The Business Case for Magnet ® Designation : Using Data to Support Strategy.

The Magnet® journey has increased in relevance as the sources of evidence reflect the complex role of the nurse in quality, safety, and the patient care experience. Creating a business case to secure the resources required to embark and travel on the Magnet journey is an essential tool for the chief nurse. Identifying expenses, cost savings or avoidance, and return on investment for nursing services are all important elements of a business case.

Through managing the global pandemic, it has become obvious that the RN workforce contributes to quality patient care in a pivotal role. The pandemic has highlighted the need for a strategy to ensure that the nursing workforce is valued and recognized in a meaningful way and that their well-being is addressed. Nurses are leaving their current jobs and, in some cases, the profession at an incredible rate. In 2021, 62% of hospitals in the United States reported an RN vacancy rate higher than 7.5%. According to a recent survey by Nursing Solutions, Inc,[1] less than a quarter of hospitals had an RN vacancy rate less than 5%. High percentages of RN vacancies can negatively impact hospitals.[2] Since 2016, “the average hospital has turned over about 83% of its RN staff and 90% of its overall workforce, with the cost of turnover for a bedside RN ranging between $28,400 and $51,700, enough to cause many hospitals to lose between $3.6 and $6.5 million per year.”[2] Chief nurses must reenergize and reprioritize efforts for long-term retention and support of professional nursing practice versus short-term retention strategies that do not address the reasons for the vacancies. One significant cost expenditure during the pandemic has been the extraordinary need and reliance on agency and traveler nurses due to resignations of RNs.[3] Reports in some markets describe fees of $12 000/wk for each RN, paying up to $250/h. On the basis of average reported traveler use, hospital costs are estimated at $17 million dollar increases in annual labor budgets for an average 500-bed healthcare facility.[4]

The Importance of Magnet®

Magnet designation and the preceding journey are more important than ever as the sources of evidence (SOEs) reflect the role of the nurse in quality, safety, and the patient care experience.[5] As the Magnet SOEs continue to emphasize and require outcomes in the top benchmarks, the attainment of Magnet status is an external signal that quality, service, and patient-centered care are visible and alive in the organization. There are currently approximately 580 Magnet-designated organizations, about 9% of US hospitals. In addition, Magnet recognition is a signal to the nurses in the organization, and the nurses considering joining the organization, that there is a commitment to nursing. Creating a business case to secure the resources required to embark on the Magnet journey will be an essential tool for the chief nursing officer (CNO). Each CNO should create a framework of the goals that they hope to achieve through both the Magnet journey and the Magnet designation over time.

Lake et al[6] conducted a meta-analysis of the nursing work environment and 4 sets of outcomes. The researchers examined nurse job outcomes, safety and quality ratings, patient outcomes, and patient satisfaction. There are consistent significant associations between the work environment and all outcome classes; better work environments were associated with lower odds of negative nurse outcomes, higher patient satisfaction, and better quality and safety outcomes. Magnet recognition has been reported to have a positive effect on quality, safety, mortality, patient experience, and RN turnover and vacancy.[6] Mounting evidence leads to a quantifiable business case for Magnet, and a review of the evidence will be shared.

History of the Magnet Recognition Program®

In an essay, Dr Muriel Poulin,[7] one of the co-researchers of the original Magnet hospital study, shared how the researchers took a different research approach to examining the root causes of hospital nursing turnover. Rather than examine reasons why RNs left their jobs, researchers focused on the driving forces that resulted in organizations with low RN vacancy and turnover rates. The combination of identifying factors that attracted and retained professional nurses was combined with identified factors reported from hospitals with clinical excellence. The identification of elements that were important to nurses—autonomy in practice, shared governance, collaboration, and teamwork; and opportunities for career development through clinical ladders, professional development, and continuing education—continues to be highly valued by professional nurses today.[7]

Why Consider Magnet?

