An Irish Hospital's Trailblazing Journey

FigureST. JAMES'S HOSPITAL (SJH) was given the opportunity to become involved in the Magnet4Europe (M4E) interventional research project in 2019. M4E was an exciting initiative aimed at improving the mental health and well-being of nurses and clinicians by reshaping the work environment. M4E was the largest interventional study of its kind, which was conducted over 4 years, and involved 67 hospitals in 6 European countries (Ireland, Belgium, England, Germany, Norway, and Sweden). Each individual hospital was twinned with an established Magnet® Hospital in the US, and SJH was matched with the Long Island Jewish Medical Centre (LIJ) in New York. The objective of the M4E study was to implement and evaluate the effectiveness of the Magnet Model® outside of the US setting in achieving improved clinical work environments, staff mental health and well-being, productivity, patient outcomes, and cost-effectiveness. Mental health challenges, such as depression and fatigue, frequently affect healthcare professionals in acute hospital environments.1 The M4E study provided an opportunity for staff to get involved in facilitating change and implementing strategies that would ultimately improve well-being. SJH's involvement in this study resulted in initiating changes that positively influenced the workplace environment, such as establishing shared governance structures that included direct care nurses and establishing recognition programs. The impact of these enhancements was evident based on responses to our M4E survey for nurses and clinicians. Although we still had areas to work on, by the time the study ended, we felt that we had made significantly positive improvements. Both the Magnet Recognition Program® (Magnet) and Pathway to Excellence® Program (Pathway) are awarded by the American Nurses Credentialing Centre (ANCC) to recognize nursing excellence and quality patient care. Both programs aim to improve the working environment for nurses while promoting nursing as a profession and improving patient outcomes.2 Since joining the M4E project, it has been the intention of the SJH nursing team to pursue Magnet recognition. However, because we didn't have nationally benchmarked data related to nurse-sensitive clinical indicators, patient experience, and registered nurse satisfaction, which is a requirement for this particular recognition program, we decided instead to pursue Pathway. The Pathway framework assists in creating and sustaining positive work and learning environments and very much focuses on staff well-being, which is critical to achieving superior organizational outcomes. SJH AND IRISH HEALTHCARE Ireland has a dual healthcare system consisting of public and private options. The public system is available to all. This system is run by the Health Service Executive (HSE), which obtains funding from general taxation and provides a range of services, including hospital care, GP services, and community health services. The private sector offers access to private hospitals and clinics to those who choose to pay for private health insurance. SJH is a Voluntary Hospital, which is state-funded with its own hospital board but provides services on behalf of the HSE under a service-level arrangement. It's the largest acute academic teaching hospital in Ireland and is based in Dublin's south inner city. Our fundamental purpose is the delivery of health treatment, care, and diagnosis as well as health promotion and preventative services at local, regional, and national levels. The hospital's academic partner is Trinity College Dublin. By international standards, SJH is a substantial acute hospital service provider. The hospital occupies a prominent position in the public eye and is recognized for prioritizing innovation and excellence of care delivery on an academic health campus. SJH provides acute, emergency, national, and regional specialist services and residential care, across a vast range of medical and surgical specialties and places high emphasis on excellence of delivery, research, innovation, and education. Our nursing team consists of just over 2,200 nurses. MAGNET AND PATHWAY COMPARISON The ANCC Pathway and Magnet programs provide two separate frameworks for organizations to follow to promote nursing excellence and improve engagement, nurse retention, and interprofessional collaboration to provide safe, high-quality care to patients, thereby improving their health outcomes. Although the programs complement each other and align in many of the requirements within the evidence submission, they differ in the specifics (see Table 1). TABLE 1: - Pathway to Excellence and Magnet comparison Pathway to Excellence Magnet The process Application (includes eligibility requirements) Application (includes eligibility requirements) Submit written documentation: 60 elements of performance (EOP) Submit written documentation: 103 sources of evidence (SOE) Peer review by appraisers Peer review by appraisers Nurse survey to verify enculturation of evidence submitted Site visit to verify enculturation of evidence submitted Commission on Pathway to Excellence Commission on Magnet Recognition The standards Shared Decision Making Structural Empowerment Leadership Transformational Leadership Safety New Knowledge, Innovations, & Improvements Quality Exemplary Professional Practice Well-Being Empirical Outcomes Professional Development The data to be included in the written documentation No requirement for nationally benchmarked data of achievement of minimum outcomes Nurse-sensitive clinical indicators; majority require national benchmarking Assessed under well-being standard in written evidence; and survey following successful review of evidence Nurse satisfaction data collection and national benchmarking Element in Quality standard requires pre and post data Patient satisfaction data collection and national benchmarking External benchmarking used to guide nursing practice decisions and improve outcomes; the benchmarks must be external and not necessarily at the national level Empirical outcomes/data are expected throughout the document (approximately 50% of document) Requirement for nursing research (2 completed and 1 ongoing; demonstrated culture of nursing research) OUR JOURNEY The Nursing Excellence team at SJH successfully submitted a business case to the hospital's Chief Executive Officer in June 2023. In July 2023, our Nursing Excellence team reviewed our readiness as an organization to apply for Pathway by completing a “self-assessment of organizational culture” form. This assessment