Abstract
Advanced practitioners (APs), including nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists, and pharmacists, are pivotal in health care. Despite their critical role, record numbers of APs are leaving the profession, primarily due to poor work-life balance, which contributes to burnout and high turnover rates. This article explores the impact of administrative time on AP job satisfaction and retention, drawing from recent surveys and case studies. Findings indicate that dedicated administrative time significantly enhances job satisfaction and reduces burnout, with data showing that APs with administrative time are less likely to leave their roles. The Advanced Practitioner Society for Hematology and Oncology (APSHO) prioritized addressing AP burnout in 2024 by advocating for structured administrative time. Following an extensive review of the literature and survey data, the APSHO Administrative Time Subcommittee recommends 8 hours of administrative time per week as reasonable for a full-time AP in clinical outpatient practice. Additionally, this committee proposes a comprehensive model for implementing administrative time. The call to action is clear: to sustain a high-quality health-care workforce, it is essential to support APs through policies that promote work-life balance, retention, and operational efficiency.
Advanced practitioners (APs), including nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists, and pharmacists, are the backbone of health care, providing essential services across various medical fields (Kurtzman & Barnow, 2017). However, despite their critical role, many are leaving the profession in record numbers. Multiple studies report shortages, administrative burden, and professional burnout at significant levels (Klein et al., 2020; Tai-Seale et al., 2017). As of 2023, there were more than 160,000 certified PAs and more than 263,000 NPs in the United States (U.S. Bureau of Labor Statistics, 2023a, 2023b), yet 15.3% of NPs and 10.7% of PAs left their positions in 2021 (NSI Nursing Solutions, 2022). The main reason cited for this exodus is poor work-life balance (American Academy of Physician Assistants, n.d.). When APs leave their positions, the work they leave behind often becomes the responsibility of already busy colleagues, leading to longer shifts and thus perpetuating a cycle of reduced work-life balance and, ultimately, increased turnover. The Advanced Practitioner Society for Hematology and Oncology (APSHO) identified AP burnout as a priority focus in 2024.
To support APs in the workplace and reduce turnover, implementing policies that promote work-life balance is essential. Policies that improve working conditions for APs and reward their meaningful contribution to high-quality patient care in different clinical settings not only increases job satisfaction but also retains employees, increasing the longer-term labor market and improving patient outcomes (Hnath et al., 2023). Proulx (2021) describes Emory Healthcare's examination of factors that led to AP dissatisfaction, poor productivity, and job turnover. One factor noted was that APs with dedicated administrative time are 17% less likely to leave (Hartsell & Noecker, 2020; Proulx, 2021). Building upon this work, Toth (2023) describes work within Texas Oncology to develop an administrative time schedule for oncology/hematology APs. Not only did they note higher AP satisfaction rates and improved work-life balance, but AP retention rates increased as well.
The APSHO 2023 Leadership Summit identified the need for providing administrative time for non–patient-facing clinical responsibilities as one effective avenue for improving work-life balance and thus reducing burnout. This launched the establishment of a subcommittee within the 2024 APSHO Leadership Summit to further address this need.
A representative sample of APSHO members (n = 116) was queried about administrative time in their practice in the first quarter of 2024. It was noted that 67% of respondents have administrative time in their practice. The majority of the respondents (62%) reported between 4 and 8 hours of administrative time weekly. Of those who did not have administrative time, 87% noted that the lack of administrative time increased feelings of burnout or job dissatisfaction.
Another survey was sent to APSHO members who identified themselves to be in a community practice setting (n = 199) in March 2024. Of these community APs, only 52% had administrative time. The number of hours allotted for administrative time varied from 1 to 20 hours per week, with the majority (79%) having between 4 and 8 hours weekly.
A survey of APSHO Institutional Members (institutions with 100 or more APs) sent in March 2024 found that all 10 respondents granted full-time APs with administrative time varying from 4 to 12 hours per week. Multiple respondents indicated that administrative time was only for outpatient APs and could vary according to job role, service area, research, or participation in quality improvement projects.
DEFINING ADMINISTRATIVE TIME
Following a review of literature related to administrative time and the data collected from the surveys, it became clear that there are different terms used for administrative time. These terms could include flex (flexible) time, dedicated time, and protected time.
For the purposes of this article, a definition of administrative time was established by the subcommittee as follows: Administrative time is defined as all non–direct patient-facing responsibilities that are critical for delivering efficient and optimal patient care and may include responsibilities that are necessary for the effective functioning of the oncology health-care organization.
It was also essential to develop a list of examples of activities or tasks that are commonly performed during AP administrative time. Table 1 divides administrative activities into patient-related tasks and organizational/professional growth.
Table 1. Administrative Time.
| Patient-related tasks | Organizational/Professional growth |
|---|---|
|
|
Patient-related tasks include activities related to patient management, care coordination and communication, and records documentation (Hooker & Cawley, 2017). The organizational and professional growth category includes activities related to AP professional growth and development and institutional obligations such as annual compliance coursework and administrative duties.