Haller et al[8](p334) state: “It is not the destination that matters, but the transformational journey that accompanies the effort where the true gains lie for most healthcare organizations.” Nursing leadership must examine their organization's challenges and work toward a performance-driven culture fostered by the Magnet journey. Positive outcomes found in Magnet hospitals compared with non-Magnet hospitals reinforce the value of nursing. More than 30 years of research is highlighted here with samples of findings:

Higher nurse job satisfaction[9]

Higher likelihood among nurses to communicate about errors and participate in error-related problem solving,[10] thereby contributing to improved patient safety

Higher adoption of National Quality Forum safe practices in Magnet organizations[11]

Lower patient fall rates[12]

Lower risk-adjusted rates of 7-day mortality, nosocomial infections, and severe intraventricular hemorrhage of very low–birth-weight infants[13]

Lower nurse-reported adverse events[14]

Lower rate of nurse occupational injuries[15]

Higher patient satisfaction[16]

Lower rate of catheter-associated urinary tract infections[17]

Lower patient mortality[18]

Lower failure to rescue[19]

Lower odds of having a hospital-acquired pressure injury[20]

With several decades of literature supporting the improvements in key clinical, nurse, and patient outcomes, working to leverage the Magnet framework to organize and elevate nursing services in an organization is worthy of the CNO's strategic consideration. The process of assessing the organizational nursing services' strengths and opportunities or gaps against the Magnet SOEs that are evidence-based and proven to improve outcomes is a meaningful approach to ensuring excellence in clinical quality. Although there are costs associated with obtaining Magnet recognition, there is a body of evidence that points to the multiple opportunities to demonstrate the return on investment (ROI). Identifying expenses, cost savings, or avoidance and ROI are all important elements of a business case. Rather than being seen as a “cost,” nursing care must be seen as an investment to deliver safe and high-quality care resulting in positive patient outcomes and nursing excellence.

Developing the Business Case: A Nursing Imperative

Increasingly, the CNO has a responsibility to articulate the value of nursing services.[21] The COVID-19 pandemic has elevated the importance of this quantification. Nurses have been the foundation of care delivery during the pandemic, and the presence, innovation, knowledge, and demonstration of caring science made an indelible impression on the world. Attention to the nursing work environment and mental health needs of the nursing workforce requires structural changes in care delivery and professional practice models, and these imperatives are also in alignment with the SOEs. The SOEs highlight the contribution of nurses to improved quality outcomes, cost avoidance, and increased patient satisfaction, thus further substantiating the value recognized during the pandemic.

The development of a business case[22,23] is “a strategic tool for change”[22](p414) and can help organizations make choices regarding the investment of resources. The creation of a business case for adopting or continuing the Magnet journey is essential for a CNO to ensure that there is stakeholder support and resources dedicated to address core requirements to obtain and maintain nursing excellence. Key elements of the business case include addressing strategic fit, program objectives, review of options, affordability, and achievability. Business cases should outline expected quantifiable results and benefits, as well as risks and costs. In addition, identifying a plan for areas that are projected to improve should be accompanied by metrics and targets with a timeline for achieving the benefits. Developing a strong partnership with the chief financial officer (CFO) is a vital component to building the business case for Magnet. The CNO should be jointly accountable for achieving identified outcomes along with other key executive team members.

Building the Business Case for Magnet

There are several important steps in building a business case. The CNO must ensure that seeking Magnet recognition is aligned with the strategic priorities of the organization as well as the organizational vision and mission. A strategic plan for nursing services must be developed. Seeking Magnet designation demonstrating nursing excellence should be an important strategic effort reflected in the nursing strategic plan. Even if the CNO decides that timing is not right to apply for Magnet recognition, organizing nursing services around the Magnet conceptual model and SOEs will build a strong foundation for excellence in nursing care.

