The Association between Health Professional Shortage Area (HPSA) Status, Work Environment, and Nurse Practitioner Burnout and Job Dissatisfaction

Abstract

Clinicians in health professional shortage areas (HPSAs) often work in practices with fewer resources and higher workloads, challenging recruitment and retention efforts. Nurse practitioners (NPs) frequently care for underserved patients in HPSAs. As a result, HPSA NPs may be susceptible to poor workforce outcomes, including burnout and job dissatisfaction. Using multiple logistic regression, our study assessed the relationship between the work environment and the odds of burnout and job dissatisfaction, and whether HPSA status moderated the relationship between a good work environment and lower odds of these negative outcomes. Consistent with prior research, we found that better work environments significantly decreased the odds of burnout and job dissatisfaction. Working in an HPSA was not associated with NP burnout or job dissatisfaction, nor did HPSA moderate the relationship between the work environment and NP job outcomes. Thus, improving work environments holds promise for reducing negative NP workforce outcomes regardless of HPSA designation.

A shortage of primary care providers has significant implications for patients, communities, and the United States (U.S.). Currently eighty-three million Americans live in areas without adequate numbers of health care providers,¹ which is a matter for concern as insufficient primary care provider supply is associated with negative outcomes, including higher rates of hospitalization, lower patient-rated health quality, and even higher mortality.^2-6 Access to primary care is key to the prevention and management of chronic and acute health conditions, and thus improved population-level health.⁷ Despite the well-demonstrated importance of primary care in improving the health of populations and decreasing health inequities, the availability of primary care is disparate across the U.S. Over seven thousand health professional shortage areas (HPSAs) exist, constituting regions, populations, or facilities where the number of primary care providers is low relative to need.¹ The Health Resources and Services Administration (HRSA) estimates that over 15,000 primary care providers are needed to eliminate HPSAs.¹

Health professional shortage areas face unique challenges in attracting and retaining health care providers. In these areas, providers are challenged by extended hours, low pay, and frequent on-call shifts without coverage.⁸ Health professional shortage area providers may also lack the essential staff, supplies, or the appropriate network of specialists to manage higher patient volumes,⁹ and they work within an extreme provider to patient ratio of 1:3,500.¹⁰ In contrast, as of 2021, the average provider to patient ratio in the U.S. is 1:1,320.¹¹ In addition to insufficient salaries, poor working conditions are among the top reasons given by providers for leaving HPSA areas.¹² These factors may contribute to negative job outcomes such as burnout and job dissatisfaction among providers.

Burnout is a work-related phenomenon characterized by a state of emotional exhaustion^13,14 affecting up to 60% of primary care providers in the U.S.¹⁵ The World Health Organization (WHO) defines burnout as an occupational phenomenon,¹⁴ and consensus exists that a poor work environment is the primary contributor of developing burnout across occupations.¹³ Provider burnout and job dissatisfaction are directly related to patient outcomes and health care cost^16,17 and remain significant contributors to workforce turnover.¹⁸ Addressing negative job outcomes remains an important intervention point for workforce recruitment and retention in underserved areas, which by definition includes all HPSAs.

Lack of resources coupled with higher workloads may contribute to poor working conditions for providers working within HPSA practices, leading to higher levels of burnout and job dissatisfaction.^19,20 Previous research has demonstrated that federally qualified health centers (FQHCs), which automatically qualify for facility HPSA designation,¹ have higher levels of burnout among physicians, NPs, physicians assistants, and staff.²¹ Another study of 296 clinics enrolled in the Centers for Medicare and Medicaid (CMS) FQHC Advanced Primary Care Practice Demonstration found 6% higher odds of burnout (adjusted OR=1.6, p<.001) and 5% higher odds of intent to leave (adjusted OR=1.5, p<.001) among clinicians (i.e., physicians, NPs, physician assistants) and staff (i.e., nurses, medical assistants, technicians).²² While these findings present alarming trends, they were limited to FQHCs and lacked a direct comparison to non-FQHCs.

