Skip Navigation LinksHome > April 2014 - Volume 44 - Issue 4 > Magnet® Environments and the Affordable Care Act
Text sizing:
Journal of Nursing Administration:
doi: 10.1097/NNA.0000000000000049
Departments: Magnet(R) Perspectives

Magnet® Environments and the Affordable Care Act

Lundmark, Vicki PhD

Free Access
Article Outline
Collapse Box

Author Information

Author Affiliation: Director, Institute for Credentialing Research, American Nurses Credentialing Center®, Silver Spring, Maryland.

The author declares no conflicts of interest.

Correspondence: Dr Lundmark, American Nurses Credentialing Center, 8515 Georgia Ave, Suite 400, Silver Spring, MD 20910 (

An important element of the Affordable Care Act is the National Quality Strategy (NQS),1 which was developed by the Secretary of Health and Human Services and submitted to Congress in 2011.2 National Quality Strategy is not a federal initiative but a national one that involves aligning public and private sector stakeholders in efforts to achieve better healthcare. It relies on federal agencies to play key roles in implementing the strategy.3 Recent NQS progress reports to Congress describe the establishment of long-term goals1 and the collaborative work underway to align quality measures.4 Examining recent research findings through the lens of NQS priorities can help in understanding how Magnet® environments contribute to achieving national healthcare goals.

Figure. No caption a...
Image Tools

The NQS established 6 priorities to guide national efforts for improving healthcare: safety, person- and family-centered care, communication and care coordination, effective prevention and treatment of illness, best practices for healthy living, and affordable care.2 Long-term goals for each area are described in the annual progress reports. For example, the 3 long-term goals identified for improving safety include reducing preventable hospital admissions and readmissions, reducing the incidence of adverse healthcare-associated conditions, and reducing harm from inappropriate or unnecessary care.1,4 The measures listed in the National Impact Assessment of Medicare Quality Measures2 are each classified by a specific NQS priority area, although some could be classified under more than 1.

For example, studies have found Magnet organizations to have lower odds of failure to rescue for surgery patients aged 21 to 85 years,5 lower rates of nosocomial infections and severe intraventricular hemorrhage for very low-birth-weight infants,6 and lower rates of patient falls.7,8 These findings are consistent with the NQS goals for making care safer. Two of those same studies also found that Magnet organizations have lower odds of mortality,5,6 which corresponds to the NQS goal for promoting the most effective treatment and prevention practices.

Studies of turnover and occupational injuries address the NQS priority of making care more affordable. Magnet organizations have been found to have lower rates of RN turnover and total turnover,9 as well as lower rates of negative occupational health outcomes among nurses (including musculoskeletal injuries, blood and body fluid exposure, and other injuries).10 Turnover is costly,11 and nurse injuries have been associated with higher turnover rates among newly licensed RNs.12

Studies that directly measure Magnet characteristics are of particular interest. Many organizations that have not chosen to seek Magnet recognition may have similar practice environments. The most commonly used measure of Magnet characteristics is the Practice Environment Scale of the Nursing Work Index (PES-NWI).13 Based on the original Magnet hospital research, the PES-NWI is the most useful measure of the nursing practice environment currently available and has been endorsed by the National Quality Forum.14 All PES-NWI items can be mapped to the 5 components of the Magnet Model®.15 Through use of the PES-NWI or another variation of the Nursing Work Index–Revised (NWI-R), a body of research about Magnet characteristics has been building both inside and outside the United States. Examples include studies by van den Heede et al in Belgium,15 Schubert et al in Switzerland,16 and Wilkins and Shields17 in Canada.

Relevant to the NQS priority for safety are studies that found practice environments rated higher on Magnet qualities have lower failure to rescue rates,18-20 lower rates of catheter-associated urinary tract infections,21 and lower odds of readmissions among Medicare patients with heart failure, myocardial infarction, and pneumonia.22 Relevant to the NQS priority for effective prevention and treatment are studies that found practice environments rated higher on Magnet qualities have lower 30-day mortality18-20 and higher compliance with left ventricular ejection fraction assessment for heart failure patients.23 Studies that found relationships between practice environments rated higher on Magnet qualities and lower rates of sharps injuries24 or nurse occupational injuries10 are relevant to the NQS priority for affordable care because such injuries incur medical and work productivity costs25 or increase the likelihood of costly turnover.11,12

Characteristics of Magnet environments have also been linked to patient satisfaction. For example, 3 different studies relevant to the NQS priority for person- and family-centered care found practice environments with higher ratings of Magnet qualities have higher patient satisfaction.26-28 All of them used the PES-NWI or the NWI-R to measure practice environments. One study26 used patient satisfaction items from the national and publicly reported Hospital Consumer Assessment of Healthcare Providers and Systems survey.2

As the Institute of Medicine’s 2004 report29 concluded, features of the nursing work environment are critical to keeping patients safe. The Magnet Recognition Program defines expectations for the features of a practice environment that will support nursing excellence. As dynamic organizational factors,22 these features are amenable to change and improvement. Future research should increase understanding about the mechanisms by which better practice environments lead to better care.30

Back to Top | Article Outline


1. US Department of Health & Human Services. National Strategy for Quality Improvement in Health Care: 2012 Annual Progress Report to Congress. Accessed December 10, 2013.

