COVID-19 – What would Margaret Newman say?

Dorothy Jones and Jane Flanagan
See also Newman’s Theory of Health
as Expanded Consciousness

Although not the only global challenge we face, COVID-19 has the world’s attention while disrupting so many familiar routines. For those so fortunate, there is the new normal of working from home and countless conference calls that seem to blur one day into the next, almost erasing the confines of time while confining us to a physical space.  When things get back to “normal” what will that look like?

For those in service industries, there is the chaos of being the person in the midst of unsafe places whether the grocery store, a bus or as an employee in a hospital.  Making connections while fearing, am I safe? Do I have what I need to protect myself/ my family? And, sometimes knowing you do not have what you need, and in that moment, your awareness of the disparity of those who have and those who do not is heightened.  What will it be like when things get back to “normal?

 Then there are those who in a whirlwind, may have lost their job.  Now they are struggling to pay bills, perhaps visiting food banks for the first time mixed in with home schooling young children or a full house of grown children now back to the safety of their childhood home.  When and what will be that return to “normal”?  For every scenario, there is opportunity, freedom and new ways of being. There is also potential binding or unraveling.  But no matter the reality, there are the chants to “get back to normal”

Dr. Margaret Newman

This idea of “getting back to normal” raises the question; “What would Margaret say?” We think the answer is …actually, not very much.  She would smile gently and acknowledge each person who spoke and told his or her personal story. She would be present and authentically listen.  Her silence would spur more stories until in the sheer dizziness of it all, the cacophony would stop and everyone would look to her and wonder what she is thinking. Again, silence and this time the room would go quiet.  Finally, she would speak: “I’m just curious about people wanting to go back to normal, what do people think of that?”  Then she would sit and wait for us to react…and we would.  We would discuss how we cannot “go back” and about the opportunity in the chaos. What went well in nursing practice during COVID – 19 that was reflective of nursing and what did not?  She would smile, as we would envision a new future that informed by COVID-19, and the inequities of an illness, linked to an environmental crisis and manifested in our most vulnerable. An illness that has stuck down older adults, minorities and is on a path to literally destroying second and third world countries.  Go back?  No, we would not be going back we would be envisioning a new future, one with boundaryless opportunities.

There is for some, an increased awareness, that the inequities of COVID-19 along with the murder of George Floyd and other racial incidences has heightened the issue of structural racism that has always been simmering under the surface. Go back?  Oh no, we will not go back. Not to complacency, not to a world where nurses today are lauded for their actions during a crisis, but who will return to being a hidden entity, part of the bed charge.  No, we are now in a world that recognizes, yes there were many deaths, but because of nursing care, because of nursing’s commitment to meeting the person where they were at, commitment to delving into knowing other, upward of 85% of those who had COVID and were hospitalized were successfully discharged.  Yes, nursing care! It was the authentic presence of nurses who connected with patients in new ways and journeyed with them on a path of discovery, nurses learning to recognize the pattern of the critically ill when the normal mode of communication was no longer possible, and nurses who transformed the care environment. It was not a cure or a vaccine that made the difference; it was “the difference nursing makes” that made the difference.

The COVID-19 virus made visible a pattern of turbulence and disruption within the global whole.  Lack of awareness to growing social challenges, loss of freedom creation of boundaries and isolation confounded the environment within which the virus emerged. Within this context, the virus took on new meaning and yielded variety of responses. Using the theoretical lens of Health as Expanding Consciousness, Margaret would reflectively and carefully suggest that being exposed to the global and dramatic changes of the day has already begun to reshape/repattern us. She would envision the voice of nurses advocating on behalf of patients, on behalf of the myth of curing rather than healing, on behalf of older adults, racial and ethnic minorities.  Margaret would not support “going back”; instead, she would reflect on the meaning of the unfolding pattern emerging before us …within the context of an illness.

The event COVID-19 has served to make visible the invisible for society as a whole.  Recognition that we are all connected and interrelated. The actions and behaviors of one individual directly affecting the very life of another. Response to the virus has revealed a complex, dynamic human pattern of the whole within a dynamic and changing environment. As the illness experience is unfolding, individual responses shaped by factors including  vulnerability,  gender, age and the older adults, race, ethnicity, compromised health status, poverty, lack of insurance, homelessness, exposure to environmental stressors and population density, and personal responses to life challenges have been made visible. Compromised relationships, sustained loneliness and disconnection challenged human becoming and threatened choices about health and wellness. Rather than creating new problems, COVID-19 has manifested not only a serious disease but made visible longstanding global societal challenges that have gone unnoticed or suppressed.

