.

2. Even though PPS encourages better clinical practice by examining outcomes, the reimbursement system neither directs nor encourages agencies to experiment with new models of care. PPS is based on financial numbers and comparative statistics used by agencies during cost-based reimbursement (Humphrey, 2002).

3. The home care industry has been reeling from rapid regulatory and financial changes since the BBA of 1997 and may be discouraged by the thought of voluntarily submitting to further criteria and standards (M. M. Allison, personal communication, January 29, 2003).

4. Agencies have responded to PPS by focusing on improving information technology, telehealth, and other administrative systems, neglecting resources for clinical services and professional education and rewards (Humphrey, 2002).

5. There is a lack of knowledge among home health agencies of the benefits of magnet recognition on recruitment and retention.

6. There are costs involved in applying for magnet recognition as well as making the changes necessary to meet magnet criteria. There is a $1,000 application fee, a $500 review fee for each appraiser, and a $1,500 per day honorarium per appraiser during the site visit. The applicant is also responsible for travel and lodging expenses for at least two appraisers (ANCC, 2002). The cost for implementing the standards will vary according to the amount of change required to meet the criteria.

The time is right for home care agencies to join the "magnet movement". PPS and OASIS have been successfully integrated and agency outcomes are now able to be compared nationally. Home healthcare agencies stand to gain as much from magnet recognition as their hospital counterparts: improved patient outcomes, enhanced status in the community, and the ability to recruit and retain competent nurses. Although the process of applying for magnet recognition is thorough and lengthy, it helps to move the agency toward excellence (ANCC, 2002).

How to Receive Magnet Recognition

The ANCC magnet program is a voluntary form of external professional nurse peer review (Aiken, 2002). The healthcare organization must meet certain eligibility criteria (see Figure 1) in order to apply for magnet recognition. The review process consists of four major steps:

1. Within 2 years of completing the initial application, the applicant submits documentation that demonstrates how the healthcare organization implements the Scope and Standards for Nurse Administrators (ANA, 1996).

2. Program appraisers who are professional nurses with experience in quality indicators, nursing services administration, and nursing care review the written documentation for Core Measurement and Magnet Measurement Criteria. Meeting the Core Measurement Criteria indicates that the organization operates at a basic acceptable level. Magnet Measurement Criteria are indicators suggesting that a facility is functioning at a level of excellence (Urden & Monarch, 2002).

3. If the organization scores in the "excellent" range for the Magnet Measurement Criteria a site visit will follow. The site visit process encourages community participation and public comment. Its purpose is to verify and clarify the written documentation and evaluate the organizational culture (ANCC, 2002).

4. The appraisers submit their recommendations to the Commission on Magnet Recognition which reviews the findings and makes a determination. If magnet designation is awarded, the healthcare organization is notified immediately and a nationwide press release is issued by ANCC. The magnet recognition status is valid for a 4-year period, after which the recipient must reapply (ANCC, 2002).

Conclusion

Home care leaders have recognized the need to improve the working conditions of the nurse in order to recruit and retain qualified nurses (Ellenbecker & Cushman, 2001). The task may seem daunting, but the path has been outlined by the standards of the Magnet Recognition program which are "really measures of and a pathway to excellence" (M. M. Allison, personal communication, January 29, 2003). Home care agencies must be proactive in preparing for the imminent nursing shortage by beginning the process of becoming magnet facilities now.

REFERENCES