2. US Department of Health & Human Services. Centers for Medicare and Medicaid Services (CMS). National Impact Assessment of Medicare Quality Measures: March 2012. (Prepared by Health Services Advisory Group, Inc). Accessed December 10, 2013.

3. US Department of Health & Human Services. The National Quality Strategy: Fact Sheet. September 2013. Accessed December 10, 2013.

4. US Department of Health & Human Services. National Strategy for Quality Improvement in Health Care: 2013 Annual Progress Report to Congress. Accessed December 10, 2013.

5. McHugh MD, Kelly LA, Smith HL, Wu ES, Vanak JM, Aiken LH. Lower mortality in Magnet hospitals. Med Care. 2013; 51 (5): 382–388.

6. Lake ET, Staiger D, Horbar J, et al. Association between hospital recognition for nursing excellence and outcomes of very low-birth-weight infants. JAMA. 2012; 307 (16): 1709–1716.

7. Dunton N, Gajewski B, Klaus S, Pierson B. The relationship of nursing workforce characteristics to patient outcomes. Online J Issues Nurs. 2007; 12 (3). Accessed December 10, 2013

8. Lake ET, Shang J, Klaus S, Dunton NE. Patient falls: association with hospital Magnet status and nursing unit staffing. Res Nurs Health. 2010; 33: 413–25.

9. Staggs VS, Dunton N. Hospital and unit characteristics associated with nursing turnover include skill mix but not staffing level: an observational cross-sectional study. Int J Nurs Stud. 2012; 49 (9): 1138–1145.

10. Stone PW, Gershon RR. Nurse work environments and occupational safety in intensive care units. Policy Polit Nurs Pract. 2006; 7 (4): 240–247.

11. Hatcher BJ, Bleich MR, Connolly C, Davis K, Hewlett PO, Hill KS. Wisdom at Work: The Importance of the Older and Experienced Nurse in the Workplace. Princeton, NJ: Robert Wood Johnson Foundation; 2006. Accessed December 10, 2013.

12. Brewer CS, Kovner CT, Greene W, Tukov-Shuser M, Djukic M. Predictors of actual turnover in a national sample of newly licensed registered nurses employed in hospitals. J Adv Nurs. 2012; 68 (3): 521–538.

13. Lake ET. Development of the practice environment scale of the Nursing Work Index. Res Nurs Health. 2002; 25 (3): 176–88.

14. Lake ET. The nursing practice environment: measurement and evidence. Med Care Res Rev. 2007; 64 (suppl 2): 104S–122S.

15. van den Heede K, Florquin M, Bruyneel L, et al. Effective strategies for nurse retention in acute hospitals: a mixed method study. Int J Nurs Stud. 2013; 50 (2): 185–194.

16. Schubert M, Ausserhofer D, Desmedt M, et al. Levels and correlates of implicit rationing of nursing care in Swiss acute care hospitals—a cross sectional study. Int J Nurs Stud. 2013; 50 (2): 230–239.

17. Wilkins K, Shields M. Employer-provided support services and job dissatisfaction in Canadian registered nurses. Nurs Res. 2009; 48 (4): 255–263.

18. Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital care environment on patient mortality and nurse outcomes. J Nurs Adm. 2008; 38 (5): 223–229.

19. Friese CR, Lake ET, Aiken LH, Silber JH, Sochalski J. Hospital nurse practice environments and outcomes for surgical oncology patients. Health Serv Res. 2008; 43 (4): 1145–1163.

20. Wiltse Nicely KL, Sloane DM, Aiken LH. Lower mortality for abdominal aortic aneurysm repair in high-volume hospitals is contingent upon nurse staffing. Health Serv Res. 2013; 48 (3): 972–991.

21. Stone PW, Mooney-Kane C, Larson EL, et al. Nurse working conditions and patient safety outcomes. Med Care. 2007; 45 (6): 571–578.

22. McHugh MD, Ma C. Hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Med Care. 2013; 51 (1): 52–59.

23. Newhouse RP, Dennison Himmelfarb C, Morlock L, Frick KD, Pronovost P, Liang Y. A phased cluster-randomized trial of rural hospitals testing a quality collaborative to improve heart failure care: organizational context matters. Med Care. 2013; 51 (5): 396–403.

24. Clarke SP. Hospital work environments, nurse characteristics, and sharps injuries. Am J Infect Control. 2007; 35 (5): 302–309.

25. Leigh JP, Gillen M, Franks P, et al. Costs of needlestick injuries and subsequent hepatitis and HIV infection. Curr Med Res Opin. 2007; 23 (9): 2093–2105.

26. Kutney-Lee A, McHugh MD, Sloane DM, et al. Nursing: a key to patient satisfaction. Health Aff. 2009; 28 (4): w669–w677.

27. Seago JA. Unit characteristics and patient satisfaction. Policy Polit Nurs Pract. 2008; 9 (4): 230–240.

28. Vahey DC, Aiken LH, Sloane DM, Clarke SP, Vargas D. Nurse burnout and patient satisfaction. Med Care. 2004; 42 (suppl 2): II57–II66.

29. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004.

30. Norman I. The nursing practice environment. Int J Nurs Stud. 2013; 50 (12): 1577–1579.

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins