PICOT Question and Literature Search

Available online at www.sciencedirect.com

Nur s Out l o ok 6 8 ( 2 0 2 0 ) 1 4 �2 5 www.nursingoutlook.org

Elements of the healthy work environment

Co * C E-m

0029-6 https:

associated with lower primary care nurse burnout

Linda Y. Kim, PhD, MSN, RN, PHNa,b,*, Danielle E. Rose, PhD, MPHb,

David A. Ganz, MD, PhD, MPHb,c,d, Karleen F. Giannitrapani, PhD, MPHe,f, Elizabeth M. Yano, PhD, MSPHb,g, Lisa V. Rubenstein, MD, MSPHd,g,h,

Susan E. Stockdale, PhD, MAb,i aCedars-Sinai Medical Center, Los Angeles, CA

bVA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System,

Los Angeles, CA cDivision of Geriatrics, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, CA

dRAND Health, Santa Monica, CA eVA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA fDepartment of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA gDepartment of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA

hDivision of General Internal Medicine and Health Services Research, UCLA Geffen School of Medicine, Los Angeles, CA iDepartment of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, Los Angeles, CA

nflicts of interest: No conflicts of intere orresponding author: Linda Kim, Cedars ail address: [email protected] (L.Y. K 554/$ -see front matter Published by El //doi.org/10.1016/j.outlook.2019.06.018

A B S T R A C T

Background: Little is known about the relationship between primary care nurses’ work environment and burnout, particularly in settings where patient-centered medical homes (PCMH) have been implemented. Purpose: To investigate the relationship between PCMH nurses’ work environment and burnout. Methods: Multivariable analyses were performed using two waves of survey data from PCMH registered nurses (RNs; n = 170) and PCMH licensed vocational nurses (LVNs; n = 181) in 23 primary care clinics. Findings: True collaboration was inversely associated with PCMH RN burnout (b =�2.6, 95% confidence interval [CI] = �4.29, �0.08, p < .01). Meaningful recog- nition was inversely associated with PCMH LVN burnout (b =�5.1, 95% CI =�8.36, �1.82, p < .01). In models with all nurses, RN (vs. LVN) position was associated with higher levels of burnout (b = 6.2, 95% CI = 2.47, 9.84, p < .01). Discussion: This study highlights the important role of the work environment in reducing PCMH nurse burnout. Strategies to foster team collaboration and meaningful recognition should be investigated to reduce PCMH nurse burnout. Cite this article: Kim, L.Y., Rose, D.E., Ganz, D.A., Giannitrapani, K.F., Yano, E.M., Rubenstein, L.V., & Stock-

dale, S.E. (2020, January/February). Elements of the healthy work environment associated with lower pri-

mary care nurse burnout. Nurs Outlook, 68(1), 14�25. https://doi.org/10.1016/j.outlook.2019.06.018.

A R T I C L E I N F O

Article history: Received 6 December 2018 Received in revised form 26 May 2019 Accepted 21 June 2019 Available online June 27, 2019

Keywords:

Healthy work environment Interprofessional collaboration Nurse burnout Patient-centered medical home Primary care nurses

st have been declared by the authors. Sinai, Nursing Research Department, 8711 W. 3rd Street, Los Angeles, CA 90048. im). sevier Inc.

Nur s Out l o ok 6 8 ( 2 0 2 0 ) 1 4�2 5 15

Introduction

Work stress and burnout are significant concerns in nursing, as they not only affect individual nurses per- sonally and professionally, but also the organizations in which they are employed and the patients they care for (Jennings, 2008). Nurse burnout has been linked to lower quality of care, poorer patient safety and health outcomes, and lower patient satisfaction (Cimiotti, Aiken, Sloane, & Wu, 2012; McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011; Poghosyan, Clark, Fin- layson, & Aiken, 2010). Consequently, Bodenheimer and Sinsky (2014) suggested that the Triple Aim— national goals to optimize population health by (1) enhancing patient experience, (2) improving population health, and (3) reducing costs— expanded to the Qua- druple Aim, adding the fourth goal of improving the work life of health care providers, including nurses. The American Association of Critical-Care Nurses

Healthy Work Environment (AACN HWE) Standards, first issued in 2005 (Table 1), increased national and international attention to the work environment’s impact on nurse retention, team effectiveness, nurse and patient outcomes, and burnout, particularly in acute care settings (American Association of Critical- Care Nurses, 2016). However, attention to these stand- ards applied in other settings including ambulatory care settings is also much needed, especially since the various service/departments in which nurses work, tasks performed, and the role played by the health care staff as well as the type of patients treated, may impact levels of nurse burnout (Monsalve-Reyes et al., 2018). In primary care settings, nurses’ role differs from

that of acute care nurses, especially following imple- mentation of patient-centered medical homes (PCMH)—a team-based model of patient care delivery that encompasses the core functions of primary health care. Within the PCMH model, responsibility for patients is shared by all team members in the PCMH, in contrast to the traditional physician-centric approach. The PCMH model also emphasizes continu- ity and long-term relationships with patients, in con- trast to acute care settings that focus on fixing what “broke” and sending the patient back to primary care. As such, primary care nurses practicing within a

PCMH model often share responsibilities for patient

Table 1 – AACN HWE Standards (AACN, 2016)

