Fourteen Forces of Magnetism and the Department of Veterans Affairs
As the nation’s largest healthcare provider, the Department of Veterans Affairs has the mandated responsibility of caring for “those who shall have borne the battle, their widows and orphans.” This paper provides an analysis of the Department of Veterans Affairs (VA) using the “Fourteen Forces of Magnetism” developed by Bliss-Holtz, Winter, Scherer and Elaine (2004) as a guide to assessing whether the organization has structures in place to for recruitment, retention, and support of a qualified workforce and to support the professional practice of nursing. The paper presents an overview of the VA, its location, size and age as well as some unusual history of the organization. A discussion concerning the VA’s image is followed by an analysis of its sub-unit configuration. A summary of the research and salient findings concerning whether the VA is in a solid position to recruit, retain, and support a qualified workforce and to support the professional practice of nursing are presented in the conclusion.
Review and Discussion
Overview of the Department of Veterans Affairs.
Location. The VA maintains healthcare facilities in the form of 155 medical centers (at least one in each state), 1,400 outpatient clinics and 209 so-called “Vet Centers” across the country and in Puerto Rico. In fact, approximately 70 million people or a quarter of the U.S. population, are potentially eligible for VA benefits and services based on their active military services or because they are family members or survivors of veterans (About VA, 2008; Facts About the Department of Veterans Affairs, 2008).
Size. Today, the VA is responsible for maintaining the largest medical education and health professions training program in the U.S. And VA facilities are affiliated with more than 100 medical schools, 55 dental schools and more than 1,200 other educational institutions throughout America (Facts About the Department of Veterans Affairs, 2008). Approximately 90,000 healthcare professionals are trained in VA medical centers each year; in fact, over half of the physicians currently practicing in the United States received some of their professional education within the VA healthcare system (Facts About the Department of Veterans Affairs, 2008).
Age. Congress established the U.S. Veterans Bureau in 1921 following the end of World War I (VA Nursing Service, 2005). The current VA was originally established by Executive Order 5398, signed by President Herbert Hoover on July 21, 1930 to consolidate these services; at the time of its creation in 1930, the VA had 54 hospitals (Facts About the Department of Veterans Affairs, 2008). According to the organization’s fact sheet, “The Department of Veterans Affairs (VA) was established on March 15, 1989, succeeding the Veterans Administration. It is responsible for providing federal benefits to veterans and their families. Headed by the Secretary of Veterans Affairs, VA is the second largest of the 15 Cabinet departments and operates nationwide programs for health care, financial assistance and burial benefits” (Facts About the Department of Veterans Affairs, 2008, p. 2).
Unusual history. The VA’s motto, “To care for him who shall have borne the battle and for his widow, and his orphan,” is taken from President Abraham Lincoln’s second inaugural address (the Origin of the VA Motto, 2008), which also appears on the west wall of the Lincoln Memorial in Washington, D.C. (pers. obs.).
Image. One of the most pressing issues facing the VA today is its longstanding image as an inferior provider of healthcare services. The organization’s poor image in this regard has even been highlighted in prime time television series that parody the VA time and again (i.e., “The Simpsons,” where a patient is taken to a VA hospital and pronounced dead only to be taken to a civilian hospital where the patient’s condition was upgraded to “alive”). Scandals ranging from malfeasance to gross malpractice by various healthcare providers have also rocked the organization over the years (pers. knowl.).
Sub-unit configuration. Nurses in the VA system are employed in every healthcare setting, including medical centers, outpatient clinics and Vet Centers where appropriate. According to the VA’s Office of Nursing Service, the VA also has one of the largest nursing staffs of any healthcare system in the world today. “Numbering more than 59,000 nationwide,” the fact sheet advises, “the VA nursing team – composed of registered nurses, licensed practical nurses, vocational nurses and nursing assistants – provides comprehensive, complex, and compassionate care to the nation’s veterans” (VA Nursing Service, 2005, p. 2).
Consistencies and Inconsistencies between the Intent of Each Force of the Fourteen Forces of Magnetism and the Current State of the VA.
Force 1: Quality of Nursing Leadership. Notwithstanding the enormous challenges facing the VA in providing high quality medical services to its veteran patients, the quality of the nursing leadership exemplified in the organization has consistently been cited as superior in recent years by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Force 2: Organizational Structure. The VA organizational structure is outlined above; however, VA nurses also work in outpatient clinics, nursing home units and home-based primary care programs (VA Nursing Service, 2005).
Force 3: Management Style. With almost 60,000 nursing staff assigned in various capacities nationwide, it is reasonable to assert that there are countless management styles in place in different medical centers, outpatient clinics and home-based health care programs, but all of these VA positions are part of the U.S. Civil Service and all have corresponding job descriptions and established management requirements.
Force 4: Personnel Policies and Programs. As part of the U.S. Civil Service, the VA maintains clearly delineated personnel policies and programs in support of its stated mission of providing high-quality healthcare services for its veteran patients.
Force 5: Professional Models of Care. According to their fact sheet, “VA nurses proudly serve America’s heroes practicing the art and science of nursing by following a variety of career paths and applying the principles and knowledge in order to provide holistic, evidence-based, high quality care” (VA Nursing Service, 2005, p. 3).
Force 6: Quality of Care. The VA nursing service is dedicated to the provision of high quality healthcare services to its veteran patients. The organization’s literature clearly states, “VA Nursing is a dynamic, diverse group of honored, respected, and compassionate professionals. VA is the leader in the creation of an organizational culture where excellence in nursing is valued as essential for quality healthcare to those who served America” (About Office of Nursing Services, 2008, p. 2).
Force 7: Quality Improvement. The VA nursing service, like the larger organization in which it operates, is committed to across-the-board quality improvement. In this regard, the VA’s nursing service fact sheet reports, “VA nurses have been widely recognized for their instrumental work in initiating, developing, implementing, and monitoring the practices and policies that made VHA one of the world’s foremost authorities in patient safety and quality outcomes evidenced by performance measures – an exceptional achievement by any assessment” (Office of Nursing Services, 2008, p. 3).
Force 8: Consultation and Resources. Today, nurses in the VA provide a wide range of consultation services in their various capacities to provide advanced leadership in resource allocation and evaluation. According to the organization’s nursing fact sheet, “VA nurse researchers receive both VA and non-VA funding to conduct research to address nursing care issues for veterans. VA nursing partnerships with academic affiliates contribute to research and education, creating significant advancements in patient care. VA nursing education uses current technology to furnish distance learning programs to VA nurses nationwide” (VA Nursing Service, 2005, p. 3). In addition, nurses in the VA are part of an interdisciplinary team during periods of national emergency and are responsible for the provision of healthcare services, the provision of backup services to military hospitals, and for providing coordination assistance to local, regional and national emergency management agencies (VA Nursing Service, 2005). In addition, consultative roles for VA nurses have emerged in recent years in areas such as infection control, informatics, community health research and education (e.g. nurse executives, nurse investigators, and nursing program faculty) (VA Nursing Staff).
Force 9: Autonomy. Nursing serving in the VA’s far-flung geographic locations in various home-based healthcare capacities such as the newly introduced VA Travel Nurse Corps may experience high levels of autonomy compared to their counterparts who are employed in the VA’s more high-profile medical centers and outpatient clinics (VA Travel Nurse Corps, 2008).
Force 10: Community and Healthcare Organizations. As noted above, the VA maintains community healthcare programs throughout the country and is the largest healthcare organization in the United States today and one of the largest healthcare providers in the world (VA & Experienced Professionals, 2008).
Force 11: Nurses as Teachers. The VA has recently implemented the Clinical Nurse Leader (CNL) program to provide improved clinical leadership in all of the VA’s healthcare facilities and to better respond to individuals and families in its system of care. To date, more than 80 medical centers have requested participating in this initiative. The leadership program is expected to address and improve the following:
Cost/financial outcomes such as length of stay, patient flow, readmission rate and registered nurse (RN) turnover
Patient satisfaction, staff satisfaction and retention
Quality/internal process outcomes such as medication management, patient safety, and prevention of nosocomial infections
Practice Model Transformation such as evidence-based and collaborative, interdisciplinary practice (Office of Nursing Services, 2008).
Force 12: Image of Nursing. The VA recognizes the importance of individual care to the perception of quality healthcare in its facilities. Even if the entire organization operates in an effective and compassionate manner, if the nurse that cares for a patient fails to deliver on this level of care, the individual perception of nursing care will be diminished. To this end, the organization’s nursing fact sheet proclaims, “VA Nursing Service is dedicated to promoting optimal health, patient safety, quality health care, and the highest professional standards, in order to ensure that our veterans receive the best possible care and that our staff work in the best possible health care system” (VA Nursing Service, 2005).
Force 13: Interdisciplinary Relationships. The VA’s Web page, “VA & Experienced Professionals” (2008) states, “Our doctors, physician assistants, nurses, therapists, pharmacists, and other professionals work together in an interdisciplinary care team structure” (p. 3).
Force 14: Professional Development. VA Registered Nurses (RN) serve in four career paths including: clinical, advanced practice, supervisory/administrative, and consultative. Examples of advanced practice roles include Clinical Nurse Specialists (CNS), Nurse Practitioners (NP), and Certified Registered Nurse Anesthetists (CRNA); nurses in these roles are generally referred to as advanced practice nurses (APN) (VA Nursing Service, 2005).
Identified Strengths and Weaknesses.
A fundamental weakness of the VA has historically been a lack of adequate resources to fulfill its mandate. Indeed, the VA has experienced an enormous increase in the number of veteran patients seeking healthcare in recent years; in fact, the number of patients treated by the VA increased from 4.2 million in 2001 to nearly 5.5 million in 2006, an increase of 29% (Facts About the Department of Veterans Affairs, 2008). On the plus side, the VA nursing service has embraced the Fourteen Forces of Magnetism and has implemented steps to provide information and education concerning these forces system-wide. As one VA nurse emphasizes, “Maintaining a Magnet culture requires a continued focus on integrating the Forces of Magnetism into all nursing organizational activities. It took years to create this culture and you will now clearly understand that Magnet is a journey not a destination” (Magnet Business Case Toolkit, 2007, p. 3).
The research showed that today, the Department of Veterans Affairs is the nation’s largest healthcare provider and one of the largest healthcare providers in the world. The research also showed that notwithstanding some major constraints to the provision of high-quality healthcare services to the millions of veteran patients the organization has encountered in the past, the VA is well situated to recruit, retain, and support a qualified workforce and to support the professional practice of nursing in the 21st century. The JCAHO has consistently rated VA facilities as being equal to or superior to their civilian counterparts in recent years, and the talented and dedicated nursing staff leading the VA’s nursing service continues to provide the vision and direction needed to maintain this organization-wide improvement.
About Office of Nursing Services. (2008). Department of Veterans Affairs. [Online]. Available: http://www1.va.gov/nursing/page.cfm?pg=111.
About VA. (2008). Department of Veterans Affairs. [Online]. Available: http://www.va.gov/about_va/.
Bliss-Holtz, J., Winter, N., Scherer, Elaine M. (2004, September). An invitation to magnet accreditation. Nursing Management, 35(9), 36-42.
Facts about the Department of Veterans Affairs. (2008). Department of Veterans Affairs. [Online]. Available: http://www1.va.gov/opa/fact/vafacts.asp.
Magnet business case toolkit. (2007). Department of Veterans Affairs Nursing. [Online]. Available: http://www1.va.gov/nursing/docs/DetailedToolkitExplanation.doc.
Office of Nursing Services. (2008). Department of Veterans Affairs. [Online]. Available: http://www1.va.gov/nursing/page.cfm?pg=117.
VA Nursing Service. (2005). Department of Veterans Affairs. [Online]. Available: http://www1.va.gov/nursing/docs/VAnsgSvc-Facts_MAR2005_FNL.DOC.
VA & Experienced Professionals. (2008). Department of Veterans Affairs. [Online]. Available: http://www.vacareers.va.gov/l2_You_Professionals.cfm.
VA Travel Nurse Corps. (2008). Department of Veterans Affairs. [Online]. Available: http://www.vacareers.va.gov/l2_Occupations_TNC.cfm.
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