The growing workforce of NPs on average is more likely to practice in underserved areas²³ and can play a critical role in increasing access to care for patients residing in HPSAs. Nurse practitioners are educated and trained to deliver care to patients as independent providers, and numerous studies have demonstrated that NPs produce comparable outcomes to physicians.^24-26 Their skills include patient assessment, ordering and interpreting diagnostic tests, and designing and managing treatment plans, as well as prescribing medications.²⁷ Nurse practitioner expertise is ideally aligned with primary care as NPs specialize in health education and counseling, health promotion, and disease prevention and management.²⁸ Almost 90% of NPs are prepared to work within primary care settings.²⁹ The number of graduating NPs has grown at a rapid rate and the NP workforce is expected to further expand by over 50% by 2029.³⁰

Previous research has shown that negative features of the work environment are greater predictors of burnout above personal characteristics regardless of the practice setting or occupation.^31,32 These findings have recently been extended to the NP workforce in primary care. For example, a poor work environment characterized by lack of role visibility, unfavorable relationships with administration, and insufficient support for independent practice are associated with NP burnout even after accounting for individual NP demographics.³³ The work features that lead to burnout have also been linked to lower levels of job satisfaction. One study found that a one-unit improvement in the work environment was associated with more than two times higher job satisfaction among NPs.³⁴ Thus, targeting the work environment is key to reducing burnout and job dissatisfaction among NPs.

However, the relationship between the work environment and burnout in HPSA practices has not been well studied. We expect that the work environment will be important in all practices, but it may be that the work environment is vital to minimizing negative workforce outcomes and improving retention efforts in HPSAs for several reasons. First, the status of an organization’s work environment is the primary predictor of workforce outcomes such as burnout and job dissatisfaction.¹³ Additionally, previous research has shown that negative work environment features are cited among the top reasons clinicians leave HPSA areas,¹² indicating that targeted improvements in the work environment could alleviate provider burden and strain.

While features of HPSAs such as the location and availability of resources are not easily modifiable, improving features of the work environment can be achieved in any setting by the leadership and administration. Specifically, work environment features such as working relationships among colleagues, increasing NP autonomy, and improving the understanding of the NP role may be targeted in HPSA areas if shown to be especially effective in reducing burnout and job dissatisfaction. For example, it may be that a positive work environment is critical to reducing burnout and job dissatisfaction among NPs within HPSA areas. Alternatively, it may be that the effects of a good work environment are diminished by some of the unavoidable challenges of working within HPSAs like extreme provider shortages and working within a poorly resourced area.^8-10

Although NPs play a critical role in meeting the increased demand for primary care, little is known about NP work conditions and outcomes within HPSA settings. The 2019 National Academy of Medicine (NAM) report called for more research to expand our understanding of burnout among NPs, particularly studies considering the broader context of the work environment;³⁵ our study is uniquely designed to consider both. To address this call for research, our study investigates whether primary care HPSA status moderates the relationship between the work environment and the development of NP burnout and job dissatisfaction.

Methods

Design and data.

We completed a secondary analysis of two merged, cross-sectional datasets. A survey collected from NPs provided information on burnout, job dissatisfaction, NP demographics, and characteristics of primary care practices. Surveys were sent out to 4,831 NPs in primary care settings across six states (California [CA], Texas [TX], Pennsylvania [PA], New Jersey [NJ], Arizona [AZ], Washington [WA]) using a modified Dillman method for mixed-mode surveys³⁶ between November 2018 and October 2019. These states were chosen because at the time of survey implementation they represented the three varying levels of NP scope of practice (i.e., full [AZ, WA], reduced [NJ, PA], restricted [CA, TX]). In total, three surveys and two postcard reminders were sent to NPs. Three phone call reminders were also made to non-respondents. Greater details of the survey methodology have been previously published.³⁷ The final sample included 1,244 NPs with a 21.9% response rate.

We determined HPSA status for NP practices based on information from the Primary Care Service Areas (PCSA) 2019 file, which includes information on primary care resources and utilization within communities. The PCSA file is maintained by the Dartmouth Institute through contract with the National Center for Health Workforce Analysis at HRSA. Through HRSA the data are updated regularly and made available for research.

The NP survey data and the PCSA file were merged using ZIP code information. The NP survey included either four-digit or five-digit ZIP codes of NP practices and the PCSA file had geography codes (i.e., county, minor civil division, census tract, or facility nine-digit ZIP code). Using a crosswalk developed by the U.S. Department of Housing and Urban Development, we linked differing ZIP code levels.³⁸ If HPSA status was identified at the facility level, ZIP codes from the NP survey were linked with a nine-digit ZIP code from the PCSA file providing an exact match. To deal with differences between a five-digit ZIP code within geography codes (i.e., county, minor civil division, census tract), we used an approximate link to address overlap between census tracts (i.e., 25% of residents are associated with census tract A and 23% of residents are associated with census tract B). To determine a final HPSA ratio, we summed the fractions of residents associated with each five-digit ZIP code from the NP survey and from the geography ZIP code from the PCSA file.