Skilled communication Nurses must be as proficient in True collaboration Nurses must be relentless in pu Effective decision-making Nurses must be valued and com

clinical care, and leading orga Appropriate staffing Staffingmust ensure an effecti Meaningful recognition Nurses must be recognized and

of the organization Authentic leadership Nurse leaders must fully embr

cally live it, and engage other

Note. AACN HWE, American Association of Critical-Care Nurses Healthy W

care activities with other members of the interprofes- sional team consisting of the primary care provider and other health care professionals. They must also undertake expanded roles including chronic illness management, telephone triage, and coordination of longitudinal and comprehensive patient care delivery by initiating and informing referrals to other health care professionals and participating in team-based planning (Norful, Martsolf, de Jacq, & Paghosyan, 2017; Smolowitz et al., 2015). With the increasing number of primary care practices adopting the PCMH model of care delivery, a better understanding of the relation- ship between the PCMH practice environment and var- ious burnout experienced by primary care nurses practicing in these settings is urgently needed. Much is already known about the relationship

between various practice environment factors on nursing burnout in acute care settings (Dall’ora, Grif- fits, Ball, Simon, & Aiken, 2015; Demir, Ulusoy, & Ulu- soy 2003; Laschinger, Grau, Finegan, & Wilk, 2010; McHugh & Ma, 2014). For instance, in acute care set- tings, lower levels of nurse staffing, working night shift, or shifts that last 12 hours or longer were linked to increased nurse burnout (Dall’ora et al., 2015; McHugh & Ma, 2014). Furthermore, higher levels of burnout were reported by nurses who experienced poor interprofessional relationships, including hori- zontal/lateral violence and bullying by physicians as well as other members of the nursing team (Demir et al., 2003; Laschinger et al., 2010). On the other hand, work environment factors including sufficient staffing, authentic leadership that provides recognition and support, participatory decision-making, and effective nurse�physician relationships, all promoted through workplace empowerment, were associated with lower levels of nurse burnout (Laschinger, Finegan, & Wilk, 2011; Laschinger & Leiter, 2006; Leiter & Laschinger, 2006). These mitigating factors (e.g., true collaboration, skilled communication, effective decision-making, authentic leadership, meaningful recognition, and appropriate staffing) are essentially the components of the HWE endorsed by the AACN. While several studies have examined various factors

associated with burnout in primary care, little is known about the impact of the workplace environment on pri- mary care nurse burnout, particularly those practicing in PCMH settings (Helfrich et al., 2014; Kim et al., 2018;

communication as they are in clinical skills rsuing and fostering true collaboration mitted partners in making policy, directing and evaluating nizational operations vematch between patients’ needs and nurses’ competencies must recognize others for the value each brings to the work

ace the imperative of a healthy work environment, authenti- s in its achievement

ork Environment.

16 Nur s Out l o ok 6 8 ( 2 0 2 0 ) 1 4�2 5

Lewis et al., 2012; Meredith et al., 2015, 2018; Nelson et al., 2014; Reid et al., 2010). In one PCMH evaluation study examining primary care tasks associated with health care provider burnout, nurses were not included in the study sample (Kim et al., 2018). In other studies evaluating the impact of PCMH elements on health care provider burnout, nurses were grouped with other health care providers (Lewis et al., 2012; Meredith et al., 2015, 2018), the proportion of nurses that was actually included in the study sample is unclear (Reid et al., 2010), and/or the studies do not provide a clear descrip- tion of which PCMH practice environment elements specifically impact primary care nurses (Helfrich et al., 2014). The purpose of this study, therefore, is to investi- gate the relationship between primary care nurses’ practice environment, following PCMH implementa- tion, and their levels of burnout.

Methods

Setting and Sample

In 2010, the Veterans Health Administration (VHA) adopted and implemented Patient-Aligned Care Teams (PACT), a PCMHmodel of patient care delivery, in all pri- mary care settings. Similar to other PCMH models, PACT “teamlets” are comprised of a primary care pro- vider such as a physician, nurse practitioner, or a physi- cian assistant, and three supporting team members including a registered nurse (RN) care manager, a licensed vocational nurse (LVN), and a medical assis- tant or a clerical staff member (Kim et al., 2018; U.S. Department of Veterans Affairs, 2014). Multiple team- lets are supported by ancillary staff from other disci- plines, such as pharmacists, nutritionists/dieticians, and social workers as well as mental health professio- nals (e.g., psychiatrists, psychologists) who all work together, with the ultimate goal of providing compre- hensive, patient-centered, coordinated, high quality, safe, and accessible care to patients and their caregivers (Agency for Healthcare Research and Quality, n.d.). The sample for this study included PACT nurses prac-

ticing in 23 practices within five health care systems across Southern California and Nevada (Veterans Inte- grated Service Network or VISN 22), who were included in the larger evaluation study of the VA’s implementa- tion of PACT. Analytic sample for this study included 170 PACT RNs and 181 PACT LVNs.

Data Collection

Data for this study come from two waves of surveys (November 2011�March 2012 and August 2013�January 2014). The surveys were conducted by the RAND Corpo- ration on behalf of the VHA, described in more detail elsewhere (Meredith et al., 2015), and included approxi- mately 130 items related to leadership involvement, team decision-making, collaboration with members of

the team, and burnout. RN response rates for waves 1 and 2 were 81% and 32%, respectively; LVN response rates were 67% and 33%, respectively. Both the VHA and RAND Institutional Review Boards approved the original study protocol.

Study Measures

Nurse burnout was measured using the emotional exhaustion subscale (Appendix A) of the Maslach Burnout Inventory (Maslach, Jackson, Leiter, Schaufeli, & Schwab, 1996). Some scholars have argued that emo- tional exhaustion is the first domain that manifests as part of burnout and that variables such as job demands are more strongly associated with emotional exhaustion (Brenninkmeijer & VanYperen, 2003; Mas- lach, Schaufeli, & Leiter, 2001; Meredith et al., 2015). The nine items included statements such as “I feel burned out from my work.” Response options for each of the nine items ranged from “never” (0) to “every day” (6), with a total score ranging from 0 to 54. This scale was found to have high internal consistency (a = 0.92) among nurses in this sample. The measure was used as a continuous variable in the bivariate and multivariable analysis to assess associations with other variables. To facilitate interpretation and discus- sion of the burnout scores, the responses were catego- rized into three levels of burnout as used in previous studies (Doulougeri, Georganta, & Montgomery, 2016): low (0�16), medium (17�26), and high (27�54). Although the AACN’s HWE framework was initially

created for the critical care settings, a recent study by Connor et al. (2018) validates the use of the AACN HWE Assessment Tool, across multiple health care settings. The measures of the first five constructs of the HWE were included in this study as described below. The sixth construct, adequate staffing, was not measured in our surveys. Response options for each item ranged from “strongly disagree” (1) to “strongly agree” (5). Survey items corresponding with the HWE constructs were recategorized as 0 = “disagree” (response options 1�3) and 1 = “agree” (response options 4�5) to facilitate interpretation and discussion. A detailed description of the AACN’s HWE constructs and definitions with corresponding survey items is provided in Table 2, along with the Cronbach’s alpha for the measures used in analyses. Table 2 also shows the hypothesized relationships between the HWE constructs and burnout. In addition to HWE factors, the relationship between

primary care nurse burnout and nurse characteristics was explored. Nurse characteristics included nurse type (RN or LVN), age, gender, race/ethnicity (non-Hispanic white vs. Asian, black, Latino/a, other), and tenure (num- ber of years at this clinic). The relationship between pri- mary care nurse burnout and clinic type (e.g., hospital- based clinic, large community-based outpatient clinic [CBOC] that services 8,000 or more primary care patients, or small CBOC that services less than 8,000 primary care patients CBOC), was also explored.

Table 2 – AACN HWE Constructs and Corresponding Veterans Assessment and Improvement Laboratory (VAIL) Survey Items

AACN’s HWE Constructs and Definitions (AACN, 2016)

VAIL Survey Items Cronbach’s Alpha for VAIL Survey Items

Hypothesized Relationship with Burnout

True collaboration: Nurses must be relentless in pursuing and fostering true collaboration.

1. Overall, I am satisfied with howmy teamlet members work together.*

a = 0.81 Total collaboration has an inverse relationship to burnout; that is, an increase in total collab- oration score is associated with lower level of burnout.

Process in which unique knowl- edge and abilities of each profes- sional are respected to achieve optimal, safe, and quality care for patients. Skilled communication, trust, knowledge, shared respon- sibility, mutual respect, opti- mism, and coordination are integral to successful collaboration.

2. In this clinic, when I have a problem that involves a coworker from a different clinical or administrative discipline, I can access help to resolve the problem.*

3. In this clinic, coworkers from different clinical or administrative backgrounds frequently interact to solve quality of care problems.*

4. Our staff and clinicians have constructive work relationships. (SOAPC)y

5. The staff and clinicians in this clinic operate as real teams. (SOAPC)y

Total true collaboration score ranged from 0 to 5. Skilled communication: Nurses must be as proficient in communica- tion skills as they are in clinical skills.

1. In this clinic, it is easy to speak up about what is on your mind. (LOS)y

a = 0.87 Skilled communication has an inverse relation- ship to burnout; that is, an increase in skilled communication score is associated with lower level of burnout.

Frequent, respectful interaction, and two-way dialogue in which nurses speak with knowledge and authority related to patient care

2. People in this clinic are usually comfortable talking about problems. (SOAPC)y

3. People in this clinic are eager to share informa- tion about problems and disagreements. (LOS)y

4. When there is a conflict in this clinic, we usu- ally talk it out and resolve the problem success. (SOAPC)y

Total skilled communication score ranged from 0 to 4. Effective decision-making: Nurses must be valued and committed part- ners in making policy, directing and evaluating clinical care, and leading organizational operations.

1. Staff and clinicians are involved in developing plans for improving quality. (SOAPC)y

a = 0.80 Effective decision-making has an inverse rela- tionship to burnout; that is, an increase in effective decision-making score is associated with lower level of burnout.

Nurse involvement and full part- nership with physicians and

(continued on next page)

N u r s

O u t l o o k

6 8

(2 0 2 0 ) 1 4�

2 5

1 7

Table 2 – (Continued)

AACN’s HWE Constructs and Definitions (AACN, 2016)

VAIL Survey Items Cronbach’s Alpha for VAIL Survey Items

Hypothesized Relationship with Burnout

other health care professionals in decisions that impact patient care, including policy making, directing and evaluating clinical care, and leading organizational operations.

2. This clinic encourages staff and clinicians’ input for making changes and improvements. (SOAPC)y

3. All of the staff and clinicians participate in important decisions about clinical operations. (SOAPC)y

Total effective decision-making score ranged from 0 to 3. Authentic leadership: Leaders must fully embrace the imperative of a healthy work environment, authenti- cally live it and engage others in its achievement.

1. Provides measurable objectives for implement- ing the strategy and vision within our clinic. (LN)y

a = 0.85 Authentic leadership has an inverse relation- ship to burnout; that is, an increase in skilled communication score is associated with lower level of burnout.

Leaders are skilled communicators, team builders, agents for positive change, role models for collabo- ration, and committed to service; and are positioned within organ- ization’s key operational and gov- ernance bodies in order to inform and influence decisions that affect practice environments and nursing practice.

2. Is willing to try new clinical protocols. (ORCS)y

3. Works cooperatively with senior leadership/ clinical management to make appropriate changes. (ORCS)y

4. Understands the difficulties and challenges related to the implementation of patient-cen- teredmedical homes. (ORCS)y

Total authentic leadership score ranged from 0 to 4. Meaningful recognition: Nurses must be recognized and must recog- nize others for the value each brings to the work of the organization.

1. Recognizes and rewards progress in imple- menting change with our clinic. (LN)y

a = 0.72 Meaningful recognition has an inverse relation- ship to burnout; that is, an increase in mean- ingful recognition score is associated with lower level of burnout.

Recognition (that is of value and meaningful to the individual nurse) for their unique contribu- tion to the organization and com- mitment to their patients.

2. Encourages and supports changes in clinic pat- terns to improve patient care. (ORCS)y

Total meaningful recognition score ranged from 0 to 2. Not assessed (N/A) in this study. N/A N/A

(continued on next page)

1 8

N u r s

O u t l o o k

6 8

(2 0 2 0 ) 1 4�

2 5

T a b le

2 – (C on

ti n u ed

)

A A C N ’s

H W

E C o n st ru

ct s a n d

D e fi n it io n s (A

A C N ,2

0 1 6 )

V A IL

S u rv e y It e m s

C ro

n b a ch

’s A lp h a fo r

V A IL

S u rv ey

It e m

s H y p o th

es iz e d R el a ti o n sh

ip w it h B u rn

o u t

A p p ro

p ri a te

st a ffi n g :S

ta ffi n g m u st

en su

re a n ef fe ct iv e m a tc h b et w ee n

th e p a ti en

ts ’n

ee ds

a n d n u rs es ’

co m p et en

ci es .