Margaret would caution that “fixing” the illness (i.e. treating to cure) without addressing the whole person/environment interaction that include people and events surrounding the individual experience, could lead to a reoccurring manifestation of the underlying pattern in new ways (e.g. inequities and disparities in care). She would stress the importance of collaborating with individuals and groups in dialogue, she would identify what is meaningful, to acknowledge the collective increased awareness, and seek to uncover an underlying pattern of the whole. COVID-19 then becomes a stimulus for active discussion, identifying barriers that compromise moving forward as individuals and as a society. The insights gained through information and connecting with another create opportunities for new insights, actions and freedom to participate knowingly in actions that promote transformative change.

The importance of relationship is core to advancing the process of discovery. Partnerships that are open and evolving allow pattern to emerge and potentially increase the realization that we are all interdependent and connected within and across environments. Recognizing that what affects one-person or community can have a reciprocal impact on another. Within the discovery process there is freedom to hold on to what gives new meaning to one’s being and what binds and threatens our freedom  to become and engage in sustainable holistic healing. No, Margaret we are not going back. And she would smile, knowing we are with new heightened awareness and renewed energy, accelerating toward new potentials and  transformation.

Additional References

Newman, M. A. (2008). Transforming presence: The difference that Nursing makes. Philadelphia: F. A. Davis.

Newman, M. A., Smith, M. C., Pharris, M. D., & Jones, D. (2008). The focus of the discipline of nursing revisited. Advances in Nursing Science, 31(1), E16-E27. https://doi.org/10.1097/01.ANS.0000311533.65941.f1

Smith, M. C. (2011). Integrative Review of Research Related to Margaret Newman’s Theory of Health as Expanding Consciousness. In Nursing Science Quarterly (Vol. 24, Issue 3, pp. 256–272). https://doi.org/10.1177/0894318411409421

Posthumxnism and the Pandemic

Co-contributors with Jessica Dillard Wright:*
Jane Hopkins Walsh
Brandon Blaine Brown

One of the things that’s coming to light is how the global spread of a microscopic virus is placing the ravages of racism and inequity under the microscope. But the fact is, we don’t all see the same thing! Racism has a way of actually DISTORTING our vision. Intertwined with many other forms of social domination, racism is mercurial, innovative, even viral.” (Benjamin, 2020

Celestial Octopus

Our Celestial Octopus, emblem of the Compost Collaborative, created by nurse-artist Christian Tedjasukmana

As the Compost Collaborative,** a posthumxn rhizome of feminist, queer, nursing joy and terror, we wish to acknowledge some of the deep, enduring, and trenchant lessons of our dystopian present. As friends and scholars, we are deeply connected by a shared passion for a radical posthumxn path for the future of nursing. We first wish to convey our deep love, respect, and solidarity for the nurses who are actively engaged in the dangerous daily work of caring for folks infected with COVID19. Second, we recognize our privilege and positionality as white colonizers with access to medical care, physical goods, and material resources, knowing that power and access are not shared by all, deeply contingent on the intersections of race, gender, sexuality, class, colonial positionality. Posthumxnism is a critique of and response to humanism and its anthropocentric fixation, one that seeks to scrutinize the humxn and nonhumxn consequences of capitalism (Bradiotti, 2019). In advancing a posthumxn critique for and of nursing in the time of COVID19, we see our work growing out of the emancipatory tradition, centering critical perspectives, feminist analyses, queer inquiry, justice-oriented praxis as we navigate terra incognita (Kagan et al., 2014; Grace & Willis, 2012).

Here we sit, isolated in distant states recognizing that the dystopian imagined future is suddenly a fervent, fevered reality and nursing along with its healthcare comrades are essentially located in the interstices. Our speculative theorizing about the posthumxn present-future of nursing is in continuity with the future-oriented, space-exploring vision of Martha Rogers (1992), though our cosmic view is tempered with the urgency, pragmatism, and the reality of excavating the past while navigating the crises of our present from pandemic to scarcity to racism to climate change to colonialism to extinctions and more. The urgency for a posthumxn path forward has crashed on the doorstep and posthumxnism is ringing the bell. The posthumxn convergence is calling, Braidotti’s (2019) mash-up vision of posthumxnism and the end of life as we know it. This turn is a critical decentering of humxn in the broad landscape of our ecological terrain that subverts anthropocentric humxnism and its white, ableist, colonial, Eurocentric, cisgender, patriarchal biases, bound up in the neoliberal, capitalist world-ecology, as Jason Moore would call it. 

