2023 Magnet^® Application Manual Updates and FAQs

Frequently Asked Questions About ANCC’s 2023 Magnet Recognition Program^® Manual

The FAQs on this page offer program information and interpretive guidance on many aspects of the Magnet Recognition Program^®.

2023 Manual Updates

Updates to “Magnet Recognition Program® 2023 Magnet® Application Manual” (PDF)

General Questions

Are observational units, labor and delivery, and the OR considered to be inpatient or ambulatory units? (May 2023)

This is a decision made by the organization, in collaboration with their externally managed database vendors, to assist with the categorization of these units/ambulatory care settings. After the classification is determined, the areas must be consistently reported as inpatient or outpatient throughout the document and the Unit Level Data Crosswalk.

Why are Analysts unable to confirm if an outcome measure is acceptable? (May 2023)

The Senior Magnet Program Analyst (SMPA) role is that of a subject matter expert, clarifying program requirements, definitions, terms, and content in the Magnet Application Manual. As employees of American Nurses Credentialing Center (ANCC), SMPA’s are not able to act in the manner of a consultant or appraiser to evaluate work for potential acceptance.

What if the post-intervention data do not indicate three consecutive improvement points? (July 2023)

The empirical outcome (EO) SOEs require an improvement is demonstrated. The post-intervention data may show variability (i.e., some data points which are improvements and some data points which are not improvements); however, when trended, the data must demonstrate an improvement occurred.
Reminder: Data provided during the intervention timeframe are not included in the evaluation of the improvement trend

To meet the requirement for two references in the EO SOE presentation format, are in-text citations required/accepted? (July 2023)

In-text citations are not required in the narrative.
In-text citations will not be accepted as the required key references in EO SOE examples.

Organizational Overview

OO11

Can we include evidence-based practice (EBP) and “exempt” nursing research on our research table? (May 2023)

Only nursing research studies are to be listed on the Table of Nursing Research Studies. Evidenced-based projects, process improvement, and quality improvement projects should not be included on the Nursing Research Table.
Exempt nursing research studies approved by the Human Research Protections Program governing body should be included on the Table of Nursing Research studies.

Can we include nursing research on our Table of Nursing Research studies that is conducted at our organization by non-nurse employees? (May 2023)

A study involving a non-nurse employee can be included on the Table of Nursing Research, as long as the PI, co-PI or site PI must be a nurse employee of the organization.

Are the terms Co-Principal Investigator (Co-PI) and Co-Investigator (Co-I) interchangeable? (March 2024)

These terms are not interchangeable.

The Co-PI refers to the individual(s) with the appropriate level of authority and responsibility to direct the proper conduct of the nursing research study with another PI.
The Co-I, refers to a collaborator or other personnel on the research team, who is involved with the research study, but does not carry any level of authority or responsibility related to the research study.

Transformational Leadership

TL4a&b | TL9 | TL10 |

TL4a&b

Does the advocacy for resources mean the resource must be acquired? Does the resource have to be a human resource? (May 2023)

The advocacy does not need to result in the acquisition of the resource.
The resource does not need to be a person, it could be such things as time, money, equipment, technology.

TL9

Does the mentor have to be from within the organization? (May 2023)

The organization must employ the mentee. The organization or system must employ the mentor.
It is acceptable to use system-level organization mentor programs or plans, as long as the mentoring is occurring within the applicant organization. The mentorship can be formal or informal.
TL9e: The CNO’s mentor may be within or outside the organization.

TL10

Does the individual engaging in succession planning activities need to transition to the new role? (May 2023)

For Magnet purposes, the succession planning activities of the individual do not have to result in entrance into the new role.

Structural Empowerment

SE3/SE4EO

For SE3 and SE4EO, are cohorts at the organizational level acceptable? (January 2023)

SE3 Narrative must describe an organizational-level goal for all RNs.