S ta ffi

n g b a se

d o n p a ti e n t n e e d s,

p a ti en

t a cu

it y ,n

u rs e co

m p e te n -

ci e s,

a n d th

e st a tu

s o f th

e w o rk

e n v ir o n m

e n t.

N ot e.

L N , le a d e rs h ip

n o rm

s (C a ld w e ll e t a l. , 2 0 0 8 ); L O S , L e a rn

in g O rg a n iz a ti o n S u rv e y (G

a rv in

e t a l. , 2 0 0 8 ); O R C S , O rg a n iz a ti o n a l R e a d in e ss

to C h a n g e S u rv e y (H

e lf ri ch

, L i, S h a rp

, &

S a le s,

2 0 0 9 ); S O A P C ,

S u rv e y o f O rg a n iz a ti o n a l A tt ri b u te s fo r P ri m a ry

C a re

(O h m a n -S tr ic k la n d e t a l. ,2

0 0 7 ).

* N e w

it e m

cr e a te d fo r V A IL

S u rv e y .

y P re v io u sl y v a li d a te d su

rv e y it e m s in cl u d e d in

V A IL

S u rv e y .

Nur s Out l o ok 6 8 ( 2 0 2 0 ) 1 4�2 5 19

Analysis

Responses from nurses from both waves (wave 1: n= 220, wave 2: n= 131) were combined in the analyses of burnout. A small number of nurses participated in both waves (11 out of 351 observations) and were included in the results of main analyses shown in the paper. However, additional sensitivity analyses were conducted controlling for clustering of responses among those nurseswho participated in bothwaves. The results were similar with andwithout the 11 extra observations. In addition to the univariate analysis to describe

nurse characteristics, levels of burnout, and nurses’ perceptions of the HWE elements, bivariate analyses were performed to explore the potential relationship between independent variables and nurse burnout. Only the perceived HWE elements and covariates with statistically significant associations (p � .05) to nurse burnout in the bivariate analysis were included in the multivariable linear regression analysis. In the multivariable analysis, separate models were

conducted for each perceived HWE element (models 1�5) and three models with all the HWE elements (models 6�8): model 6 included the combined sample, model 7 included RNs only, and model 8 included LVNs only, controlling for respondent-level covariates. All analyses were performed with Stata 14.0 (Stata Corp LP, College Station, TX).

Results

Table 3 shows results for level of nurse burnout, per- ceptions of the HWE, and respondent, clinic and health care system characteristics. On average, RNs reported a medium level of burnout (M = 22.1, SD = 14.3) while LVNs reported a low level of burnout (M = 17.0, SD = 13.3). Overall, RNs’ perceptions of the HWE were slightly more favorable than LVNs’ (except perceptions of authentic leadership); however, the differences were not statistically significant. LVNs were younger but had longer years of tenure as compared to RNs. About one-third of the nurses identified as non-His- panic white (37%) were female (75%) and were employed in hospital-based clinics (44%). Results from the bivariate analysis (Table 4) indi-

cated that nurse reports of each of the HWE elements was inversely related to nurse burnout (p � .05). Nurse type (RN vs. LVN) was also significantly associated with nurse burnout (p � .05). Multivariable linear regression analyses (Table 5) indi-

cate that nurse perceptions of each of the five HWE ele- ments were inversely associated with nurse burnout in separate models (models 1�5). When all five elements of the HWE were entered together in one model (model 6), perceptions of true collaboration (b =�1.3, 95% confi- dence interval [CI] = �2.50, 0.00, p = .05) and perceptions of meaningful recognition (b =�2.8, 95% CI =�5.64, 0.04, p = .05) were inversely associated with levels of

Table 3 – Nurse Characteristics and Perceptions of the HealthyWork Environment

Total (N = 351) Registered nurse (n = 170) Licensed vocational nurse (n = 181)

n (%) M (SD) n (%) M (SD) n (%) M (SD)

Nurse burnout (score 0�54)y 321 19.4 (14.0) 161 22.1 (14.3) 160 17.0 (13.3) Perceptions of HWE* True collaboration (score �-5) 334 2.9 (1.7) 167 2.9 (1.7) 167 2.8 (1.8) Skilled communication (score 0�4) 335 2.1 (1.6) 167 2.2 (1.6) 168 2.0 (1.6) Effective decision-making (score 0�3) 333 1.6 (1.2) 167 1.7 (1.2) 166 1.5 (1.3) Authentic leadership (score 0�4) 331 2.3 (1.6) 166 2.2 (1.5) 165 2.3 (2.0) Meaningful recognition (score 0�2) 330 1.0 (0.9) 165 1.1 (0.9) 165 1.0 (0.9) Nurse characteristics* Age (years) 302 47.7 (12.3) 147 50.2 (12.0) 155 45.5 (12.3) Tenure (years) 311 5.3 (6.1) 147 5.0 (6.1) 164 5.6 (6.1) Race/ethnicity Non-Hispanic white 133 (37%) 72 (43%) 61 (32%) Latino/a 19 (3%) 11 (2%) 8 (4%) Black/African American 39 (13%) 16 (10%) 23 (15%) Asian 86 (23%) 48 (28%) 38 (19%) Other 41 (12%) 17 (9%) 24 (14%) Female 265 (75%) 137 (82%) 128 (69%) Clinic characteristics Hospital-based clinic 153 (44%) 76 (45%) 77 (43%) Large CBOC (>8,000 patients) 114 (32%) 58 (34%) 56 (31%) Small CBOC (<8,000 patients) 84 (24%) 36 (21%) 48 (26%) Healthcare system characteristics Healthcare system 1 105 (30%) 57 (34%) 48 (26%) Healthcare system 2 65 (18%) 26 (15%) 39 (22%) Healthcare system 3 52 (15%) 27(16%) 25 (14%) Healthcare system 4 84 (24%) 38 (22%) 46 (25%) Healthcare system 5 45 (13%) 22 (13%) 23 (13%)

Note. CBOC, community-based outpatient clinic; HWE, healthy work environment.