Sample.

The analytic sample included 1,135 NPs across 1,006 primary care practices within five of the six surveyed states (CA, TX, PA, AZ, WA). We excluded NPs from NJ as there was no variation in HPSA designation within the state.

Measures.

Burnout.

Nurse practitioner burnout was derived from a single item in the NP survey, which asked respondents the following question: “Overall, based on your definition of burnout, how would you rate your level of burnout?” This question generates five possible items on an ordinal scale ranging from Level 1: “I enjoy my work. I have no symptoms of burnout” to Level 5: “I feel completely burned out and often wonder if I can go on” This item has been validated for use in comparison with the emotional subscale of the Maslach Burnout Inventory.^39,40 We dichotomized burnout so that a score from 3–5 indicated burned out and a score from 1–2 indicated not burned out, which is consistent with prior research.^{19,21,33,41-43} In addition to being used in multiple studies, this measure of burnout has also been used specifically to study burnout among NPs in primary care.^33,42

Job dissatisfaction.

Data on NP job dissatisfaction was also obtained from the NP survey based on a single question to which NPs could indicate their satisfaction with their job on a four-point ordinal scale (i.e., very satisfied to very dissatisfied). Previous research has demonstrated that global measures of job satisfaction are comparable to measures with several items.⁴⁴ Additionally, this measure has been used extensively in studies of nurses and NPs.^34,45,46 As in our approach with burnout, job dissatisfaction was dichotomized so that very satisfied and satisfied were combined and very dissatisfied and dissatisfied were combined, which too is consistent with prior research.⁴⁶

Health professional shortage area (HPSA).

We determined HPSA status from the PCSA file based on possible score ranging from 0–25. The HPSA score was based on the population to provider ratio (10-point maximum), the percentage of the population below 100% of the federal poverty level (five-point max maximum), travel time to the nearest source of care outside of the HPSA designation (five-point maximum), and the infant health index (five-point maximum). We classified HPSA practices as those with a score greater than zero; otherwise it was classified as non-HPSA. A score closer to zero is indicative of a lower priority designation, while a score closer to 25 is indicative of the highest priority designation.⁴⁷

Work environment.

The work environment was derived from the NP survey, which uses the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ).⁴⁸ The NP-PCOCQ includes 29 items and four subscales: NP-Physician Relations, Professional Visibility, NP-Administration Relations, and Independent Practice and Support. The NP-PCOCQ asks NPs to report on the degree to which certain work features are present in their work within their primary care practice on a 1–4 Likert scale. Examples of items include “In my organization, NP role is well understood,” “In my organization, I have colleagues who I can ask for help” “Physicians and NPs have similar support for care management (e.g., help with patient follow-up, referrals, labs, etc.).” Consistent with prior research, we aggregated individual NP responses to the practice-level for those NPs who responded to at least 70% of the items.^49,50 We averaged individual NP responses to the practice level by subscale and then averaged the four practice-level subscales to create one continuous measure of the work environment. The NP-PCOCQ has strong psychometric properties with Cronbach’s alphas ranging between 0.87 and 0.96,^48,51,52 has demonstrated construct, predictive, and discriminant validity,^53,54 and has been used extensively in prior research.^33,34,46,50

Covariates.

We controlled for NP and primary care practice characteristics to further isolate the relationships between the work environment, HPSA, and NP burnout and NP job dissatisfaction, respectively. For NP characteristics we included age, sex, race, ethnicity, marital status, education level, years of experience, hours per week, and whether NPs managed their own patient panel. We also controlled for NP state scope of practice regulations and practice structural capabilities from the Structural Capabilities Index (SCI). The SCI is based on 27 items grouped into eight domains: shared systems for communication, care coordination, community service referrals, presence and use of electronic health record, automatic care reminders for clinicians, chronic disease registries, after-hours care, and performance feedback to clinicians. The SCI has been used in several studies and measures practice attributes linked with higher quality of care.^55-60 We aggregated individual NP responses if they responded to at least 70% of the SCI items.^46,49 We then aggregated individual NP responses by subscale to the practice level, and then further averaged the subscales to build a continuous practice-level SCI summary measure.⁶¹

Data analysis.

