Practice Environment and Workforce Outcomes of Nurse Practitioners in Community Health Centers

Abstract

The nurse practitioner (NP) workforce in community health centers (CHCs) increases access to primary care for underserved populations. Working with medically complex patients, high workloads, and low-resources in the CHC setting, CHC NPs may be susceptible to poor workforce outcomes. This study uses NP survey data collected from six U.S. states to describe and assess the relationship between CHC NP practice environment and burnout, job satisfaction, and turnover intention. CHC NPs rated their practice environments favorably and over 89% of CHC NPs reported satisfaction with their job. Better rating of NPs’ relationship with CHC administration was associated with improved job satisfaction and decreased turnover intention.

Community health centers (CHCs) are safety-net institutions that provide comprehensive primary care to populations that are frequently medically underserved, including racial and ethnic minorities, the publicly insured, and low-income individuals (National Association of Community Health Centers, 2021). Since 2000, CHC patient numbers have tripled, reaching almost 29 million in 2020 (Health Resources & Services Administration, 2021). With this growth, many CHCs struggle with adequate provider staffing; almost 70% of CHCs nationwide report at least one family physician vacancy (National Association of Community Health Centers, 2016). With a deficit of 21,400–55,200 primary care physicians estimated by 2033 (Dall et al., 2020), CHCs’ growing provider needs also face a broader national primary care physician shortage.

To ensure patients receive the care they need and meet the nation’s primary care demands, experts have recommended optimal utilization of the nurse practitioner (NP) workforce (National Academy of Medicine, 2021). NPs are advanced-practice registered nurses with additional masters or doctoral training to diagnose and manage patients’ health conditions (American Association of Nurse Practitioners, n.d.). The NP workforce has more than doubled since 2010, and is projected to increase by 6.8% from 2016 to 2030 (Auerbach et al., 2018, 2020). CHCs have relied heavily on the NP workforce, utilizing more NPs than private practices to expand access to care (Hing et al., 2011; Morgan et al., 2015).

Despite growing NP numbers in CHCs (National Association of Community Health Centers, 2021), it is clear that CHCs are competing with other employers for NPs. Fifty percent of CHCs nationwide report a NP vacancy (National Association of Community Health Centers, 2016). Higher number of NP graduates reported choosing to work in private practices compared to health centers (Faraz & Salsberg, 2019). Furthermore, safety-net providers, including those in CHCs, often report challenges with insufficient resources, time, high staff turnover, and high workload (Hayashi et al., 2009; Quinn et al., 2013). Providers in CHCs have higher odds of reporting burnout compared to providers in office-based practices (Edwards et al., 2018). CHC patients are medically and socially complex, facing issues such as poverty and lack of social support (Corallo et al., 2020; Jester et al., 2014), which could also increase the workload of providers relative to other settings (Hayashi et al., 2009). These challenging working conditions may predispose NPs to negative workforce outcomes including burnout, job dissatisfaction, and turnover.

When clinicians are burned-out, dissatisfied, or desire to leave their current job, they may provide lower quality of care (Huang et al., 2021; National Academy of Medicine, 2019; White et al., 2019). Burnout and turnover intention also lead to actual turnover (Willard-Grace et al., 2019; Griffeth et al., 2000), diminishing practices’ staffing levels, reducing access to care, and increasing administrative costs due to recruitment and onboarding of new clinicians. Understanding the factors that contribute to favorable workforce outcomes may help CHCs to better recruit and retain NPs—and for NPs already working in CHCs, improving their workforce outcomes may improve quality of patient care.

One salient predictor of workforce outcomes among NPs is their practice environment (Poghosyan et al., 2017). Practice environment is the organizational characteristics of a workplace that may help or hinder clinicians’ optimal practice (Lake, 2002). NPs’ practice environment includes NPs’ relationship with physicians, relationship with administration, professional visibility, and support for their independent practice (Poghosyan, Nannini, Finkelstein, et al., 2013). Despite NPs’ significant contribution to CHCs, little is known about the CHC NP practice environment and how to ensure favorable working conditions in the CHC setting. In this study, we 1) investigated the NP practice environment and workforce outcomes, including burnout, turnover intention, and job satisfaction in CHCs and 2) assessed the relationship between practice environment and workforce outcomes.

Methods

Data and Sample

This study analyzed cross-sectional survey data produced from a large NIH-funded study entitled: Racial and Ethnic Disparities in Chronic Disease Outcomes and Nurse Practitioner Practice (Poghosyan, 2017–2022). The survey contained questions about NPs’ demographic information, practice environment, and workforce outcomes. Surveys were sent out in 2018–2019 to NPs in six states: Arizona, Washington, New Jersey, Pennsylvania, California, and Texas. These states were selected because they had geographical diversity and varying NP scope of practice regulations. Full scope of practice allows NPs to independently diagnose, treat, and prescribe medications without physician oversight; reduced scope of practice requires that NPs collaborate with physicians to provide patient care; restricted scope of practice requires that NPs have supervision, delegation, or management by physicians to provide patient care (American Association of Nurse Practioners, 2021). Data collection in the parent study followed a modified Dillman method (Dillman et al., 2014). Full information about sampling and data collection has been published elsewhere (Harrison et al., 2021). A total of 1,244 NPs completed the survey and final response rate of 22% was achieved. In the survey, NPs self-reported their practice setting, this study analyzed data only from NPs practicing in CHCs (n = 269 NPs).