SE4EO Organizational-level cohorts are acceptable. The graph may depict the achievement of the organizational goal through the presentation of a cohort. An organization-level cohort could include nurses from all departments, e.g., all nurse managers, and all clinical nurses across the organization.

Does the organizational level goal presented in SE3 need to be the same organizational level goal presented in SE4EO, when a cohort is used? (January 2023)
Yes, organizations must align SE3 and SE4EO. SE4EO presents the goal described in SE3. However, while the goal needs to be the same, it may be at a cohort level.

Example using a cohort group:

SE3: Organization level professional board certification goal is 43%.

SE4EO: Organization level professional board certification goal is 43% for all Nurse Managers across the organization.

SE3/SE4EO/SE5/SE6EO

Is the list of National Certifications currently included in the DDCT changing to include only board certifications? (May 2023)

Yes, the list of National Certifications currently included in the DDCT is changing to include only board certifications. The current list will be in effect until December 31, 2023. Please refer to information on the Magnet Website related to Accepted Certifications in the DDCT and about implementation of the new process. (https://www.nursingworld.org/organizational-programs/magnet/program-tools/accepted-certifications/)

Do we need to provide a certification goal for each year presented, or can we develop a goal for our organization to meet by the end of year two? (May 2023)

You may provide an annual goal OR a goal for improvement by the end of year two. In either case, three years’ worth of graphed data (baseline plus two years) must be provided.
If you choose to develop a goal for improvement by the end of year two, you must include progression data for year one.
You must demonstrate that nursing has met the targeted goal for improvement (or maintenance as applicable) in professional nursing board certification.

If we choose to use a maintenance goal, does it have to be the same as the current level? (May 2023)

A Maintenance goal may be used if the organization is greater than or equal to 51%. For example, if the current level is 60%, it is acceptable to have a maintenance goal of 51%.

SE5/SE6EO

For SE5 and SE6EO, are cohorts at the unit or division level acceptable? (May 2023)

SE5 Narrative must describe a unit’s or division’s action plan for registered nurses’ progress toward obtaining professional board certification.
SE6EO Unit or division level cohorts are not acceptable, e.g., all clinical nurses across the division are not acceptable.

SE4EO/SE6EO/SE8EO

Do the three years of graphed data need to be presented as calendar years? (May 2023)

No, any three years of graphed data (e.g., calendar year, fiscal year) are acceptable as long as the timeframes are complete and within the 48-month timeframe.

SE7/SE8EO

If we choose to use a maintenance goal, does it have to be the same as the current level? (May 2023)

A maintenance goal is acceptable if the organization is >80%
Organizations must demonstrate that nursing has stayed above or equal to the >80% during the specified time frame.

SE10EO

Do SE10EOa and SE10EOb both require examples from ambulatory care settings? (May 2022)
No. SE10EOa may occur in an ambulatory care setting or at the inpatient unit or division level. SE10EOb must occur in an ambulatory care setting.

SE11a

What nationally accredited transition to practice programs are accepted for the 2023 Magnet Application Manual? (May 2023, updated May 2024)

The current accredited transition to practice programs accepted by the Magnet Program Office for SE11a are ANCC Practice Transition Accreditation Program (PTAP), ANCC Advanced Practice Provider Fellowship Accreditation (APPFA), Commission of Collegiate Nursing Education (CCNE), and Accreditation Commission for Education in Nursing (ACEN).

SE11a

If a system has a nationally accredited transition to practice program at the system level, would this fulfill the requirement for SE11a at the applicant organization? (May 2023, revised July 2023)

Yes, if the applicant organization is part of the system’s nationally accredited transition to practice program designation, a system certificate (or other documentation) is acceptable.
During site visit, organizations must demonstrate that the five domains are enculturated in all of the relevant transition to practice programs in the organization, regardless of if an organization has an accredited transition to practice program.

SE 11b-f

Can we use system transition to practice programs to meet the required elements for SE11b-f? (May 2023)

A non-accredited training program may be used as a part of the transition to practice program that facilitates effective transition for SE11b-f.