To demonstrate the variation in NP and practice attributes across HPSA designation, chi-squared tests were used for categorical variables and t-tests were used for continuous variables. Frequencies and percentages were used to describe the overall sample of primary care practices. To assess the relationship between factors (work environment and HPSA) and outcomes (burnout and job dissatisfaction), we used multiple logistic regression with controls for potential covariates. Odds ratios were estimated to determine the strength and the direction of the relationship. We made additional adjustments for the clustering of NPs within primary care practices using Huber-White sandwich estimators.^62,63 In Model 1, we tested the bivariate, or unadjusted relationship between the work environment and NP burnout and job dissatisfaction, respectively. In Model 2, NP characteristics were added in, and in Model 3, practice characteristics were added in. In Model 4, the moderator, HPSA status, was added in as a main effect variable. In Model 5, an interaction term was tested (HPSA x work environment) with HPSA and the work environment being tested as main effect variables as well. We assessed the risk for multicollinearity using variance inflation factors (VIF). In brief, a variance inflation factor (VIF) of greater than 2.5 would suggest that the variance of the regression coefficient is overestimated due to collinearity.⁶⁴ None of the variables in our models exceeded the 2.5 threshold with the average VIF being 1.23, providing evidence that the risk for multicollinearity in our analysis was low. Significance levels were set at <.05 and all statistical analysis were completed in STATA Version 15.1 (StataCorp LLC, College Station, TX, USA).

Results

Descriptive characteristics of NPs by HPSAs and non-HPSAs.

Table 1 shows the descriptive characteristics of the 1,135 NPs in our sample of which 467 NPs worked in HPSAs. On average, NPs were 49 years of age. Over three-quarters of our sample self-identified as White and 86% as female. Over 80% of NPs had at least a master’s degree, two-thirds had at least four years of experience, almost 70% worked full time (>40 hours/week), and less than half managed their patient panel independently. There were no significant differences across individual NP characteristics between HPSAs and non-HPSAs apart from race (p=.007), ethnicity (p=.009), and education level (p=.018). No differences in burnout (p=.781) or job dissatisfaction (p=.415) were observed between HPSA and non-HPSA practices using the chi-squared analysis. In total, 26% of our sample were burned out, and almost 10% were dissatisfied with their work.

Table 1.

CHARACTERISTICS OF NURSE PRACTITIONERS BY HPSA STATUS^a (N= 1,135 NPS)

	All NPs (n= 1,135)	Non-HPSA NPs (n=668)	HPSA NPs (n=467)	p-value
Age (years), m (SD)				.060
Age	48.6 (12.0)	48.1 (11.8)	49.4 (12.1)
Sex, n (%)				.468
Female	976 (86.0)	576 (86.2)	400 (85.7)
Male	151 (13.3)	89 (13.3)	62 (13.3)
Race, n (%)				.007
White	894 (78.8)	519 (77.7)	375 (80.3)
Black	41 (3.6)	22 (3.3)	19 (4.1)
Asian	111 (9.8)	82 (12.3)	29 (6.2)
Other	74 (6.5)	36 (5.4)	38 (8.1)
Ethnicity, n (%)				.009
Non-Hispanic	1,007 (88.7)	607 (90.9)	400 (85.7)
Hispanic	105 (9.3)	47 (7.0)	58 (12.4)
Marital status, n (%)				.882
Married	840 (74.0)	498 (74.6)	342 (73.2)
Not Married	283 (24.9)	163 (24.4)	120 (25.7)
Education, n (%)				.018
ADN, ASN, BSN	49 (4.32)	19 (2.8)	30 (6.4)
Masters	942 (83.0)	569 (85.2)	373 (79.9)
DNP/PhD	133 (11.7)	73 (10.9)	60 (12.9)
Years of experience, n (%)				.405
≤3 years	253 (22.3)	140 (21.0)	113 (24.2)
4–9 years	376 (33.1)	230 (34.4)	146 (31.3)
≥10 years	497 (43.8)	294 (44.0)	203 (43.5)
Hours per week, n (%)				.185
Less than 20 hours	48 (4.2)	29 (4.3)	19 (4.1)
20–40 hours	324 (28.6)	204 (30.5)	120 (25.7)
40+ hours	763 (67.2)	435 (65.1)	328 (70.2)
Panel management, n (%)				.088
Co-managed panel	634 (55.9)	391 (58.5)	243 (52.0)
Managed own patient panel	498 (43.9)	275 (41.2)	223 (47.8)
Burnout status, n (%)				.781
Not burnout out	821 (72.3)	478 (71.6)	343 (73.5)
Burned out	294 (25.9)	178 (26.7)	116 (24.8)
Job satisfaction status, n (%)				.415
Satisfied	1,013 (89.3)	590 (88.3)	423 (90.6)
Dissatisfied	108 (9.5)	70 (10.5)	38 (8.1)