Conducting an internal and external stakeholder analysis as a 1st step is a critical process that should be carefully conducted. A stakeholder analysis includes identifying the people involved in the process, including the executive team and the Board of Trustees; understanding their level of support; and developing a plan to engage them along the journey. Without this level of thoughtful analysis, the CNO could be down the path in implementing and addressing the Magnet standards when plans could be derailed. Honestly identifying the potential objections or obstacles to obtaining Magnet recognition is important for the CNO. It is essential to develop a list of the core leaders, peers, staff, and influencers initially to gain support.

Many resources are available to a nurse executive to build a business case. A good example is available on the Agency for Healthcare Research and Quality website[24] The example uses a toolkit for building the case to prevent pressure injuries. An example of a stakeholder analysis and building a business case on a smaller scale are included in the toolkit, which could easily be adapted to building a business case for the pursuit of Magnet recognition.[24]

Identifying ROI Opportunities

Decades of literature support that Magnet-recognized organizations have better outcomes in clinical care, nursing workforce, and patient experience. The CNO must identify the outcomes that are directly attributable to excellence in nursing care and areas where strengthening the structure and process of nursing care delivery can lead to organizational cost savings. Identifying the potential cost savings, cost avoidance, and reputational and market benefits[25] of being Magnet designated require a comprehensive look at opportunities within the organization. Cross walking the improvement opportunities with the challenges that are present in each organization must be done to present a compelling reason to invest in the Magnet journey. Working collaboratively with the CFO to get an estimate of the attributable cost savings that can be obtained by meeting performance improvement targets will help the CNO gain evidence to support the financial expenditures. For organizations with robust cost accounting financial systems, determining the actual organizational costs for adverse events is a better way to strengthen CNO and CFO partnerships and ownership of a Magnet environment as a best practice and organizational goal.

During COVID-19, the need for agency nurses impacted the areas where surges were highest. These costs were extraordinary with some hospitals paying traveling nurses as much as $12 000 weekly[4] and agencies up to $250/h. Hospitals in need of nursing staff have little choice but to pay the rates demanded or close beds. High-rate hikes shifted the finite supply of nurses toward more affluent areas and healthcare organizations, often leaving rural and urban public hospitals short-staffed.[4] Creating a recruitment and retention strategic plan that lessens the reliance on agency nurses is a critical 1st step for the CNO. Partnerships with schools of nursing for recruitment strategies and using the Magnet framework to bolster retention efforts will aid the efforts. Clearly articulating the value that nurses bring to improved quality and clinical outcomes and patient experience will assist in value-based purchasing program[26] introduced by Centers for Medicare & Medicaid Services, while also having a financial benefit for the organization. The hospital value-based purchasing program encourages hospitals to improve the quality, efficiency, patient experience, and safety of care that Medicare beneficiaries receive during acute care inpatient stays to improve patient outcomes and recognize hospitals that provide high-quality care at a lower cost. Table 1 outlines the areas that the literature supports and that contribute to ROI opportunities and the implications for chief nurses.