After establishing this groundwork, APSHO leadership determined that APs would benefit from recommendations establishing a structured approach to advocate for and implement administrative time for APs (Figure 1). The following sections outline a comprehensive model for advocating for and implementing administrative time for APs.
Figure 1.
Approach to advocating for administrative time.
DEVELOP A TASK FORCE
Advocating for dedicated administrative time for APs is vital to promoting professional fulfillment, enhancing patient care, and optimizing organizational performance. Developing a task force of APs, physician leaders, health-care administrators, and relevant stakeholders is a crucial first step. Other stakeholders include an AP champion, practice president or medical director, human resources director, information technology (IT) director, chief executive officer, chief financial officer, division chief, and a director of operations. This diverse group can provide varied perspectives, expertise, and support in advocating for AP administrative time. The task force should determine the target settings for the proposed changes, such as inpatient and/or outpatient, surgical, or community settings. Clear goals, roles, and responsibilities should be established to ensure cohesion and effectiveness. Together, this group can empower APs to thrive in their roles and contribute to a healthier patient care environment (Kurtin et al., 2023).
ESTABLISH A STRATEGIC PLAN
A strategic approach to advocating for administrative time is essential to the success of the campaign. The task force needs to develop ideas into organized components, which include:
Setting a clear purpose
Identifying short- and long-range performance measurements of success
Preparing for operational or process planning changes.
Leaders of the task force should familiarize themselves with professional approaches to strategic planning, change management, and business acumen prior to making a formal proposal (Cleveland Clinic, n.d.). Sharing the strategy with approvers will help them understand the return on investment (ROI) of this change. Clear objectives followed by tasks to accomplish these objectives create transparency for all stakeholders and approvers (Cleveland Clinic, n.d.). Preparing and agreeing upon short and long-term measures of success will better define the desired ROI for implementing administrative time for APs (Cleveland Clinic, n.d.).
High-level strategies might include optimizing staffing ratios, investing in administrative support infrastructure, streamlining documentation processes, and advocating for policy changes to recognize the value of administrative time for APs.
IDENTIFY KEY STAKEHOLDERS
Engaging key stakeholders is pivotal in garnering support for any initiative. Thorough identification of all pertinent stakeholders ensures inclusive discussions. Crafting tailored messages for each stakeholder, akin to an “elevator pitch,” will enable each stakeholder to understand the message clearly. Each stakeholder brings a unique viewpoint on how the implementation will impact their department. For instance, a chief of operations might focus on clinic operations and patient service implications, while a chief financial officer would be concerned with the initiative's financial impact.
Incorporating APs as crucial stakeholders from the outset is imperative. Their insights into administrative time goals are fundamental to success (Kurtin et al., 2023). Data from surveys indicating high levels of job stressors and burnout within the AP workforce (Klein et al., 2020) underscore the importance of implementing administrative time to address burnout, thereby enhancing retention and engagement, ensuring patient continuity, and sustaining productivity levels.
IDENTIFY KEY INSTITUTIONAL/PRACTICE METRICS
When considering the implementation of dedicated administrative time for APs, it is common to anticipate a decrease in productivity. However, surveys indicate that APs report greater productivity and higher job satisfaction when provided with dedicated administrative time (Toth, 2023; Direct Shifts, 2022). Furthermore, APs with allocated administrative time are 17% less likely to leave their organization, resulting in improved retention rates and the potential for maintaining or even increasing productivity levels (Hartsell & Noecker, 2020; Proulx, 2021).
An important part of this process is identifying relevant metrics for the clinical setting and specialty. This involves collecting quantitative and qualitative data on APs’ current administrative workloads, patient care activities, and job satisfaction levels. Surveys, time-tracking studies, and focus groups can provide valuable insights into the impact of administrative tasks on APs’ professional lives.
The amount of time beneficial to an AP and team varies by institution and depends upon the role and responsibility the AP holds. In a survey of 116 APSHO APs conducted in March 2024, about 1/3 of respondents had 4 hours or fewer each week, 1/3 of respondents had 5 to 8 hours per week, and 1/3 of respondents had 10 or more hours per week. Of those who did not have administrative time, 87% noted that the lack of administrative time increased feelings of burnout or job dissatisfaction.
Financial metrics may include breakeven cost analysis, minimum daily patient quotas, and tracking relative value units (RVUs). Additionally, practices emphasizing professional development and research may consider implementing a clinical ladder portfolio, minimum research contribution thresholds, or requirements for submitting abstracts, posters, and/or published work.
Monitoring AP satisfaction is another critical metric. Job satisfaction significantly influences retention efforts and directly impacts operational and financial metrics, as well as patient care (Xuecheng et al., 2022). While there may not be a universally agreed-upon method for calculating the cost of AP turnover, estimates range from one to three times an AP's salary (Hartsell & Noecker, 2020). Regardless of the approach, turnover incurs costs. Improving job satisfaction and AP contentment will inevitably mitigate turnover expenses. Additionally, investing in patient satisfaction surveys can play a vital role in retaining experienced APs and ensuring continuity of patient care.