* Observations do not sum up to full sample (n = 351) due to missing data.

2 0

N u r s

O u t l o o k

6 8

(2 0 2 0 ) 1 4�

2 5

Table 4 – Bivariate Analysis: Perceptions of Healthy Work Environment and Covariates Associated with Nurse Burnout

b CI p

Perceptions of HWE True collaboration (score 0�5) �2.6 �3.5 �1.7 <.001 Skilled communication (score 0�4) �2.7 �3.8 �1.7 <.001 Effective decision-making (score 0�3) �3.1 �4.2 �2.1 <.001 Authentic leadership (score 0�4) �2.2 �3.3 �1.1 <.001 Meaningful recognition (score 0�2) �4.4 �6.4 �2.3 <.001

Nurse characteristics RN (ref: LVN) 5.1 1.3 8.8 .010 Age>45 years 3.0 �0.4 6.3 .079 >6 years in clinic 1.9 �2.8 6.7 .403 Non-Hispanic white (ref: Hispanic) �1.2 �4.0 1.6 .393 Male (ref: female) 2.6 �1.8 7.0 .235

Clinic characteristics (ref: VA Medical Center) Large CBOC (>8,000 patients) 2.9 �0.2 6.1 .067 Small CBOC (<8,000 patients) 0.2 �4.0 4.4 .929

Healthcare system characteristics (ref: Healthcare System 1) Healthcare system 2 �0.1 �4.5 4.3 .955 Healthcare system 3 �0.7 �4.6 3.1 .707 Healthcare system 4 0.3 �4.2 4.8 .881 Healthcare system 5 0.9 �4.8 6.7 .742

Wave (time) �2.0 �6.4 2.4 .350 Note. CBOC, community-based outpatient clinic; HWE, healthy work environment; LVN, licensed vocational nurse; RN, registered nurse.

Nur s Out l o ok 6 8 ( 2 0 2 0 ) 1 4�2 5 21

nurse burnout. Additionally, the RN (as compared to LVN) position was associated with substantially higher levels of burnout (b = 6.2, 95% CI = 2.47, 9.84, p < .01). Results of the RN only model (model 7) showed that perceptions of true collaboration were inversely associ- ated with levels of RN burnout (b =�2.6, 95% CI =�4.29, �0.84, p< .01). In the LVN onlymodel (model 8), percep- tions of meaningful recognition were inversely associ- ated with LVN burnout (b =�5.1, 95% CI =�8.36, �1.82, p< .01).

Discussion

The seminal article, From triple to quadruple aim: Care of the patient requires care of the provider (Bodenheimer & Sinsky, 2014) calls attention to the urgent need to improve the work life of health care providers by improving their practice environment and reducing burnout so that in turn, they may help achieve the ulti- mate goal of improving population health. Findings from this study address this call and make several important contributions to expand the current litera- ture on nurse burnout in primary care settings. This study is the first study to apply the AACN’s HWE

framework to assess the nursing practice environment within a primary care setting with the PCMH model. Findings from this study underscore the importance of an HWE as a key factor associated with lower levels of nurse burnout in the PCMH. All five HWE elements showed a strong relationship with lower levels of pri- mary care nurse burnout in the bivariate analysis. Among HWE elements, perceptions of true

collaboration between members of interprofessional PCMH teams were strongly associated with lower lev- els of burnout for primary care RNs. True collaboration that encompasses effective communication, knowl- edge of each other’s role, shared responsibility, trust, and mutual respect may be especially critical for pri- mary care RNs who play a key role in coordination of longitudinal and comprehensive patient care delivery in team-based models. Given the special importance of collaboration, a

comprehensive quality improvement program to improve team collaboration may be an effective strat- egy to reduce primary care RN burnout. Examples of quality improvement initiatives aimed at improving team collaboration include standardized task sharing processes, workflow mapping, co-location of team members, regular huddles and team meetings as well as use of information technology such as instant mes- saging, to share frequent and timely information (Sin- sky et al., 2013). Other potentially effective strategies to improve team collaboration include interprofes- sional team training such as the Primary Care version of Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) and the “Nurse for a Day” nurse-shadowing program that pairs medical residents with nurses acting as the resident’s precep- tor with the ultimate goal of the nurse-resident dyad developing a better understanding of each other’s roles as well as improved communication and collabo- ration (Jain, Luo, Yang, Purkiss, &White, 2012). Buy-in and support from nurse leaders and managers

are crucial in order to promote successful adoption and spread of evidence-based practices aimed at facilitating PCMH team collaboration and preventing primary care

T a b le

5 – M u lt iv a ri a b le

L in

e a r R e g re ss

io n A n a ly si s:

H e a lt h y W

o rk

E n v ir o n m

e n t E le m

e n ts

a n d C o v a ri a te s A ss

o ci a te d w it h N u rs e B u rn

o u ty

M o d e ls

w it h H W

E E le m

e n ts

a n d C o v a ri a te s A ss o ci a te d

w it h N u rs e B u rn

o u t (s co

re 0 -5 4 )

1 (n

= 3 13

) 2 (n

= 3 1 3 )

3 (n

= 3 1 2 )

4 (n

= 3 1 2 )

5 (n

= 3 1 0 )

6 (n

= 3 0 9 )

7 R N

o n ly

(n = 1 5 8 )

8 L V N

o n ly

(n = 1 5 1 )