Table 1

Selected ROI Opportunities and the Implications for Chief Nurses

Area of ROI Opportunity	Evidence	CNO Implications
Clinical quality and patient safety
Patient falls	Lower fall rates in Magnet hospitals. Each prevented fall saved $34 294.[27-31]	Assess organization's current fall rate Set a target for improvement Work with the CFO to identify cost avoidance
Communication of errors and near misses	Improved patient safety[10]	Analyze organizational data to determine cost avoidance
Failure to rescue	Lower failure to rescues resulting in improved mortality[32,33]	Identify cost of failure to rescue; set a target for improvement
Hospital-acquired pressure injuries	Lower hospital-acquired pressure injuries (HAPIs in Magnet hospitals[24])	Cost of HAPI ranges from $20 900 to $151 700 per pressure ulcer. The AHRQ study suggested $14 506 as an estimate for pressure injury cost/case when hospital acquired.[24] Identify current hospital-acquired pressure injuries. Set a target for improvement and calculate direct cost and estimate between $14 506 and $43 180 per event.
CLABSI, CAUTI (2017), and nosocomial infection rate	Costs of all hospital-acquired conditions[34-36] estimate CAUTI costs at $13 793 (range, $5019-$22 568) per case. CLABSI costs estimated at $48 108 (range, $27 232-$68 983) per case.	Costs of CAUTI estimated at $13 793 and CLABSI at $48 108 for each case. Identify current hospital-acquired CLABSI and CAUTI. Set a target for improvement and calculate direct cost and estimate at $13 793 for each CAUTI event and $48 108 for each CLABSI event avoided.
Nursing satisfaction
RN turnover	RN turnover: nurses (28%) less likely reporting intention to leave in Magnet hospitals[6]	Each RN who leaves costs the organization approximately between $28 400 and $51 700. Determine cost for each percentage point of reduction in turnover. Identify turnover reduction cost savings and align with a recruitment and retention plan and a nurse satisfaction plan.
RN job satisfaction	Job satisfaction higher in Magnet hospitals that non-Magnet[6]
Agency use	Reports in some markets of agency staffing fees of $12 000/wk for[1] RN = $300/h[3,4] Each RN who leaves costs the organization approximately between $28 400 and $51 700. For every 20 travel RNs eliminated, a hospital can save, on average, $3 084 000.[1,36]	Determine the number of new nurses needing to be hired to reduce agency. Develop an aggressive recruitment and retention plan engaging clinical nurses in the plan. Align recruitment strategies with the Magnet journey. Partner with human resources, CFO, and marketing to implement the plan. Strengthen academic/practice partnerships to ensure a predictable flow of new graduates. Implement a nurse residency program so that new graduates commit to the organization.
Patient satisfaction
Patient satisfaction	Magnet hospitals are 16% more likely to have satisfied patients.[6]	Patient experience benefits to having higher HCAHPS scores can be directly linked to nursing care. Capture increased reimbursement gains due to higher patient satisfaction score.
Financial outcomes
Net inpatient income	On overage, Magnet hospitals receive an adjusted net increase inpatient income of $104.22-$127.05 per discharge after becoming a Magnet—translating to addition $1 229 770—$1 263 926 in additional income/y[12]	Calculate your inpatient revenues pre and post Magnet designation.
Readmission rates	30-day readmission rates reported lower in Magnet hospitals[37] Reports of 2499 hospitals in 2021 penalized for high readmission rates[38] The average penalty is a 0.64% reduction in payment for each Medicare patient stay from the start of this month through September 2021. The fines can be heavy, averaging $217 000 for a hospital in 2018, according to Congress' Medicare Payment Advisory Commission.[39] Average readmission cost of $15 200.[37]	Calculate your readmission rates along the Magnet journey and pre and post Magnet designation. Determine improvement target and calculate cost impact of lower readmission rates.
Value-based purchasing measures	Hospitals known for nursing excellence perform better on value-based purchasing measures.[39,40]	Work with CFO to determine nursing contribution to value-based purchasing measures.
Efficiency and effectiveness due to innovation SOEs	New knowledge, innovation, and improvement sources of evidence provide opportunity to identify nursing's value to cost effectiveness.	Calculate cost savings on innovation projects and include them in the ROI calculation

Abbreviations: AHRQ, Agency for Healthcare Research and Quality; CAUTI, Catheter associated urinary tract infection; CLABSI, Central line bloodstream infection; HAPI, Hospital acquired pressure injury; HCAHPS, Hospital Consumer assessment of healthcare providers and systems.

Identifying the Expenses

Once the ROI opportunities are identified in areas of clinical quality, RN turnover and vacancy, agency cost reduction opportunities, and improved patient experience, the next important activity to build a business case is to outline the expenses. In the case of Magnet recognition, identifying the costs of the application fee, the document submission and appraisal fees, the site visit fees for travel, and the ongoing annual fees is quantifiable. To aid in this, in January 2021, the American Nurses Credentialing Center (ANCC) changed the fee structure to be more predictable across budget years and better spread out the cost for a 4-year period.

As an example, for a 500-bed hospital, the document submission appraisal and support fee when an organization applies is $39 050.[41] This new cost structure allows an organization to better predict the payments over 4 years. Table 2 shares the fee structure for a 500-bed hospital as of the end of 2021. Total 4-year fees in 2022 are $78 100 (excluding site visit travel expenses).

Table 2

Magnet Fees for a 500-Bed Hospital

Assumption: 500-Bed Hospital[41]
Description of Fee	Amount
Application fee	$6000
Appraisal and support fee for document submission	$41 395
Year 1 annual support service fee	$13 799
Year 2 annual support service fee	$13 799
Year 3 annual support service fee	$13 799
Total fees (without site visit travel)	$88 792

Other costs can be incurred with the Magnet journey such as consultants and document writing editing services, but these are optional. The resources that the ANCC provides to applicants are robust, including assessment tools, strategies for conducting gap analyses, webinars, and Magnet analyst consultation support. In addition, the introduction of a Web-based, online application and document storage system called ADAM is an excellent repository for an organization's Magnet documents. The document library allows multiple users to store and manage documents in the account.

Generally, in developing a business case, “the costs should be those over and above the normal costs for running a nursing care service within a hospital.”[23](p269) The costs of implementing a substantial quality infrastructure, data capture, and shared governance processes are evidence-based approaches to managing a healthcare system and should not be included in direct costs of Magnet expenses based on widespread adoption across settings. Therefore, estimates of costs for the Magnet journey can be estimated at approximately $250 000, depending on bed size and organizational resources.[23]

Determining Hospital ROI

The ROI “is an understandable and easily calculated metric for determining the efficiency of an investment.”[42](p1) The ROI analysis provides the CNO with a percentage of return and also allows the comparison of other efforts and initiatives that the organization might be considering. The CNO needs to consider all costs that the Magnet journey might involve above those efforts that are needed to deliver patient care. The CNO must also consider all benefits that can reasonably be achieved. These targets should be set in partnership with the CFO, the chief human resource officer, and the chief executive officer.[43]

Once agreement with the executive team has been reached on the expected financial benefits and the anticipated costs, the formula for ROI can be applied. The CNO should determine the cost savings and financial benefits, subtract the expenses, and divide by the costs of the Magnet journey and then multiply by 100 to determine the ROI in a percentage format. For example, to determine the ROI of a quality improvement project on a unit that will cost $25 000 to implement and yields $35 000 in increased reimbursement, the ROI would be expressed as

The ROI determination is meant to make a credible effort to determine the benefit as a result of the intervention or program put in place and its impact on the improvement.

Leverage the SOEs

A review of the 2023 manual,[44] SOE reveals an opportunity for the CNO to leverage the standards to create a positive work environment where nurses want to work, attends to nurses' well-being, and addresses racial disparities in healthcare. The “Future of Nursing”[45] report clearly identified the role of the nurse as a critical lever to address the inequity in health outcomes. The “Future of Nursing” report and the new AACN Essentials[46] both speak to the important role of nurses in leveling the playing field in healthcare outcomes, to eradicate racism and health disparities so that all people receive the care that they need and deserve.

The COVID-19 pandemic heightened the awareness of systemic racism in healthcare. The complex interrelationship of factors, namely, unequal access to education, employment, housing, healthcare, and other systems, resulted in increased vulnerability of persons of color during the pandemic. The role of the nurse in identifying and addressing health inequities is vital. Nurses can provide primary, preventive, and chronic disease care in especially vulnerable populations.[47] Nurses have an important leadership role in addressing these disparities. The organizational requirements for Magnet designation require organizations to share how they are addressing these equity disparities.