In cases where practice leadership or the Csuite express reluctance, initiating a small pilot program over 3 to 6 months could be beneficial. Establishing agreed-upon metrics to monitor financial and patient volume data before and after implementation is essential.
IDENTIFY VALUE OF ADMINISTRATIVE TIME
Highlighting the value of administrative time involves demonstrating its positive impact on both APs and the health-care organization. Improved job satisfaction, reduced burnout, and enhanced patient care quality are significant benefits. Additionally, showcasing cost savings from reduced turnover and increased productivity can strengthen the case. Reports from APs regarding improved quality of life, work-life balance, and more timely completion of daily patient tasks can supplement the measurement of the success of implementation. Considering a pre- and postimplementation survey for APs may be beneficial for some AP groups to highlight the value of implementation.
IDENTIFY POTENTIAL BARRIERS
While administrative tasks are essential for ensuring high-quality patient care and professional growth, APs face numerous barriers that hinder their ability to allocate adequate time to these activities. Addressing these barriers through collaborative efforts can create environments that enable APs to thrive in their practice and contribute to improved health-care outcomes.
Addressing barriers requires a multifaceted approach involving health-care organizations, policymakers, administrative team members, APs, as well as stakeholders who work with APs, such as medical assistants, nurses, and schedulers. Examples of barriers include workforce vacancies, understaffing, undefined expectations of administrative time, technological equipment shortages, and lack of support from executive leaders.
ASSESS TECHNOLOGY NEEDS
An AP's productivity is heavily influenced by technology. They need access to essential devices, programs, and electronic environments. Assessing IT needs based on the role of the AP, their responsibilities, and the time required for each task is vital.
Providing appropriate technology, such as computers with adequate memory, fast processors, and compatibility with site-specific programs (e.g., Epic), is crucial (Lowe-MacAuley, n.d.). The work environment, whether remote or onsite, also influences additional IT needs. Ensuring privacy for HIPAA-related needs and providing ergonomic office equipment for remote work are important considerations.
DEVELOP A POLICY AND EVALUATE IT
Developing an administrative time policy for APs involves establishing guidelines and expectations while fostering a culture that values AP contributions beyond direct patient care. This policy is a roadmap for balancing direct patient care with critical non–patient-related activities, professional development, and institutional obligations.
Successful implementation relies on effective communication and collaboration among health-care providers and administrators. Having buyin from key stakeholders across the organization is crucial. Communication plans should inform stakeholders about the new policy and its implications. Conducting training sessions to educate staff on the rationale behind the policy and its expected outcomes will help ensure success. Pilot programs allow for real-time feedback and adjustments before full-scale implementation, ensuring a seamless transition and minimizing disruptions to patient care.
Evaluating the policy's impact is imperative for ongoing refinement and optimization. Feedback from health-care providers and team members provides valuable insights into the policy's effects on work-life balance, job satisfaction, and retention. Defined metrics can be tracked over time, providing insights into the policy's impact on health-care delivery. By continuously monitoring and evaluating the policy's outcomes, institutions can adapt and refine their approach to maximize benefits for patients, health-care providers, and the entire health-care institution.
SHARE AN EXECUTIVE SUMMARY
An executive summary provides a concise overview of the rationale, implementation, and expected outcomes of the administrative time policy. This summary should highlight the importance of supporting APs, the benefits of dedicated administrative time, and the strategic plan for achieving these goals. Clear, compelling, and data-driven, the executive summary serves as a key communication tool for stakeholders and decision-makers.
CONCLUSIONS
The implementation of dedicated administrative time for APs is not merely a logistical adjustment but also a strategic imperative for enhancing health-care delivery. Advanced practitioners play a critical role within the interdisciplinary team in providing high-quality, cost-effective patient care. However, the increasing turnover rate and burnout among APs highlight an urgent need for systemic changes to support their professional success and well-being.
By developing a comprehensive task force, establishing a strategic plan, identifying key stakeholders, and implementing pilot programs with measures of success, health-care organizations can effectively advocate for and integrate administrative time for APs. Addressing potential barriers, assessing IT needs, and continuously evaluating the policy's impact will ensure that this initiative not only improves job satisfaction and retention among APs but also enhances overall organizational performance and patient outcomes.
Following an extensive review of the literature and data collected from surveys, this committee recommends 8 hours of administrative time per week as reasonable for a full-time AP in clinical outpatient practice. This should be a standard practice adopted across outpatient oncology clinics.
As health care continues to evolve, it is imperative to recognize and support the diverse contributions of APs. Providing them with the necessary administrative time is a fundamental step toward fostering a more sustainable and effective health-care system. By prioritizing the well-being of APs, we ultimately invest in the future of health care, ensuring that patients receive the best care possible from a dedicated and fulfilled workforce.
The call to action is clear: health-care organizations must take proactive steps to implement and support administrative time for APs. Through collaboration, strategic planning, and continuous improvement, we can create an environment where APs thrive, leading to better outcomes for patients.
Footnotes
The authors have no conflicts of interest to disclose.
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