An international effort to curb provider burnout and improve patient care

In a Q&A, Penn Nursing’s Linda Aiken describes how a hospital earning Magnet designation creates a better, safer experience for patients and clinicians, plus the push to expand such credentialing beyond the U.S.

Linda Aiken of Penn's School of Nursing
Linda Aiken is a professor of nursing and founding director of the Center for Health Outcomes and Policy Research at Penn’s School of Nursing. (Image: Courtesy of Penn Nursing)

Linda Aiken, who founded Penn Nursing’s Center for Health Outcomes and Policy Research, has been improving the quality of United States hospitals for four decades. 

Aiken began this work in the early 1980s, as a nursing shortage left many places without the necessary care providers. Yet certain hospitals were somehow immune, not only fully staffed, but with even more clinicians clamoring to join their ranks. 

Linda Aiken of Penn's School of Nursing
Linda Aiken is a professor of nursing and founding director of the Center for Health Outcomes and Policy Research at Penn’s School of Nursing. (Image: Courtesy of Penn Nursing)

“We decided to study those hospitals to find out what were they doing right,” says Aiken, a professor of nursing. “We found that they were taking some of the same steps that made multinational corporations successful, like engaging the workforce and valuing the internal expertise of their people.” 

That research resulted in what’s known today as Magnet designation, a credentialing process for hospitals created in the 1990s by the American Nurses Association. It offers facilities a blueprint for stronger nurse and physician recruitment and retention, better outcomes and shorter stays for patients, and much more. “Everything is just better in a Magnet hospital,” Aiken says.  

Aiken and collaborators from KU Leuven in Belgium have now brought the concept to the EU through a project called Magnet4Europe. Since early 2020, 65 hospitals in Belgium, England, Germany, Ireland, Sweden, and Norway have participated in a randomized, waitlisted, controlled trial, with intervention based on a Magnet-focused redesign, plus mentoring from a U.S. Magnet hospital. Aiken and colleagues recently published their research protocol in the journal BMJ Open.

What’s the backstory for the Magnet designation?

The concept of Magnet has been around for 40 years, and the basic idea comes from research on complex organizations and particularly on successful multinational corporations. What are their attributes? What makes them successful?

In 1980 there was a nursing shortage. Many of the leading nurse executives had observed that even during big labor shortages, some hospitals had waiting lists of nurses who wanted to work there. We documented that these hospitals had specific organizational features, like transformational leaders committed to their workforce, and we thought, why can’t you replicate those features in other hospitals? Out of that came the idea for Magnet.

Why use of the word ‘magnet’ for this?

Nurses were drawn to these hospitals and the hospitals were retaining them, too, like a magnet drawn to metal. The idea evolved into a voluntary credentialing system for organizations with these traits, which we could then operationalize into a blueprint of sorts.

If you follow an architectural drawing, you can replicate the house the architect imagined; here we established a credentialing system with a detailed set of steps that any hospital could follow. There are now close to 600 hospitals with formal accreditation as Magnet hospitals. Most of them are located in the United States.

How did the work in Europe emerge?

We’ve been doing research in the EU for more than 15 years. A project of ours called RN4CAST established that, like in the U.S., these organizational characteristics are also important for hospitals in Europe. Workplaces where nurses were engaged and empowered, where they had good working relationships with physicians and were respected for their expertise, those places had lower patient mortality, shorter patient length of stay, and better financial pictures.

A few years ago—this was before the pandemic—the European Commission announced a call for proposals focused on workplace improvement, observing that workers in every sector seemed to be experiencing more burnout and felt less satisfied. We proposed a randomized trial testing the Magnet program as an intervention to improve hospitals.

This had already been proven in the U.S., but the question was, would it work in Europe, and if it could be established and sustained, would it improve patient outcomes and the mental health and well-being of the clinician workforce?

Burnout among health care workers has been going on since long before COVID. How does the pandemic factor in?

We’ve been studying burnout at the Center for Health Outcomes and Policy Research, and we were able to establish that it has been increasing over time. Before the pandemic 50% of nurses were experiencing high burnout in U.S. hospitals, though it was less for those in Magnet hospitals. Then the pandemic came, and burnout increased even more, but we found that the pandemic wasn’t necessarily the reason for it.

In both the U.S. and Europe, it became clear that there were big flaws in the health care system that predated COVID but that were also exacerbated by COVID. The pandemic made them more visible and there became a broader recognition among hospital leadership of just how bad it was to have half of their nurse workforce and a third of their doctors experiencing high burnout. So, the pandemic increased the interest in doing something about it. That makes Magnet4Europe very timely.

Where does the project currently stand?

We were formally funded in January 2020. We’ve recruited a critical mass of hospitals in six countries in Europe willing to test this manual that had been built over 40 years, this architectural blueprint. We’ve also implemented this idea of ‘twinning,’ often used in international initiatives, which pairs an expert with a non-expert.

In this case we put a call out to U.S. Magnet hospitals and 70 or so said they would be interested in mentoring a European hospital. We got more volunteers than we needed, which shows me how committed U.S. hospitals are to creating a better work environment for health professionals. We have a group of the best hospitals in America that volunteered to do this, including six Penn Magnet hospitals. The twinning helps these hospitals in Europe develop a strategic plan.

All of this is done in a research context, which is the point of publishing the protocol paper. This is a rigorous randomized trial using specific criteria so that we know whether this takes and whether provider and patient outcomes change. The bottom line is that this has to be an institution-wide intervention. You can’t change a workplace without everybody in the workplace buying in.

Linda Aiken is a professor of nursing and founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania’s School of Nursing, a professor in the Department of Sociology in the School of Arts & Sciences, and a senior fellow at the Leonard Davis Institute of Health Economics.

Funding for this research comes from the European Union’s Horizon 2020 research and innovation program under the project Magnet4Europe: Improving Mental Health and Wellbeing in the Health Care Workplace (Grant 848031).