Ultimately, all these efforts maximize the value on investment of nursing services. Table 3 provides a selected look at the SOEs and provides guidance to link the SOE examples with the value that nurses bring.

Table 3

Leveraging the SOEs for Cost Capture: Selected Opportunities

2023 Domain/SOE	Potential Cost Capture	Impact and Value
Transformational leadership
TL3EO Strategic planning	An improved patient outcome that aligns with a goal in the nursing strategic plan and creates value for the organization	When developing or revising the nursing strategic plan, work to impact an outcome that clearly demonstrates value, cost avoidance, or cost savings.
TL4 Advocacy and influence	Advocacy at VP, nurse manager, and clinical nurse level for resources that map to goals. Link resources obtained to goals such as reducing agency spend, improving retention efforts, and creating a predictable supply of new hires.	Evaluate carefully where resources obtained would impact cost efficiency, improved clinical or quality outcomes.
TL5 Nurses' well-being	Investment in nurses' well-being can be linked to reduction in turnover and vacancy rates.	A more stable work environment created by lower turnover
TL6 Organizational change	Consider a goal of improving value in interprofessional care models, care delivery redesign	Maximize the impact of nursing practice, which may result in cost savings
TL 8EO Nurse participation in organization-level decision-making group	Choose an improved patient outcome project that includes clinical nurses in the decision-making process	Links to lower cost/case or reduced length of stay, avoidable costs, or direct cost savings
TL 9 Mentoring plan at all levels	Mentoring plans and succession planning reduces costs of recruitment efforts and executive search firm fees	Avoid disruptions in service due to transitional and interim leadership
TL 10 Succession planning
TL11 EO Advocacy for resources	Use the resource acquisition in an ROI model	Directly link resources that improved quality and lower costs
Structural empowerment
SE1EO Professional development	Capture the financial impact of improved outcomes as result of nurse participation in an organization committee	Think strategically about clinical nurse appointments to committees that can demonstrate cost effectiveness
SE2EO Strategy involving organizational participation and professional organization participation	Capture the financial impact of improved outcomes as result of nurse participation in a professional organization
Exemplary professional practice
Organizational overview for workplace environment	Magnet requires a plan in place for caregiver well-being, diversity, equity and inclusion efforts, and zero tolerance for bullying, incivility, and workplace violence. The chief nurse should work to determine the ROI of these programs on turnover and vacancy rates.	All of these programs are well documented in the literature to create a positive work environment, which in turn decreases turnover and vacancy rate. Efforts to put these plans in place can be a recruitment tool and a retention strategy.
EP1EO Evidence-based practice changes	Improved patient outcomes (such as falls, infection rates, mortality, hospital-acquired pressure ulcers) can be linked directly to lower costs.	This evidence, supported by a professional practice model, can support the CNO efforts to articulate the value of professional nursing practice.
EP3EO Nurse satisfaction	Nurse satisfaction can be directly linked to intention to stay, turnover, and vacancy rate.	The chief nurse should consider focusing on resources and staffing, autonomy, and fundamentals of quality nursing care to capture the biggest ROI for the Magnet journey.
New knowledge, innovations, and improvements
NK2 Research	Consider advocating for a research study that will improve cost outcomes of nursing care	New knowledge generation improves patient care outcomes.
NK7 Innovation	Consider the value proposition of innovation, and capturing the potential for saving time, money, and increased efficiency	Innovation is “establishing new ways of achieving high quality, effective, and efficient care.”[44](p14)
NK 8EO Technology	Conduct pre-post evaluation of cost savings with technology solutions for improving care	A technology-enabled outcome can often lead to cost savings or cost avoidance.
NK9EO Redesign of workflow	Conduct pre-post evaluation of cost savings with workflow redesign for improving care	A redesign of workflow that results in an improved outcome can often lead to cost savings or cost avoidance.

Abbreviation: VP, vice president.