Notes:

^ap-values generated from chi-squared tests for categorical and t tests for continuous variables. The minimum number of NPs reporting on personal characteristics was at least 1,112 in all cases.

m = mean; SD = standard deviation; n = number; NP = nurse practitioner; HPSA = health professional shortage area

Descriptive characteristics of primary care clinics by HPSAs and non-HPSAs.

Table 2 shows the descriptive characteristics of the 1,006 primary care practices that employed NPs. Of these practices, 406 were in HPSAs. Almost 60% of HPSA practices were located within reduced or restricted scope of practice states (p<.001). The overall score of the work environment was significantly higher among HPSA practices compared with non-HPSA practices (3.3 vs. 3.2; p=.023).

Table 2.

CHARACTERISTICS OF PRIMARY CARE PRACTICES BY HPSA STATUS^a (N=1,006 PRIMARY CARE PRACTICES)

	All Practices (n= 1,006)	Non-HPSA Practices (n=600)	HPSA Practices (n=406)	p-value
State Scope of Practice, n (%)				<.001
Full	269 (26.7)	103 (17.1)	166 (40.9)
Reduced/Restricted	737 (73.3)	497 (82.8)	240 (59.1)
Overall Work Environment Scale, m (SD)				.023
Aggregated subscales	3.2 (0.5)	3.2 (0.5)	3.3 (0.5)
Overall Structural Capability Index, m (SD)				.542
Aggregated subscales	0.6 (0.2)	0.6 (0.2)	0.6 (0.2)

Notes:

^ap-values generated from chi-squared tests for categorical and t tests for continuous variables. The minimum number of clinics with information primary care practice characteristics was at least 950 in all cases.

m = mean; SD = standard deviation; n = number; NP = nurse practitioner; HPSA = health professional shortage area

The association between the work environment, HPSA, and NP burnout.

Before building the multivariable models, we assessed for multi-collinearity among all the potential independent variables. Variance inflation factors were calculated and found to be less than five. Thus, there is little concern of multi-collinearity. Table 3 presents the results demonstrating the moderating effect of HPSA on the association between the work environment and NP burnout. In Model 1, we assess the unadjusted association between the work environment and burnout; A one-unit increase in the work environment is associated with an 81% drop in the odds of NP burnout (OR=0.19, p<.001). This relationship remains consistent after adjusting for NP and practice characteristics. In Model 4, we tested HPSA as a main effect variable and did not find that HPSA was significantly associated with NP burnout (OR=0.89, p=.505). We further tested our moderation hypothesis in Model 5 showing both an interaction between HPSA and the work environment in addition to HPSA and the work environment as main effect variables. As Model 5 produced insignificant interaction effects, Model 4 remains the final model for interpretation indicating that the work environment remains the primary predictor of NP burnout.

Table 3.