SE14a/SE14b/SE15

Do the contribution(s) and recognition need to occur within the 48 months prior to document submission? (March 2024)

The narrative and supporting evidence for both the contributions and the recognition must occur within the 48-month period prior to the submission of written documentation.

Exemplary Professional Practice

EP12EO

Do we need to provide an organizational turnover goal for each year presented, or can we develop a goal for our organization to meet by the end of year two? (December 2023)

You may provide and annual goal OR a goal for improvement by the end of year two. In either case, three years’ worth of graphed data (baseline plus two years) must be provided.
If you choose to develop a goal for improvement by the end of year two, you must include progression data for year one.
You must demonstrate that nursing has met the targeted goal for improvement (or maintenance as applicable) in nurse turnover at the organizational level.

The source statement requires one example, with supporting evidence. What supporting evidence is required for this source? (December 2023)

The supporting evidence referenced in the source statement is the graphed data.
No other evidence is required for this source.
Refer to data display requirements on page 66 and 67 of the 2023 Manual.

EP13

What are the expectations for peer feedback? (May 2023)

The MPO is not prescriptive about the formatting or timing of the peer feedback. The organization must follow their established peer feedback process, describe the peer review process and provide evidence to substantiate the process.
For nurses and APRNs who may be the only nurse within a setting, consider other resources, including but not limited to committee members and shared governance councils to ensure these nurses are receiving and providing peer feedback.

What is the expectation for peer feedback for the CNO? (May 2023)

The CNO may receive peer feedback from other disciplines outside of nursing.

As a part of the periodic formal performance review, are we expected to present the performance review from the current year? (May 2023)

Organizations are expected to follow their own policies related to the frequency of a formal performance review.

EP19EO-EP22EO

How should data be presented if there is a change in vendors during the eight (8) quarters prior to document submission? (May 2023)

Present separate graphs for data from the two vendors. For example, four (4) quarters from the previous vendor then a new graph with four (4) quarters from the new vendor. Each graph should be set up according to the instructions in the 2023 Manual (p. 70, 74, 77 and 80) or use vendor approved graphs where applicable.

EP20EO and EP22EO

My organization has no ambulatory areas, what is my requirement for EP20EO and EP22EO? (May 2023)

Organizations without ambulatory areas do not need to submit substitute data for EP20EO or EP22EO.
The Magnet Recognition Program considers the Emergency Department an ambulatory area.

EP20EO

For EP20EO, are we required to use a “Magnet Approved Vendor” from the list of Accepted Database Vendors located on the Magnet Learning Community (MLC) for the two nationally benchmarked nurse-sensitive clinical quality indicators? (January 2023)

EP20EO requires three nurse-sensitive clinical quality indicators for all eligible ambulatory care settings. Two must be nationally benchmarked. A vendor’s national database or national database comparable data such as, but not limited to, CMS, TJC, JCI, etc., may be used. EP20EO does not require the national vendor nor the national database to be on the Accepted Database Vendors list.

EP21EO/EP22EO

How are inpatient and ambulatory patient experiences sources evaluated for the 2023 Manual? (December 2023)

For each of the four patient experience categories, the final evaluation of an organization's outperformance is one composite score of the individual four categories for the inpatient settings and one composite score of the individual four categories for the ambulatory care settings.
Refer to the guidance on pages 74-80 in the 2023 Manual for submitting patient experience data.

New Knowledge Innovations and Improvements

New Knowledge, Innovations and Improvements

NK2 |

NK2

Are the terms Co-Principal Investigator (Co-PI) and Co-Investigator (Co-I) interchangeable? (March 2024)

These terms are not interchangeable.

The Co-PI refers to the individual(s) with the appropriate level of authority and responsibility to direct the proper conduct of the nursing research study with another PI.
The Co-I, refers to a collaborator or other personnel on the research team, who is involved with the research study, but does not carry any level of authority or responsibility related to the research study.

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