The issue of burnout among physicians extends beyond the United States to countries worldwide (Dewa, Long, Bonato, & Trojanwoski, 2017). Work-life balance, autonomy, and poor health are notable contributors to burnout (Maslach & Leiter, 2016). Predicted shortages of physicians and nurses add to the challenges of providing high quality, population-based healthcare globally (Shanafelt & Noseworthy, 2017). Work-related stress impacts patients, healthcare systems, and providers with potentially negative consequences (Panagioti et al., 2018; West et al., 2018). Few researchers have investigated the job-related characteristics of Advanced Practice Providers (APPs) from various geographic regions. Thus, the research purpose was to explore the prevalence of burnout and its interrelationship to job stressors and work engagement among APPs as they are the ones targeted to fill the shortage gap of practitioners.
Methods:
A multi-site, cross-sectional, quantitative study design was used to explore the perceptions of physician assistants and advanced practice nurses, referred to collectively as APPs, working in four health systems located in various regions within the United States. Demographic and two open-ended questions were also included in the online questionnaire housed on the Qualtrics web-based platform. Institutional Review Board (IRB) approvals were obtained prior to initiation. Of the 3,939 APPs invited to participate, a sample of 1,216 completed the survey in its entirety. All four categories of advanced practice nurses were represented (clinical nurse specialists, certified nurse midwives, certified registered nurse anesthetists, and nurse practitioners), while physician assistants comprised a slightly larger percentage by provider type at 36.8%.
Well-validated and reliable instruments were selected to measure the constructs: the Maslach Burnout Inventory (MBI, 22-items); the Utrecht Work Engagement Scale (UWES, 17-items); and the Dimensions of Job Stressors scale (14-items) to assess work experience. Work-family balance was examined using a six-item theoretically based measure (Carlson, Grzywacz, & Zivnuska, 2009). A hypothesized model that considered the impact of job stressors and work engagement and their relationship to the development of burnout was tested using Structural Equation Modeling.
Results:
Using structural equation modeling (SEM), several hypothesized paths determined significant relationships. We found that stress is positively related to burnout (β = .92, p<.01), and with further testing of the mediated effects of burnout, a significant and positive indirect effect of stress on engagement through burnout was identified (b=-26.95% CI [.-18, .-35]). Note that the total indirect effect of work stress through burnout to engagement (β =-.31, p< .01) was greater than the direct effect of work stress to performance (β = -.24, p<.01). Additionally, work-family balance is negatively related to stress (β = .71, p<.01).
Conclusion:
Engagement as a unique and separate construct was reinforced with our model, thus it important to consider the indirect effects of stress on engagement. Organizational strategies coupled with individual-focused actions to improve work engagement and to minimize work stress are needed. Development of formalized and inclusive APP leadership structures, along with more clearly defined roles for APPs and team members are considered as organizational in nature. Programs and activities that support APP well-being such as a comprehensive wellness program or socialization, and professional development are also deemed as valuable from the APP perspective.