Abstract
Introduction:
Primary care clinician burnout is pervasive and detrimental. How components of teamwork and clinic culture might contribute to burnout remains unsettled.
Objective:
To examine associations between primary care clinician perceptions of specific components of teamwork and of organizational culture, and perceived stress and burnout.
Methods:
Cross-sectional survey study of primary care clinicians from 5 county health system clinics. Measures: Perceptions of teamwork related to coordination of care, and clinic provision of chronic disease self-management support; values alignment and workplace equity; and demographics.
Data Analysis:
Descriptive statistics and Spearman’s correlations to examine associations, controlling for clinic and examining response variability by clinic.
Results:
Of 72 clinicians, 64% were female and 32% non-white. About 56% had worked at least 4 years and half worked 5 to 6 half days/week or more in their clinic. Clinicians who reported having someone on the clinician’s care team routinely schedule follow-up appointments for patients with complex chronic illnesses reported lower stress and burnout. Those who perceived greater values alignment with their clinic and greater personal and employee equitable treatment had lower stress and burnout.
Conclusions:
Teamwork among clinicians and non-clinical staff, a component of teamwork that is not well-considered in current literature, could be an important piece of the puzzle to decrease the persistent and challenging issue of stress and burnout among primary care clinicians.
Keywords: diabetes mellitus, health inequities, health outcomes, mixed methods, patient-centeredness
Introduction
Professional burnout is a syndrome comprised of loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment. 1 The issue of clinician burnout is widespread, worsening over time, and bears adverse consequences for both clinicians and their patients. 2 This includes clinician job dissatisfaction, depression, substance use, reduced productivity, lower workforce retention, decreased quality of care, increased medical errors, and reduced patient satisfaction and adherence to medical advice.3,4 Organizational factors are oftentimes highly associated with stress and burnout. For instance, the work environment—for example, work process inefficiencies, excessive workloads, organizational climate factors, and deterioration in control and autonomy—have been associated with burnout among physicians. 2 The perception of a lack of fairness—environments where support is allocated based on personal privilege instead of organizational objectives—is also associated with burnout, 5 as is the lack of values alignment with leadership. 6
Some research also links teamwork to less burnout in clinicians,7 -11 though a national study did not replicate these findings. 12 This may mean that the nuances of the teamwork processes or specifics of who is part of the team matter. Teamwork in healthcare is often defined as “2 or more health care professionals” working with patients and caregivers. 10 However, clinic team members can include members not categorized as health care professionals, such as front desk staff, and inclusion of these non-clinical staff might impact burnout. For instance, non-clinical staff often partner with health care professionals in the care of patients. These team members might have responsibilities that support the patient in carrying out their care plan, accessing the health care system when needed, or keeping track of care processes that need to be addressed. This would include, for example, assuring that complex patients have follow-up scheduled.
We examined whether the way primary care clinicians perceive various aspects of teamwork, encompassing interactions among clinical and non-clinical team members, as well as elements of organizational culture (alignment of values and workplace equity), were associated with clinician experiences of perceived stress and burnout.
Methods
We examined survey data from primary care clinicians, taken from a larger cross-sectional, observational cohort survey study of clinicians and staff working in 5 primary care clinics, 2 of which included resident physicians, in an urban county health system in the Midwest United States. We recruited participants during clinic-wide staff meetings and invited them to complete a paper survey, sending a 1-time email invitation to an on-line survey to capture those not in attendance. Participants were offered a $5 gift card incentive.
Surveys of clinicians and staff measured participant perceptions of teamwork related to coordination of care and clinic provision of chronic disease self-management support, values alignment, and workplace equity (ie, organizational justice). To assess stress and burnout, we utilized previously validated questions from the Mini Z Survey, a survey to assess medical professional well-being in the work environment. 13 To assess components of teamwork, we adapted a validated patient measure of perceptions of clinical supports in chronic disease self-management to reflect the clinician perspective, 14 and developed the remaining teamwork-focused questions based on prior qualitative data collected when examining roles and processes within team-based primary care. To assess perceptions of fairness in the workplace, we adapted a previously validated measure from the organizational justice literature to reflect the clinical work setting. 15 We modified response options to create response categories within a 4-point Likert Scale of strongly disagree to strongly agree, to provide consistency across survey items. We also collected participant demographic information. Data was collected between June 2019 and February 2020. The University of Minnesota Institutional Review Board approved this study.
We examined responses to survey items related to components of teamwork and organizational culture (specifically, values alignment and workplace equity, Table 2).13-15 Our 2 dependent variables were single-item measures assessing burnout and stress 13 (see Table 2 footnote for measure details).
Table 2.