P er ce pt io n of

H W

E y

T ru

e co

ll a b o ra ti o n (s co

re 0 �5

) �2

.7 ** *

� �

� �

�1 .3 *

�2 .6 **

�0 .0 4

S k il le d co

m m

u n ic a ti o n (s co

re 0 �4

) �

�2 .9 ** *

� �

� �1

.4 �1

.2 �1

.4 E ff e ct .d

e ci si o n -m

a k in g (s co

re 0 �3

) �

� �3

.3 ** *

� �

�0 .4

0 .4

�1 .4

A u th

en ti c le a d e rs h ip

(s co

re 0 �4

) �

� �

�2 .1 ** *

� �0

.8 7

�0 .1

1 .2

M e a n in g fu

l re co

g n it io n (s co

re 0 �2

) �

� �

� �4

.5 ** *

�2 .8 *

0 .3

�5 .1 **

N u rs e ch a ra ct er is ti cs

R N

(r e f: L V N )

5 .7 **

6 .1 **

5 .8 **

4 .8 *

5 .3 **

6 .2 **

� �

F 2 7. 6 ** *

2 0 .3 ** *

2 8 .7 ** *

1 2 .9 ** *

1 3 .6 ** *

2 4 .2 ** *

3 .7 *

6 .5 **

R 2

0 .1 5

0 .1 5

0 .1 2

0 .0 9

0 .1 1

0 .1 7

0 .1 4

0 .1 8

N ot es .H

W E ,h

e a lt h y w o rk

e n v ir o n m e n t; L V N ,l ic e n se

d v o ca

ti o n a l n u rs e ;R

N ,r e g is te re d n u rs e .

*p � .0 5 ,* *p

� .0 1 ,* ** p � .0 0 1 .

y O n ly

st a ti st ic a ll y si g n ifi ca

n t re su

lt s (p

< .0 5 ) fr o m

th e b iv a ri a te

a n a ly si s w e re

in cl u d e d in

th e m u lt iv a ri a b le

li n ea

r re g re ss io n a n a ly si s.

22 Nur s Out l o ok 6 8 ( 2 0 2 0 ) 1 4�2 5

RN burnout. In addition, for primary care nurses to func- tion successfully as members of interprofessional PCMH teams, nurse managers must be actively engaged in daily functioning of PCMH teams (Giannitrapani et al., 2019). Active involvement by nurse managers in daily functioning of PCMH teams will promote efficient role- based care delivery that allows nurses to practice at the top of their education, training, and scope and may also improve the work life of primary care nurses through promotion of true PCMH team collaboration and mean- ingful recognition. In turn, primary care nurses can improve the health of the patients they care for. Findings from this study also showed a statistically sig-

nificant association between perception of meaningful recognition and lower levels of primary care LVN burn- out. Meaningful recognition may come in various forms including, but not limited to “thank you” notes, “Nurse Week” recognitions, advancement in the clinical ladder (Kelly & Lefton, 2017), or other opportunities for profes- sional and/or financial growth. Another way to recognize LVNs may be through opportunities to participate in the Daisy Award program that provides ongoing recognition for nurses’ clinical skill and compassion (Lefton, 2012). Further research should focus on the most effective ways of recognizing the contributions of the LVN role in patient care delivery and team functioning. More impor- tantly, recognition should be delivered in a way that is meaningful to the “end user” (Lefton, 2012). Another important finding from this study was the

notable variation in the level of burnout (Tables 4 and 5) between RNs and LVNs, with RNs reporting significantly higher levels of burnout as compared to LVNs. Most studies evaluate both groups of nurses as one combined sample even though RNs and LVNs experience organi- zational and professional roles differently including (a) diversified modes of care and expanded clinical duties; (b) division of labor within PCMH teams; and (c) inter- professional status in the team (Stewart, Stewart, Lampman,Wakefield, Rosenthal & Solimeo, 2015). Previous work has examined the relationship between

specific tasks performed by other health care providers and burnout (Helfrich et al., 2014; Kim et al., 2018). Although this study did not examine the level of involve- ment in PCMH teams and specific tasks performed by RNs vs. LVNs, these factors may also impact the level of burnout nurses may experience. Hence, further evalua- tion of the distinct roles various nurses have on PCMH teams and the specific patient care tasks that RNs and LVNs perform in relation to the levels of burnout they experience is needed. The findings from these studies could promote more efficient role-based care delivery, where nurses can practice at the top of their education, training, and scope.

Limitations

This study has limitations. The datawere cross-sectional survey and thus causality between the HWE factors and nurse burnout could not be determined. A longitudinal study evaluating the relationship between the primary

Nur s Out l o ok 6 8 ( 2 0 2 0 ) 1 4�2 5 23

care nurses’ practice environment and burnout would help extend findings from this and future studies. Second, previous studies investigating PCMH imple-

mentation have found that the VHA primary care clin- ics and providers were representative of primary care settings in other studies (Helfrich et al., 2014, Nutting et al., 2011). Nonetheless, findings from this study should be interpreted with some caution when gener- alizing to non-VHA primary care clinics, especially those located in international settings, as this study sample was limited to primary care clinics within one VHA region in the United States. Another limitation is that the survey was not specifi-

cally designed to measure the constructs of the AACN’s HWE, which may potentially impact internal validity; however, the measured constructs (leadership, commu- nication, team process and satisfaction, and shared deci- sion-making) mapped closely with those in the AACN’s HWE and the internal consistency of the measured con- structs was high. In addition, one of the six constructs— appropriate staffing—was not measured here, and its exclusion may have impacted the strength and direction of the relationships between the HWE constructs and burnout. Recent studies, including the study by Helfrich et al. (2014), have demonstrated the association of having a fully staffed PCMH team and lower levels of burnout. Future research using validated instruments to measure the primary practice environment such as the Practice Environment Scale of the Nursing Work Index (Lake, 2002) specifically modified for the primary care setting is needed so that findings from such studies can guide nursing and other organizational leaders in implementa- tion of targeted strategies to improve nursing and patient outcomes, particularly in primary care settings.

Conclusion

The results of this study highlight the important role of a healthy work environment, particularly, true

Never A few T a Yea

(a) I feel emotionally drained frommywork. (b) I feel exhilarated when I accomplish some- thing at work.

(c) I feel used up at the end of the workday. (d) Working with people all day is really a strain for me.