Humxns are a part of – not rulers over – global political economy-cum-world-ecology, underscored currently by the trans-species complexity of COVID19. In advancing posthumxnism, we also wish to respect and amplify ontological views that are foundational within Indigenous ways of knowing. Long erased by settler-colonial nations and scholars, these ontologies fashion a world in which humans exist coequally with the nonhumxn and the nonliving (LaDuke, 2017).

For a speed course in postanthropocentrism and posthumxnism, consider this novel virus, born of a pangolin, a bird, a pig, a lizard, a bat, a monkey. The viral RNA origins are non-humxn, the virus itself nonliving. Witness the impact as the virus quietly infects and swiftly overpowers contemporary humxnity, bringing powerful global enterprises, international trade, healthcare systems, educational structures, and communities to their knees. Here, the boundaries blur between the humxn and the nonhumxn, the posthumxn subject no longer bios but zoe (Braidiotti, 2019). The pandemic also highlights the communitarian imperative of humxn and nonhumxn life on this rock we call home, as we struggle with social distance and mourn the loss of normalcy. Making kin, Haraway’s (2016) concept of reordering multispecies world relations seems especially relevant in the face of this current crisis, underscoring how inextricably intertwined lives are and continue to become. Humxns shelter in place, leaving nonhumxn creatures to reclaim their once and future territories, roads and highways eerily deserted and quiet, free from the imposition of humxn interlopers. Signs of the postanthropos.

As we think of our planetary crisis, we recognize a cosmic unity similar to that advanced by Martha Rogers in her conceptual framework, the “Science of Unitary Human Beings” (1992). But we also recognize a necessary critique of the concept of “unitary,” problematically failing to account for the historical and contemporary power differentials and legacies of oppression between groups of people in the US and around the globe.  Rogers’ (1992) concept of unitary human beings included an irreducible, indivisible union of people and their worlds (p. 28). The concept of “unity,” however, obscures differentials of power that exist between different communities and their world that enforce inequality. 

We see a posthumxn reading of Rogers’ unitary framework in Posthumxnist Rosi Braidotti’s (2019) insistence that “we-are-(all)-in-this-together but we-are-not-one-and-the-same” (p. 52) that accounts for critical perspectives on how power and oppression structure inequality, even as we endure shared experiences. This reflection on our subjective experience is ever more prescient and poignant as United States political decision-making prioritizes economics and return to normal over humxn life, disappointing but far from surprising given our capitalist imperative to extract! Extract! Extract! And extract some more. As scholar Ruha Benjamin points out as governmental powers push to return to normal, the prepandemic normal was not so great for everyone (2020). 

The uneven unfolding of our dystopian crises belies the jingoistic and unitary notion of “we, the people.” “We, the people” will not experience the pandemic in equitable ways, even while viral RNA presumes to be a great equalizer, making no provision for race, gender, creed, color, sexuality, national identity. In truth, COVID19 etches the inequalities between us deeper still. The virus has and will continue to infect both the powerful and the powerless, though with uneven speed and inequitable consequences. The rich and powerful with unlimited access to viral testing with rapid results, symptomatic or no, while most are turned away. As millions lose their jobs, and with it, health insurance, the cracks in the U.S. healthcare “system” extend and grow wider.

The accretional benefits of power, access, economic and educational accumulation, family reserves built and fortified across generations through a legacy of colonial, white, cisgender, able heteropatriarchy buffer the privileged, making social distance and sheltering in place a relative luxury. White-collar workers collect salaries as they work from home facilitated by the endless, spidery connections that link us via technology, further highlighting our interspecies technological cyborg nature (Haraway, 1990). Even with this kind of padded seclusion there is weirdness, alienation, and violence of its own. The imperative to continue to produce belies the severity of the crisis at hand, even while it is bedecked in the privilege of safety from illness conferred by sheltering in place.