Implications for International Chief Nurses

February and Holmes[48] presented a case study of an international hospital that revealed a 5-year savings of $2.3 million through improvement in hospital-acquired infection, falls, and pressure injuries, along with nurse retention and better management of consumable goods. The authors highlighted the importance of tracking and trending progress in clinical quality and nurse outcome improvement and linking the cost savings to the Magnet journey. Adding to the evidence, Oshodi and colleagues[49] identified important aspects of the work environment related to nurse-assessed care quality measures in the United Kingdom. International CNOs need to evaluate their country's payment system, but investing in nursing services can be linked to improved patient outcomes.

Role of the Chief Nurse Executive

Exemplifying transformational leadership is no easy feat, and the last 2 years managing a pandemic has challenged even the most seasoned CNOs and the nursing leadership teams. The foundations of the forces of magnetism are evidence-based practices that result in excellence in clinical outcomes, patient experience, and nurse satisfaction. These include leadership visibility, accessibility, and communication; creating an environment where shared governance is fostered and clinical nurses are integral to decision making; and professional practice models that are in place that foster interprofessional teamwork, career development, autonomy in practice, and appropriate resource allocation. The role of the CNO is paramount in obtaining and maintaining Magnet designation. Excellent communication skills and engaging stakeholders, from the bedside to the board room, is critical. Building stakeholder support, which includes peers on the executive team, clinicians, the physician community, community members, and the Board of Trustees, is an important step in the Magnet journey. The articulation of the ROI for nursing excellence has never been more important, because resources are stretched.

Chief nurses and their nursing leadership teams have to clearly explain the benefits of a strong nursing service and explain that the ROI is robust when appropriate resources are applied to developing excellent nursing practice. The investment in resources comes with a nursing leadership responsibility to be accountable toward achieving the outcomes. Chief nurses need to be willing to monitor and evaluate the outcomes of the investment in the professional practice model. Plans need to be created to track costs, identify progress on improvement, and work with the CFO to understand the ROI of excellence in nursing care. The time is ripe to reset the organization-nurse relationship based on value for concurrent quality and cost improvement.[50] The critical role nurses play in creating value depends on the work environment described by the Magnet model.

Summary

The potential for professional nursing practice to be dismantled by hiring less educated nurses, changing skill mix, and increasing patient loads during workforce shortages is a reality. Chief nurses need to work strategically to resist quick fixes and rely on evidence-based structures and processes that result in lower turnover and vacancy rates. The Magnet program outlines an evidence-based approach to creating a positive work environment that supports clinical excellence. The larger issue is that nursing services are viewed as an expense, rather than an investment. A change that needs to occur is how the value of nursing care is measured. “Accurately measuring the cost of nursing care is one of the requirements to more precisely measure the value of nursing care, conceptualized as the comparison of nursing intensity or costs and patients' health outcomes.”[50](p214) Yakusheva et al[51] put forward the concept of value in nursing practice, balancing quality with cost, and adopting value-informed nursing practice. For nurse executives, this means looking at nursing services as human capital versus a nursing resource expense and understanding “that nurses are a highly qualified professional whose value contributions are strengthened by knowledge, skills, and talents embedded in each individual nurse.”[52](p1) This presents an opportunity for the CNO to present a compelling business case.

Whether you obtain Magnet recognition or not, using the Magnet framework and working on the Magnet journey of addressing gaps in leadership, decision making, professionalism, and outcome improvement will guide a CNO to create a positive work environment where nurses are engaged, feel valued, and have autonomy in practice.[52-55] Using the framework to achieve clinical excellence is a strategic decision that can yield positive clinical, nurse, and patient outcomes.

These are extremely challenging times for nurse leaders. Chief nurses need to work to create a robust and caring environment where understanding workforce needs drives the support that is required. There is an opportunity to leverage the Magnet SOEs to increase and sustain the nursing workforce in a meaningful way. Even during a pandemic, foundational efforts must be attended to because there is clear evidence that nurses will choose one workplace over another.