(e) I feel burned out frommy work. (f) I feel fatigued when I get up in themorning and have to face another day on the job.

(g) I have accomplishedmany worthwhile things in this job.

(h) I feel frustrated by my job. (i) I feel I’m working too hard onmy job. (j) Working with people directly puts too much stress onme.

(k) I feel like I’m at the end of my rope. (l) In my opinion, I am good at my job.

collaboration between members of interprofessional PCMH teams in reducing primary care RN burnout and meaningful recognition in reducing primary care LVN burnout. Nursing and other organizational leaders should seek to achieve the Quadruple Aim (Boden- heimer & Sinsky, 2014) by implementing evidence- based strategies to foster an HWE in primary care set- tings.

Acknowledgments

Funding for this project was supported through a grant from the VA Veterans Assessment and Improvement Laboratory for Patient-Centered Care (VAIL-PCC) and Patient Aligned Care Team (PACT) Demonstration Lab (#XVA 65-018) and VA Locally Initiated Project (LIP #65162). Dr. Kim’s time was covered by the Quality Scholars Program funded through the VA Office of Aca- demic Affiliations (#TQS 65-000) and Dr. Yano’s time was covered by a VA HSR&D Senior Research Career Scientist Award (Project # RCS 05-195). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

Supplementarymaterials

Supplementary material associated with this article can be found in the online version at doi:10.1016/j.out look.2019.06.018.

Appendix A. Maslach’s Burnout Inventory (Emotional Exhaustion Subscale)

imes r

Every Month

A few Times a Month

Every Week

A few Times aWeek

Every Day

24 Nur s Out l o ok 6 8 ( 2 0 2 0 ) 1 4�2 5

R E F E R E N C E S

American Association of Critical-Care Nurses. (2016). AACN standards for establishing and sustaining healthy work environments: A journey to excellence (2nd ed.). Aliso Viejo, CA. Retrieved from https://www.aacn.org/nurs ing-excellence/standards/aacn-standards-for-estab lishing-and-sustaining-healthy-work-environments.

Agency for Healthcare Research and Quality. (n.d.). Defin- ing the PCMH. Retrieved from https://pcmh.ahrq.gov/ page/defining-pcmh

Brenninkmeijer, V., & VanYperen, N. (2003). How to con- duct research on burnout: Advantages and disadvan- tages of a unidimensional approach in burnout research. Occupational and Environmental Medicine, 60 (Suppl. 1), i16–i20.

Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. The Annals of Family Medicine, 12(6), 573–576.

Caldwell, D. F., Chatman, J., O’Reilly, C. A. III, Ormiston, M., & Lapiz, M. (2008). Implementing strate- gic change in a health care system: The importance of leadership and change readiness. Health Care Manage- ment Review, 33(2), 124–133.

Cimiotti, J. P., Aiken, L. H., Sloane, D. M., &Wu, E. S. (2012). Nurse staffing, burnout, and health care-associated infec- tion.American Journal of Infection Control, 40(6), 486–490.

Connor, J. A., Ziniel, S. I., Porter, C., Doherty, D., Moonan, M., Dwyer, P., & . . .Hickey, P. A. (2018). Inter- professional use and validation of the AACN healthy work environment assessment tool. Am J Crit Care, 27 (5), 363–371, doi:10.4037/ajcc2018179.

Dall’Ora, C., Griffiths, P., Ball, J., Simon, M., & Aiken, L. H. (2015). Association of 12 h shift and nurses’ job satis- faction, burnout and intention to leave: Findings from a cross-sectional study of 12 European countries. BMJ Open, 5(9) e008331.

Doulougeri, K., Georganta, K., & Montgomery, A. (2016). “Diagnosing” burnout among healthcare professionals: Can we find consensus? Cogent Medicine, 3(1), 1–10.

Demir, A., Ulusoy, M., & Ulusoy, M. F. (2003). Investigation of factors influencing burnout levels in the profes- sional and private lives of nurses. International Journal of Nursing Studies, 40(8), 807–827.

Garvin, D. A., Edmondson, A. C., & Gino, F. (2008). Is yours a learning organization? Harvard business review, 86(3), 109–116.

Giannitrapani, K. F., Rodriguez, H., Huynh, A. K., Hamilton, A. B., Kim, L., Stockdale, S. E., & . . .Rubenstein, L. V. (2019). Howmiddle managers facil- itate interdisciplinary primary care team functioning. Healthcare, doi:10.1016/j.hjdsi.2018.11.003.

Helfrich, C. D., Dolan, E. D., Simonetti, J., Reid, R. J., Joos, S., Wakefield, B. J., & . . .Nelson, K. (2014). Elements of team-based care in a patient-centered medical home are associated with lower burnout among VA primary care employees. Journal of General Internal Medicine, 29 (2), 659–666.

Helfrich, C. D., Li, Y. F., Sharp, N. D., & Sales, A. E. (2009). Organizational readiness to change assessment (ORCA): Development of an instrument based on the Promoting Action on Research in Health Services (PAR- IHS) framework. Implementation Science, 4(1), 38.

Jain, A., Luo, E., Yang, J., Purkiss, J., & White, C. (2012). Implementing a nurse-shadowing program for first- year medical students to improve interprofessional

collaborations on health care teams. Academic Medicine, 87(9), 1292–1295.

Jennings, B. (2008). Work stress and burnout among nurses: Role of the work environment and working conditions. In R. G. Hughes (Ed.), Patient safety and qual- ity: An evidence-based handbook for nurses (pp. 137�158). Rockville, MD: Agency for Healthcare Research and Quality AHRQ Publication No. 08-0043.

Kelly, L. A., & Lefton, C. (2017). Effect of meaningful recog- nition on critical care nurses’ compassion fatigue. American Journal of Critical Care, 26(6), 438–444.

Kim, L. Y., Rose, D. E., Soban, L. M., Stockdale, S. E., Meredith, L. S., Edwards, S. T., & . . .Rubenstein, L. V. (2018). Primary care tasks associated with provider burn- out: findings from a Veterans Health Administration sur- vey. Journal of General Internal Medicine, 33(1), 50–56.