EFFECT OF THE WORK ENVIRONMENT AND HPSA ON NP BURNOUT AND JOB DISSATISFACTION^a

	Model 1: Unadjusted		Model 2: NP Characteristics		Model 3: Practice Characteristics		Model 4: HPSA		Model 5: HPSA x Work Environment
	OR (95% CI)	p	OR (95% CI)	p	OR (95% CI)	p	OR (95% CI)	p	OR (95% CI)	p
NP Burnout
Work Environment	0.19 (0.14, 0.26)	<.001	0.19 (0.14, 0.27)	<.001	0.21 (0.15, 0.29)	<.001	0.21 (0.15, 0.30)	<.001	0.19 (0.12, 0.31)	<.001
HPSA	—		—		—		0.89 (0.63, 1.26)	.505	0.51 (0.06, 4.25)	.538
HPSA x Work Environment	—		—		—		—		1.19 (0.60, 2.36)	.609
NP Job Dissatisfaction
Work Environment	0.09 (0.05, 0.15)	<.001	0.08 (0.04, 0.15)	<.001	0.09 (0.05, 0.18)	<.001	0.09 (0.05, 0.18)	<.001	0.08 (0.04, 0.19)	<.001
HPSA	—		—		—		0.77 (0.45, 1.32)	.337	0.40 (0.01, 14.14)	.611
HPSA x Work Environment	—		—		—		—		1.27 (0.36, 4.41)	.711

Notes:

^aOdds ratios and p values generated from multivariate logistic regression. Model 1: Unadjusted relationship between work environment and NP burnout or NP job dissatisfaction. Model 2: NP Characteristics (i.e., age, sex, race, ethnicity, marital status, education, years of experience, hours/week, managed own panel). Model 3: Practice characteristics (i.e., state scope of practice, practice structural capability index score). Model 4: HPSA. Model 5: HPSA x Work Environment.

NP = nurse practitioner; SOP= Scope of Practice; SCI= Structural Capability Index; HPSA=Health Professional Shortage Area; OR = Odds Ratio; CI = Confidence Interval; p = p value

The association between the work environment, HPSA, and NP job dissatisfaction.

Table 3 also tests the moderating effect of HPSA on the association between the work environment and NP job dissatisfaction. After adjusting for NP and practice characteristics, a one-unit increase in the work environment was associated with a 91% decrease in the odds of NPs being dissatisfied with their work (OR=0.09, p<.001). Health professional shortage area status was not found to have a significant association with NP job dissatisfaction (OR=0.77, p=.337). We also tested a fifth model, which included an interaction term (HPSA x work environment) and HPSA and the work environment as main effect variables. No significant interactions were observed; therefore, Model 4 remains the final model for interpretation, indicating that the status of the work environment is the primary predictor of job dissatisfaction among NPs.

Discussion

Using a large sample of primary care practices and NPs we evaluated the effects of the work environment and HPSA status on NP burnout and job dissatisfaction. We also assessed if HPSA moderated the relationship between the work environment and NP burnout and job dissatisfaction. Consistent with previous research, we observed that practices with better work environments had significantly lower odds of these negative outcomes among NPs. Previous literature suggested that HPSA status might attenuate the relationship between good work environments and lower odds of NP burnout and job dissatisfaction as HPSAs are known for challenging patient to provider ratios and being poorly resourced.^8-10 We did not find this to be true. Instead, we found that HPSA did not have a direct effect on NP burnout or job dissatisfaction. The lack of an association between HPSA and these job outcomes may, in part, be related to what we observed descriptively in Table 2. Nurse practitioners in HPSA settings reported slightly higher scores for their work environments than NPs in non-HPSA practices, which suggests that HPSAs may have work environments comparable to non-HPSA practices.

In HPSAs, where primary care physician shortages are problematic, our findings suggest that regardless of HPSA designation, improving the work environment remains an important avenue to improve NP job outcomes as it does at any other practice location. Features of the work environment are modifiable and subject to organizational interventions. Efforts to improve the NP work environment translate into ensuring adequate resources are available to NPs for the delivery of patient care. For example, in many primary care practices, NPs and physicians have similar roles and responsibilities in treating patients, yet in some cases, ancillary staff are not available to support NPs in their work.⁵¹

In addition to resource support, organizations should also facilitate a greater understanding of NP’s professional role and expertise within the primary care setting. The NP role and contributions to patient care are often poorly understood within health care organizations and particularly by administrative leaders,³³ leaving some practices to not use NPs to the full extent of their education, clinical expertise, and scope of practice. Nurse practitioners should also be treated as valued members of health care teams. To achieve this, work environments must be redesigned so that NP concerns are acknowledged and acted upon, information needed for patient care is communicated, and NPs have the professional visibility and opportunities for advancement commensurate with physician colleagues. Making these targeted changes to the work environment remains a solution to improve NP job outcomes regardless of HPSA designation.