enabled us to critically analyze our culture, practices, policies, and processes against the Pathway standards and identify any gaps that needed immediate focus. It became apparent from our review, that our organization was in an ideal position to apply for designation. Our colleagues at LIJ also provided encouragement and support for this journey. This insight was subsequently shared with the Executive Nurse Management Team who supported the decision to apply. The success of our Pathway journey depended very much on teamwork, a value that's incorporated within our recently developed Professional Practice Model. Over 100 nurses were directly involved in the preparation of the submitted documents. Our promotion and education of Pathway throughout the hospital involved every nurse; ensuring that we were living the Pathway standards as part of our daily work. Gaining the support of all our nurse leaders was vital to promote the engagement and involvement of all our nurses. The process also presented some challenges, which are highlighted in Table 2. TABLE 2: - Challenges US Ireland Established accreditation programs Newer concept for nursing in Ireland License for hospitals to operate renewed frequently License for hospitals to operate is obtained as a one-off process at establishment stage. SJH has a service-level agreement with the HSE. Nursing roles within the framework are defined for American nurses Different nursing roles, grades, and titles identified within Ireland Verbiage is well-known to an American audience; easily understood abbreviations CNO (Chief Nursing Officer) Interprofessional Difference in verbiage proved a challenge, especially during the survey DoN (Director of Nursing) Multidisciplinary We employed a variety of methods to create awareness of the Pathway framework among our teams and to demonstrate how we were already embodying its principles. Here are some of the ways we shared our Pathway journey with our colleagues: Creating Pathway standards writing teams Distributing monthly Pathway newsletters Establishing a Link nurse program, whereby a designated Pathway to Excellence link nurse promotes best practices and provides guidance to colleagues Organizing Pathway competitions Sharing “Pathway Pearls” (highlights or key information from the Pathway to Excellence Program) in advance of the nurse survey We're delighted to say that SJH is the first hospital in Ireland to achieve Pathway designation (March 2025), and we're proud to have this recognition for our hospital and our nursing team. We were extremely happy with our survey results and with the high percentage of nurses (76%) who completed the survey. As part of the M4E project, we carried out 3 nurse and clinician surveys that have enabled us to measure our improvements since we embarked on the journey to Pathway. We've selected the results from the M4E survey completed before our Pathway journey began to compare with our Pathway survey results (see Table 3). The questions weren't exactly the same for both surveys, but they're based on very similar themes. We were delighted with our high scoring results, which also showed a significant improvement when compared with the M4E survey results, which we attribute to the initiatives we put in place during our Pathway journey.TABLE 3:: Survey resultsBENEFITS TO SJH NURSING TEAM Achieving Pathway designation recognizes that SJH is committed to maintaining and improving a positive practice environment. Creating a positive practice environment is aligned with SJH's mission and vision and assists us in achieving our strategic objectives. Our vision is that our hospital will be a great place to work, a great place to learn, and a great place to be a patient. In order to achieve this vision, we recognize the importance of safeguarding clinician well-being. Obtaining this designation demonstrates that we've engaged nurses who provide high-quality care to our patients. We value and recognize our nurses, which is evident through our current 2% vacancy rate within the direct care nursing cohort. SJH recently has been recognized among the top 200 employers in Ireland, based on thousands of employee evaluations and public perception data collected through independent research. IMPACT ON NURSING IN IRELAND We're proud to be the first hospital in Ireland to receive the Pathway designation, elevating the status of nursing in Ireland and providing the opportunity to influence national policy. Having a hospital in Ireland designated as a Pathway to Excellence organization has a profound impact on nursing. This prestigious recognition from ANCC signifies a commitment to creating a positive practice environment for nurses, enhances nursing recruitment and retention, boosts job satisfaction, and promotes shared decision-making and leadership. This designation also highlights the hospital's dedication to quality, safety, and professional development, ultimately leading to better patient outcomes and positioning Irish nursing on the global stage. IN-HOUSE PRIDE Within our hospital, there's a profound sense of collective pride. This designation has provided our nurses with the opportunity to showcase how their dedication and efforts align with the SJH vision. Our staff feel respected and empowered, as reflected in the positive staff survey results. We've also seen an increase in job applications and requests from undergraduates to study here as part of Erasmus+, a European program that offers university students the opportunity to study or do an internship in another country. NATIONAL PERSPECTIVE From a national standpoint, SJH nursing is recognized as a center of excellence. Our Pathway designation is acknowledged not only hospital-wide but also across our region and nationally. Our experience of partaking in this process and being successfully designated has enabled us to provide guidance and mentorship to other Irish hospitals nationally, similar to the guidance we received from our M4E partner, LIJ. MOVING FORWARD The Pathway designation process was a fantastic opportunity to continue collaborating with SJH nursing and the wider team to enhance patient experiences and outcomes, but our journey doesn't end here! Our next steps involve building on our journey to reach the ultimate goal of achieving international Magnet recognition in the coming short years, once we have a structured, robust benchmarking system in place. Together, we'll continue to strive for nursing excellence and make a lasting impact on the nursing profession, both nationally and internationally.

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