These same principles, sheltering in place and social distance, further marginalized those individuals already on the margins. Hourly-wage earners, the billions of global workers like shopkeepers, caterers, restaurant workers, wait staff, ticket takers wonder how they will survive, subjugated by the laws of Cheap Nature, if they do not have enough money for food and rent (Moore, 2016). Or for medical bills. Or a ventilator. The mundane slow violence of life under capitalism is amplified, writ large under times of crisis, as speculative, nightmarish hypotheticals become breathtaking realities, a startling necropolitics of neoliberalism, the biopolitical power to determine who lives and who dies as a function of capitalism (Mbembe, 2019; Nixon, 2011). This doesn’t even begin to account for the racist violence and inequities of mass incarceration and detention, the impossibility of social distancing for individuals within institutions, and the callous disposability this implies for the individuals trapped by incarceration or detention and those charged with their care.

Posthumxnism asks us to consider what we are capable of becoming, together as humxn and nonhumxn for a more just, egalitarian, and equitable future. This is our charge as posthumxn nurses – to imagine AND THEN CREATE a present-future, one that makes space for the plurality of beings and ways of being in the world, building the bridge as we leap. In building this path, we can cultivate zoecentric knowledge that subverts biocentrism, gazing past the anthropocentric, humxnistic, and exclusionary philosophies that privilege extraction and profit over nature, nonhumxns, and dehumxnized humxns.

The present-future requires that we – as nurses and everyone else – embrace methodologies for cross-pollination between, among, alongside, and interconnected with actors from all crevices of our world ecologies: ecological, geological, political, environmental, animal, mineral, pop-culture, art, media and technology. All bets are off: nothing is too weird or too daring, a radical departure from current modes of nursing thought (Braidotti, 2019). The divisions between theory and philosophy come tumbling down as we seek critical reflection, explanations, understanding, connection, fusion. In this apocalyptic present-future, multispecies posthumxn nursing knowledge can be knit, sung, woven, danced, spun, rapped, embroidered, dyed, hummed, planted in a garden, or spray-painted on train cars, the interrelation of humxn and nonhumxn all a part of the process of posthumxn-becoming. And this proposition of posthumxn knowing is congruent with fine threads of nursing thought, as we consider Rogers (1992) ideas of color, humor, sound, Carper’s (1978) aesthetic way of knowing and the emancipatory ways of knowing advanced by Chinn and Kramer (2018). 

In this space-time of pandemic ennui, which coincidentally coincides with the Year of the Nurse and the Midwife, what we must nurse is radical solidarity, a recognition that we are all in this together, even though we aren’t all the same (Haiven & Khasnabish, 2014). And the stakes are ominously high, should we fail to embrace this communitarianism. A future for healthcare, for sky, for nurses, for ALL people, for plants, for animals, for insects, for viruses, for bacteria, for trash, for compost, for kids, for terra, for seas, for space – any future at all – demands that we work together, composting the boundaries that separate us. This is not what we as nurses imagined for “our year,” but it is poetic-ironic that this is what we face. Together. 

“Despair is not a project, affirmation is.” (Bradiotti, 2019, p. 3).


**We call ourselves Compost Collaborative, a nod to feminist multispecies ecologist Donna Haraway, who captivated our collective imagination and informs our approaches to decaying boundaries of all kinds in nursing and in life. We are scholastically and tentacularly connected in our collaborative work as nurse-compost-scholars. This post was written by Jessica Dillard-Wright, Jane Hopkins Walsh, and Brandon Blaine Brown. Our collaborative is fungible, however, and our ideas are collective, part of a social process influenced by people, animals, environments, and ideas far and wide.

References

Benjamin, R. (2020, April 15). Black skin, white masks: Racism, vulnerability and Refuting black pathology. Retrieved from https://aas.princeton.edu/news/black-skin-white-masks-racism-vulnerability-refuting-black-pathology

Braidiotti, R. (2019). Posthuman Knowledge. Polity Press.

Carper, B. A. (1978). Fundamental Patterns of Knowing in Nursing. Advances in Nursing Science, 1(1), 13–24.

Chinn, P., & Kramer, M. (2018). Knowledge Development in Nursing: Theory and Process (10th ed.). Elsevier.