Turnover critically challenges the ability of primary care systems to meet the demands for care, particularly in HPSAs. Thus, understanding burnout and job dissatisfaction in the NP workforce is essential as these negative outcomes are key predictors of turnover.⁶⁵ We found that HPSA did not affect burnout or job dissatisfaction or the relationship between a good work environment and lower levels of burnout and job dissatisfaction among NPs. This contrasts with prior research which found that health care providers working in FQHCs or other HPSA facilities have higher levels of burnout.^21,22 Variability in burnout and job dissatisfaction across different types of HPSA designations (i.e., geographic HPSA, population HPSA, and facility HPSA) indicate that there are likely features of facility HPSA designations, as in the case of FQHCs, which lead to higher levels of negative job outcomes. Our definition of HPSA was operationalized so that we accounted for both geographic and population features (i.e., shortage of physicians, health index, population wealth) and facilities that automatically qualify HPSA designation, such as FQHCs, were included in our analysis. Future work should further explore the differences in job outcomes among NPs working within facility HPSA designations, which include FQHCs and FQHC look-alikes, Indian health facilities, Indian Health Service and Tribal hospitals, and certified rural health clinics.⁶⁶ Our findings and those of previous research indicate that there may be features of automatic facility HPSA designations, particularly FQHCs, which lend themselves to higher levels of burnout and job dissatisfaction.²¹ Future work should also consider differences in job outcomes among NPs specifically working with other marginalized groups such as people experiencing homelessness, people with low incomes, and migrant and/or seasonal farmworkers.⁶⁶

Depending on state scope of practice regulations, NPs work autonomously and in collaboration with different members of the health care team. State-level scope of practice regulations remain a significant barrier to NPs delivering care in states with reduced and restricted scope of practice regulations. We show that 60% of HPSA practices are located within reduced or restricted scope of practice states and we controlled for scope of practice in our analysis. These restrictive scope of practice regulations are particularly problematic when they overlap with HPSAs as the supply of NPs is limited by the supply of physicians that are available to provide supervisory or collaborative agreements. Previous work has demonstrated that HPSAs in full scope of practice states are associated with greater NP supply.^67,68 Within the next 10 years, it is estimated that 34 states will have a physician shortage below the national mean.⁶⁹ While research has demonstrated that NPs provide comparable care and quality to physicians,^24-26 these scope of practice restrictions persist despite recommendations from the National Academy of Medicine and the Federal Trade Commission to remove them.^70,71 To meet the needs of patients within HPSAs and ensure equitable access to primary care health services these outdated scope of practice barriers should be lifted.

Limitations.

Our study has some limitations including the use of cross-sectional survey data, which limits our ability to draw causal inferences regarding the moderating effect of HPSA on the relationship between the work environment and NP burnout and job dissatisfaction. Additionally, the definition of HPSA is based on physician supply, not on NP supply; this may overestimate a shortage in certain areas when there is not one after NPs and physician assistants are accounted for. These workforce shortage definitions were formed in the mid-1960s⁷² (for reference, the first NP program was created in 1965),⁷³ indicating that the HPSA definitions should be further expanded to include NPs and physician assistants, given their growing roles and critical contributions to primary care.

Our sample was also limited in terms of racial and ethnic diversity as most of our NP sample was White and non-Hispanic. Our sample reflects the lack of diversity in the NP workforce nationally.^74,75 It is well-documented that clinicians from underrepresented backgrounds face exclusion, social isolation, and discrimination from both patients and colleagues—these factors may affect their experience of burnout or job dissatisfaction.⁷⁶ It may also be that racially and ethnically diverse NPs may experience a greater impact from work environment changes and HPSA location on job outcomes. However, our sample did not provide enough minority NPs to test this differential impact.

Conclusions.

Certain geographic regions in the U.S. experience challenges in attracting and retaining health care providers.¹ Health professional shortage areas have been described as having poor work environments, in part, because of the high clinician workloads in these settings. Our analysis showed that HPSA designation does not diminish the positive effects of a good work environment on NPs. Regardless of setting, improving the work environment remains the primary approach to alleviating burnout and job dissatisfaction among NPs. While it is true that HPSA settings have challenges in attracting and retaining health care providers, NPs remain a promising workforce to meet population needs in HPSA settings if their scopes of practice are expanded by favorable state policies to reflect the full extent of NPs’ training and licensure, as well as substantive evidence demonstrating safe patient outcomes related to NP care.