Relationships Between Teamwork and Organizational Culture With Stress and Burnout.
| Stress* | burnout † | ||
|---|---|---|---|
| Mean (standard deviation) | Spearman’s partial correlation coefficients | ||
| Teamwork questions | |||
| 1. For those with complex chronic illnesses, someone on our care team routinely schedules follow-up appointments. (n = 70) | 2.53 (0.85) | −0.30 ‡ | −0.28 ‡ |
| 2. Someone on our clinic care team routinely contacts complex chronic disease patients to see how things are going between appointments. (n = 69) | 2.20 (0.68) | −0.06 | −0.12 |
| 3. Our outreach staff always contact patients to schedule needed tests, referral appointments, and screenings. (n = 70) | 2.30 (0.75) | −0.07 | −0.13 |
| 4. We utilize care coordinators when needed for complex cases. (n = 72) | 3.21 (0.73) | −0.08 | −0.17 |
| 5. We have the ability to refer patients to in-clinic resources for chronic disease self-management, such as staff who provide education, nutritional advice, or support with medication management. (n = 72) | 3.49 (0.63) | −0.05 | −0.06 |
| Organizational culture questions | |||
| 1. My professional values are well-aligned with those of my clinic leaders. (n = 72) | 3.21 (0.60) | −0.36 § | −0.41 § |
| 2. In general, the treatment I receive in my clinic is fair. (n = 71) | 3.14 (0.57) | −0.31 ‡ | −0.25 ‡ |
| 3. For the most part, this clinic treats its employees fairly. (n = 70) | 3.16 (0.63) | −0.33 § | −0.28 ‡ |
Survey question and responses: “I feel a great deal of stress because of my job.” Response level: higher scores on the 4-point Likert scale of agreement indicate greater stress. 12
Survey question and responses: “Overall, based on your definition of burnout, how would you rate your level of burnout?” Response levels: 1. I enjoy my work. I have no symptoms of burnout. 2. I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out. 3. I am definitely burning out and have 1 or more symptoms of burnout, for example, emotional exhaustion. 4. The symptoms of burnout that I’m experiencing won’t go away. I think about work frustrations a lot. 5. I feel completely burned out. I am at the point where I may need to seek help. Higher scores indicate greater burnout. 12
P < .05.
P < .01.
We calculated descriptive statistics of our clinician respondents. We used Spearman’s correlations to examine associations between clinician’s perceptions of both teamwork and organizational culture and both burnout and stress. We adjusted for clinic since each clinic might provide different resources. We defined correlation magnitudes according to the published standard by Cohen. 16
To explore the possibility that differences in specific clinic staff or procedures might impact how clinicians answered Teamwork Question 1, we examined response variability by each clinic site (Table 3). As a sensitivity analysis, we analyzed data without resident physician respondents to ensure that their participation was not driving our results.
Table 3.
Variability of Responses by Clinic to Question About Scheduling Follow-Up.
| Number of responses by clinic to Teamwork Question 1: “For those with complex chronic illnesses, someone on our care team routinely schedules follow-up appointments.” | ||||
|---|---|---|---|---|
| Clinic | Strongly disagree | Disagree | Agree | Strongly agree |
| A | — | 5 | — | — |
| B | — | 2 | 1 | 1 |
| C | 2 | 10 | 4 | 1 |
| D | 1 | 2 | 4 | 1 |
| E | 2 | 15 | 11 | 8 |
Results
Forty-nine clinicians (nurse practitioners, physician assistants, and physicians) and 23 resident physicians from 5 clinics responded to the survey. Sixty-four percent were female, and 32% were non-white. Clinician demographics are outlined in Table 1. The response rate was >95% of those in attendance at the staff meetings and was approximately 50% for all clinicians and staff employed in the clinics. The number of years the clinician had worked in the clinic ranged from 0 to 1 years to more than 11 years with 56% working 4 or more years. When responding about the amount of time the clinician provided patient care in their clinic, responses ranged from 1 to 2 half days to >8 half days with 51% working 5 to 6 or more half days a week.
Table 1.
Participating Clinician Demographics.
| Female gender, n (%) | 46 (64) |
| Age in years, mean (SD) | 42 (12) |
| Race, n (%) | |
| White | 48 (68) |
| Asian | 11 (16) |
| Black | 5 (7) |
| Other | 7 (10) |
| Hispanic ethnicity, n (%) | 8 (11) |
| Clinician type, n (%) | |
| Non-resident | 49 (68) |
| Resident physicians | 23 (32) |
| Years of experience in this clinic, n (%) | |
| 0-1 | 13 (18) |
| 2-3 | 19 (26) |
| 4-6 | 11 (15) |
| 7-10 | 11 (15) |
| 11+ | 18 (25) |
| Half days of patient care per week, n (%) | |
| 1-2 | 15 (21) |
| 3-4 | 20 (28) |
| 5-6 | 17 (24) |
| 7-8 | 18 (25) |
| >8 | 2 (3) |
When respondents rated their burnout (on a 5 point scale) and stress (on a 4 point scale), where higher scores indicate greater burnout and stress, the means were 2.51 (SD = 0.92) and 2.79 (SD = 0.84), respectively. Associations between clinician perspectives on teamwork and organizational culture with stress and burnout are outlined in Table 2. Among teamwork questions, the perception that someone on the clinician’s care team routinely scheduled follow-up appointments for patients with complex chronic illnesses (Teamwork Question #1) was moderately correlated with both stress and burnout (Spearman’s partial correlation coefficients of −0.3 and −0.28, respectively; P < 0.05 for both), such that those clinicians who had someone scheduling follow-up reported less stress and burnout. All 3 organizational culture questions that assessed the concepts of values alignment and working in an equitable climate/workplace had moderate associations with both stress and burnout, such that greater values alignment and greater perceived equity were associated with less stress and burnout (correlation range −0.25 to 0.41, P < 0.05 for all). In our sensitivity analysis, excluding resident physicians did not change the magnitudes or directionality of our correlations.
When examining our data for potential contributors to these findings, we found a range of variation within 4 of the 5 clinics in whether clinicians perceived having someone to routinely schedule follow-up appointments for those with complex chronic illnesses, where at least 30% of respondents within a clinic disagreed with their colleagues on the agree-disagree scale (Table 3).
Discussion
Our findings demonstrate a correlation between lower stress and burnout, and clinicians’ perceptions that someone on their team routinely schedules follow-up appointments for patients with complex chronic illnesses. This could mean that clinicians who perceive that teamwork with scheduling support is not working effectively also experience more burnout. Previous literature has connected the perception of better team culture with reduced levels of burnout. 8 Alternatively, if clinicians are taking on at least part of this task, studies demonstrate that participating in larger amounts of self-reported clerical work (including “calling for appointments, doing prior authorizations, faxing forms, requesting records, etc.”) was associated with increased levels of clinician burnout. 17 We did not assess clinician clerical burden in our study, so we can only hypothesize about this potential contribution to the observed associations.
We found that clinicians within the same clinic often had a range of perceptions about whether someone on their care team scheduled follow-up appointments for patients with complex chronic illnesses (Table 3). If clinic-level systems were consistent across clinicians, one might expect that clinicians would have similar responses. It is unclear from our study if clinicians are actually experiencing differences in the availability of scheduling support, or if the variation is due to differing perceptions. It could be that clinicians who are burned out are not taking the time to connect with staff who schedule appointments, or they are disengaged and do not know about this resource. Alternatively, it could be that some clinicians are teamed with efficient and effective staff and therefore experience high-functioning teamwork, including scheduling of follow-up care, which contributes to less burnout and stress.
We also found a strong correlation between stress and burnout, and clinicians’ responses related to values alignment and workplace equity. This reflects other work demonstrating that employees who report values alignment with leadership, and who report fair treatment, also report lower levels of stress and burnout. 18 Our findings are consistent with previous research. The correlation level (at least 0.3) for these variables, considered a moderate effect size, 16 is similar to the correlation among clinicians’ perceptions that someone on their team schedules follow-up appointments and their reported stress and burnout.
We did not see correlations with the clinicians’ other perceptions of teamwork in their clinics, and stress and burnout. This may be due to the limited variability in the responses for many of the questions. For example, most clinicians agreed they could refer to within-clinic interprofessional resources (Question 5 in Table 2). This lack of variability could limit the statistical power to detect differences in associations with stress and burnout. Or, this difference in correlations among the teamwork-focused questions could indicate that some interprofessional staff and their roles are more “visible” to clinicians in their day-to-day work, but scheduling staff are more disconnected from the clinicians and therefore their sense of scheduling tasks is less known.
Limitations of this study include the use of cross-sectional observational data, which prevent causal interpretations. Staffing models may have varied among clinics and perception of adequate clinic support may have also differed among clinicians. There are potential variables that may have impacted both burnout and support such as clinic staff burnout and patient volumes that we have not been able to account for in this study and would be areas for potential investigation. We surveyed clinicians in 5 primary care clinics in a county health system in 1 geographic area. It is unclear if our findings are specific to a safety-net setting, defined as “delivering a significant level of health care and other needed services to uninsured, Medicaid and other vulnerable patients,” 19 such as that of the county health system clinics in this study, or whether the findings are generalizable to other primary care clinic settings where contributions to clinician burnout may differ. 20 Our small sample size might limit effect size and mask true differences in correlations.
Our finding that clinicians who believe that they have clinic support to schedule follow-up for complex patients have decreased stress and burnout, warrants further investigation. More research is needed in the best way to design teamwork processes, including those that include non-clinician staff. Incorporating non-clinician staff in clinic workflows that support patients with chronic diseases may help to minimize clinician burnout. Our research suggests that teamwork among clinicians and non-clinical staff, a facet often overlooked in existing literature, may serve as a significant element in addressing the ongoing and complex problem of stress and burnout among primary care clinicians.
Acknowledgments
We thank the clinicians who participated in our survey for sharing their time and perspectives.
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award number K23DK118207 and was supported by the by the National Institutes of Health’s National Center for Advancing Translational Sciences, grant UL1TR002494. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
ORCID iD: Elizabeth A. Rogers 
https://orcid.org/0000-0002-4819-7178
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