Grace, P. J., & Willis, D. G. (2012). Nursing responsibilities and social justice: An analysis in support of disciplinary goals. Nursing Outlook, 60(4), 198-207. https://doi.org/10.1016/j.outlook.2011.11.004

Haiven, M., & Khasnabish, A. (2014). The Radical Imagination. Fernwood Publishing.

Haraway, D. (1990). A manifesto for cyborgs: Science, technology, and socialist feminism in the 1980s. In L. Nicholson (Ed.), Feminism/postmodernism (pp. 190–233). Routledge.

Haraway, D. (2016). Staying with the trouble: Making kin in the Chthulucene. Duke University Press.

Kagan, P., Smith, M., & Chinn, P. (2014). Introduction. In P. Kagan, M. Smith, & P. Chinn (Eds.), Philosophy and Practices of Emancipatory Nursing: Social Justice as Praxis (pp. 1–20). Routledge.

LaDuke, W. (2017). All our relations: Native struggles for land and life. Haymarket Books.

Mbembe, A. (2019). Necropolitics (M. Tauch, Trans.). Duke University Press.

Moore, J. (2016). The Rise of Cheap Nature. In Anthropocene or capitalocene: Nature, history, and the crisis of capitalism (pp. 78–115). Kairos Books.

Nixon, R. (2011). Slow violence and the environmentalism of the poor. Cambridge MA:     Harvard University.

Rogers, M. E. (1992). Nursing science and the space age. Nursing Science Quarterly, 5(1), 27-34.

*About the contributors

Jess Dillard-Wright, MA, MSN, CNM, RN

A regular blogger for Nursology.net, Jess is a nurse-midwife and a PhD candidate at Augusta University. Her dissertation is an intellectual history of nursing and feminism, a history of the present untangling the faults and fissures that characterize the interrelationship between feminism and the profession, focusing specifically on Cassandra Radical Feminist Nurses Network. When she is not thinking about nursing, you’ll find Jess hanging out with her three kids and partner. Together, they like to go to the beach, play silly game(may we humbly suggest Throw Throw Burrito?), read books, and *try* to bake amazing things.

Brandon Brown MSN, RN-BC, CNL,

Brandon is a faculty member and Doctor of Education student at the University of Vermont and is one of the founding members of the Nursing Theory Collective. His research interests center upon the philosophical analysis of nursing theory, practice, and pedagogy through a critical posthuman and post-anthropocentric lens. When Brandon is not doing scholarly work, you can find him spending time with his family hiking, canoeing, and camping.

Jane Hopkins Walsh

Jane is a theory loving, Spanish speaking pediatric nurse practitioner at Boston Children’s Hospital. A Nursing PhD Candidate at Boston College, Jane is an immigrant rights activist who is co-enrolled in a certificate program at the Center for Human Rights and International Justice at the Lynch School of Education. Her main areas of interest are global health, im/migrant populations, and community based service delivery models to deliver nursing care for underserved children, emerging adults and families. She was awarded two global grants through Boston Children’s Hospital to coordinate services for children with complex care needs in remote areas of Honduras, and to explore the elevated incidence of chronic kidney disease in Central America with a transnational team. Links to her favorite NGO and volunteer immigrant rights groups can be found at the end of her blog posts on radicalnurses.com

 

 

 

Visions for 2020 – the Year of the Nurse

To all Nursology.net visitors – welcome to the Year 2020!  As we enter this year, we members of the site management and blogging teams join in celebrating the “Year of the Nurse and Midwife” and offer our visions for the coming year and beyond!

The year 2020 was designated In January 2019 by the World Health Organization (WHO) as the “Year of the Nurse and Midwife”  in honor of the 200th birth anniversary of Florence Nightingale.  Far from being a mere sentimental expression recognizing the importance of nursing and midwifery worldwide, this designation is part of a worldwide effort to improve health globally by raising the status of nursing and midwifery.  Here is the statement issued in establishing this designation:

The year 2020 is significant for WHO in the context of nursing and midwifery strengthening for Universal Health Coverage. WHO is leading the development of the first-ever State of the World’s Nursing report which will be launched in 2020, prior to the 73rd World Health Assembly. The report will describe the nursing workforce in WHO Member States, providing an assessment of “fitness for purpose” relative to GPW13 targets. WHO is also a partner on The State of the World’s Midwifery 2020 report, which will also be launched around the same time. The NursingNow! Campaign, a three-year effort (2018-2020) to improve health globally by raising the status of nursing will culminate in 2020 by supporting country-level dissemination and policy dialogue around the State of the World’s Nursing report.