Lake, E. T. (2002). Development of the practice environ- ment scale of the Nursing Work Index. Research in Nurs- ing & Health, 25(3), 176–188.

Laschinger, H. K. S., Finegan, J., &Wilk, P. (2011). Situa- tional and dispositional influences on nurses’ work- place well-being: The role of empowering unit leadership. Nursing Research, 60(2), 124–131.

Laschinger, H. K. S., Grau, A. L., Finegan, J., &Wilk, P. (2010). New graduate nurses’ experiences of bullying and burnout in hospital settings. Journal of Advanced Nursing, 66(12), 2732–2742.

Laschinger, H. K. S., & Leiter, M. P. (2006). The impact of nursing work environments on patient safety out- comes: The mediating role of burnout engagement. Journal of Nursing Administration, 36(5), 259–267.

Leiter, M. P., & Laschinger, H. K. S. (2006). Relationships of work and practice environment to professional burnout: Testing a causal model.Nursing Research, 55(2), 137–146.

Lefton, C. (2012). Strengthening the workforce through meaningful recognition. Economics, 30(6), 331.

Lewis, S. E., Nocon, R. S., Tang, H., Park, S. Y., Vable, A. M., Casalino, L. P., & . . .Birnberg, J. M. (2012). Patient-centered medical home characteristics and staff morale in safety net clinics. Archives of Internal Medicine, 172(1), 23–31.

Maslach, C., Jackson, S. E., Leiter, M. P., Schaufeli, W. B., & Schwab, R. L. (1996).Maslach burnout inventory (3 ed.). Palo Alto, CA: Consulting Psychologists Press.

Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of Psychology, 52(1), 397–422.

McHugh, M. D., Kutney-Lee, A., Cimiotti, J. P., Sloane, D. M., & Aiken, L. H. (2011). Nurses’ widespread job dissatisfac- tion, burnout, and frustration with health benefits signal problems for patient care.Health Affairs, 30(2), 202–210.

McHugh, M. D., & Ma, C. (2014). Wage, work environment, and staffing: effects on nurse outcomes. Policy, Politics, & Nursing Practice, 15(3�4), 72–80.

Meredith, L. S., Batorsky, B., Cefalu, M., Darling, J. E., Stockdale, S. E., Yano, E. M., & Rubenstein, L. V. (2018). Long-term impact of evidence-based quality improve- ment for facilitating medical home implementation on primary care health professional morale. BMC Family Practice, 19(1), 149.

Meredith, L. S., Hackbarth, N. S., Darling, J., Rodriguez, H. P., Stockdale, S. E., Cordasco, K. M., & . . .Rubenstein, L. V. (2015). Emotional exhaustion in pri- mary care during early implementation of the VA’s medical home transformation: Patient-aligned Care Team (PACT).Medical Care, 53(3), 253–260.

Monsalve-Reyes, C. S., San Luis-Costas, C., G�omez- Urquiza, J. L., Albend�ın-Garc�ıa, L., Aguayo, R., & Ca~nadas-De la Fuente, G. A. (2018). Burnout syndrome and its prevalence in primary care nursing: A

Nur s Out l o ok 6 8 ( 2 0 2 0 ) 1 4�2 5 25

systematic review and meta-analysis. BMC Family Prac- tice, 19(1), 59.

Nelson, K. M., Helfrich, C., Sun, H., Hebert, P. L., Liu, C. F., Dolan, E., & . . .Sanders, W. (2014). Imple- mentation of the patient-centered medical home in the Veterans Health Administration: Associations with patient satisfaction, quality of care, staff burn- out, and hospital and emergency department use. JAMA, 174(8), 1350–1358.

Norful, A., Martsolf, G., de Jacq, K., & Poghosyan, L. (2017). Utilization of registered nurses in primary care teams: A systematic review. International Journal of Nursing Studies, 74, 15–23.

Nutting, P. A., Crabtree, B. F., Miller, W. L., Stange, K. C., Stewart, E., & Ja�en, C. (2011). Transforming physician practices to patient-centeredmedical homes: Lessons from the national demonstration project. Health Affairs, 30(3), 439–445.

Stewart, K. R., Stewart, G. L., Lampman, M. M., Wakefield, B., Rosenthal, G., & Solimeo, S. L. (2015). Implications of the patient centeredmedical home for nursing practice. The Journal of nursing administration, 45(11), 569.

Ohman�Strickland, P. A., John Orzano, A., Nutting, P. A., Perry Dickinson,W., Scott�Cawiezell, J., Hahn, K., & . . .Crabtree, B. F. (2007). Measuring organizational

attributes of primary care practices: Development of a new instrument.Health Services Research, 42(3p1), 1257– 1273.

Poghosyan, L., Clarke, S. P., Finlayson, M., & Aiken, L. H. (2010). Nurse burnout and quality of care: Cross�na- tional investigation in six countries. Research in Nursing & Health, 33(4), 288–298.

Reid, R. J., Coleman, K., Johnson, E. A., Fishman, P. A., Hsu, C., Soman, M. P., & . . .Larson, E. B. (2010). The group health medical home at year two: Cost savings, higher patient satisfaction, and less burnout for pro- viders. Health Affairs, 29(5), 835–843.

Sinsky, C. A., Willard-Grace, R., Schutzbank, A. M., Sinsky, T. A., Margolius, D., & Bodenheimer, T. (2013). In search of joy in practice: A report of 23 high-func- tioning primary care practices. The Annals of Family Medicine, 11(3), 272–278.

Smolowitz, J., Speakman, E., Wojnar, D., Whelan, E. M., Ulrich, S., Hayes, C., &Wood, L. (2015). Role of the regis- tered nurse in primary health care: meeting health care needs in the 21st century.Nursing Outlook, 63(2), 130–136.

U.S. Department of Veterans Affairs. (2014). Analyze tasks for the patient centered medical home. Available at https://www.patientcare.va.gov/primarycare/pact/ Resources.asp