Nurses and midwives are essential to the achievement for universal heath coverage. The campaign and the two technical reports are particularly important given that nurses and midwives constitute more than 50% of the health workforce in many countries, and also more than 50% of the shortfall in the global health workforce to 2030. Strengthening nursing will have the additional benefits of promoting gender equity (SDG5), contributing to economic development (SDG8) and supporting other Sustainable Development Goals. (from https://www.who.int/hrh/news/2019/2020year-of-nurses/en/)

As members of the Nursology.net management team, we are welcoming the 2020 “Year of the Nurse and Midwife” with our visions for this coming year and beyond.  We hope our ideas will inspire you to join in making these values and visions a reality!

Maggie Dexheimer Pharris –

2020 vision. During an eye exam, there is a moment when just the right corrective lens falls into place and suddenly we appreciate 20/20 clarity of vision. Remarkable!  So too it is with theory. In this new decade may nurses around the world find just the right nursology theory to clearly see the path to creating a meaningful practice and equitable, accessible, and healing systems of care!

Karen Foli – 

Unity among nurses based on the care we offer and the universal experiences we share. kindness directed toward patients and fellow nurses, even when they may be unable to reciprocate in that moment. Wisdom to understand how nursing power can be harnessed to forward a sustainable, balanced work life and advocate for improvements in patient and family care. And for nurses’ truth to be spoken freely, a reality to be heard and honored.

Peggy Chinn – 

A renewal of deep respect and tireless dedication for the core values of our discipline – protection of the dignity of each individual, advocacy for the needs of those we serve, and belief in the healing potential of our caring relationships.

Marlaine Smith – 

An accelerating appreciation for the distinctive knowledge of the discipline and the unique contribution that this knowledge can make to the health, well-becoming and quality of life of those we serve. With this appreciation will come the growth of research that is focused on the theories of nursology and practice models that are theory-guided.  Our focus on human wholeness, health as well-being/becoming, the human-environment-health interrelationship and caring is what is missing and most needed in healthcare.

Jane K. Dickinson  –

My vision is that all nurses will know, value, and be guided by nursing knowledge and take caring to the next level in education, practice, and research.

Jessica Dillard-Wright – 

Because 2020 has been declared the Year of the Nurse by the World Health Organisation, my vision for the year is that nursing will embrace the emancipatory potential of our discipline, recognizing the interface between nursing knowledge, nursing praxis, and wellbeing on a global scale. In so doing, we can dismantle injustice and mobilize our profession to nurse the world.

Jacqueline Fawcett

 Now is the perfect time to accept NURSOLOGY as the proper name for our discipline and profession. Now is the perfect time to realize that all individuals licensed as Registered Nurses or equivalent designation worldwide are NURSOLOGISTS. Now is the perfect time for all nursologists to realize they are “knowledge workers” who engage in development, application, and dissemination of nursology discipline-specific knowledge so that we know and everyone else knows the what, why, how, where, and when of our work with those individuals and groups who  seek our services.

Chloe Littzen – 

My vision for nursing in 2020 is that we find unity among our diversity, despite settings, education levels, or beliefs, and work collaboratively to advance the discipline, enabling all nurses epistemic authority and well-being.

Rosemary Eustace – 

The year 2020 is a great reminder of the “200” unique contributions nurses and midwives make each day to improve health, health care, health policy and nursing across diverse settings.  As we celebrate this milestone, let us light our lamps in unity to advance nursing knowledge that is congruent with contemporary health care demands. Let us keep the Power of Nursology alive!

Marian Turkel – 

Vision for 2020: Nursing theory will guide nursing education, nursing practice and nursing research. RN-BSN, BSN and MSN programs will have at least one nursing theory course in the curriculum.  DNP and PhD curriculum will have 2 nursing theory courses.  Nursing faculty and Registered Nurses in the practice setting doing research will use a nursing theory to guide their practice and research.  The Nursology leaders will collaborate with the American Academy of Nursing to organize a conference similar to the Wingspread Conference. The American Nurses Credentialing Center will collaborate with the Magnet Recognition Program©® to require hospitals to have a nursing theory as the foundation for achieving Magnet©® Status Recognition.