Independent Variables

The independent variable was NP practice environment, measured by the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ) (Poghosyan, Nannini, Finkelstein, et al., 2013). The NP-PCOCQ is a psychometrically reliable and valid tool with established construct, discriminant, and predictive validity (Poghosyan, Nannini, Finkelstein, et al., 2013). The NP-PCOCQ contains 29 items grouped into four subscales: 1) Professional Visibility, representing understanding of NPs’ role, competencies, and education (subscale items include, “in my organization, NP role is well understood”); 2) NP-Administration Relations, representing practice administration’s communication with and support of NPs (e.g., “I feel valued by my organization”); 3) NP-Physician Relations, representing respect, collaboration, trust, and support between NPs and physicians (e.g., “I feel valued by my physician colleagues”); and 4) Independent Practice and Support, representing support for NPs’ independent practice (e.g., “I do not have to discuss every patient care detail with a physician”) (Poghosyan, Nannini, Finkelstein, et al., 2013; Poghosyan, Nannini, Stone, et al., 2013). Items were scored using a 4-point Likert scale, from strongly disagree to strongly agree, with higher scores indicating better NP practice environment. We calculated individual-level NP-PCOCQ subscale means for participants that responded to at least 70% of the items (Downey & King, 1998), then calculated the mean organization-level score on each subscale by aggregating the responses of all NPs within the same practice as practice environment is an attribute of the organization (Lake, 2002).

Outcome Variables

The outcome variables were NP-reported burnout, job satisfaction, and turnover intention. Burnout was measured with a single item asking NPs to rate their level of burnout on a Likert scale of 1 (I have no symptoms of burnout) to 5 (I feel completely burned out and often wonder if I can go on). Job satisfaction was measured with a single item asking NPs to rate how satisfied they are with their job, from 1 (very dissatisfied) to 4 (very satisfied). Single-item job satisfaction and burnout measures have demonstrated psychometric reliability (Dolan et al., 2015; Wanous et al., 1997) and have frequently been used in primary care workforce studies (Alidina et al., 2014; Rabatin et al., 2016). Turnover intention was measured by asking NPs to rate their likelihood of leaving current positions within the next year, from 1 (very unlikely) to 4 (very likely). Single-item turnover intention measure has frequently been used in nursing workforce studies (Nantsupawat et al., 2017; Poghosyan et al., 2020).

Covariates

We considered NPs’ demographic, professional, and practice characteristics as covariates. Demographic and professional characteristics included NPs’ age, gender, race, ethnicity, marital status, years licensed as NP, years employed in current practice, hours worked each week, and having own patient panel (i.e., either independently caring for a panel of patients or having both own panel and panel they co-manage with other providers). Practice characteristics included care coordination availability, whether practice has extended hours (open on weekends), numbers of NPs and physicians in practice, urban versus rural location, and NP scope of practice regulations in each state.

Statistical Analysis

All analyses were completed using SAS 9.4 software (SAS Institute Inc, 2016). Descriptive statistics were calculated to describe the NP sample characteristics. Proportional odds cumulative logit regression models were used to analyze the relationship between organizational-level practice environment scores and ordinal NP outcomes. We tested the proportional odds assumption using the Score Test for the three outcomes and each subscale of the NP-PCOCQ (main independent variable). Alpha level for the Score test was set at a conservative p-value of .10; no tests were significant, indicating cumulative odds model can be used (Kelly, 2017).

We assessed for randomness of missing data and found no pattern between missing data and demographic variables. Thus, complete case analysis was used. We tested for multicollinearity using variance inflation factor; all values were less than 5, indicating no significant multicollinearity (James et al., 2021). To account for the nesting structure of our data, where 269 NPs were nested in 222 CHCs, we used generalized estimating equation in our regression models. For model parsimony, bivariate analysis for proposed covariates and outcome variables were completed prior to building multivariable regression models. Covariates that were significant (p-value < 0.20) were included in the final models (Hosmer & Lemeshow, 1989). All models included demographic covariates regardless of the bivariate results.

Separate regression models were built for each outcome variable containing the significant covariates, demographic covariates, and the organization-level subscale scores of NP-PCOCQ as main independent variables. Cumulative odds ratios (ORs) and associated 95% confidence intervals (CIs) were reported to assess the direction and strength of the associations from regression models. We also conducted sensitivity analysis by treating our ordinal outcomes as continuous variables and conducted linear regression.

Results

Sample Characteristics

Overall, we used data from 269 NPs in 222 CHCs. Descriptive statistics of CHC NPs’ demographic and practice characteristics are presented in Table 1. The average age of participants was 46.9 and the majority of participants identified as female, white, non-Hispanic, and married. The average number of years licensed as an NP was 10.3 and majority of the participants worked 20–40 hours per week. Over 70% of the participants reported that their practice has care coordination and half reported that their practices were open on weekends. Approximately 84% of CHC NPs worked in urban areas while 16% worked in rural areas. Almost 80% of the NPs reported having their own patient panels.

Table 1.

Characteristics of Community Health Center Nurse Practitioners

Characteristics n (%)	CHC NP (n=269)
Age in years m (SD)
Age	46.9 (12)
Gender
Female	236 (88.4)
Male	31 (11.6)
Race
White	186 (70.2)
Non-White	79 (29.8)
Ethnicity
Hispanic	33 (12.5)
Non-Hispanic	231 (87.5)
Married
Married	179 (67)
Not Married	88 (33)
Years licensed as NP m (SD)
Years licensed	10.3 (9.1)
Years employed in practice
3 years or less	138 (56.6)
4–9 years	57 (23.4)
10 or more years	49 (20)
Hours worked each week
Less than 20 hours	22 (8.2)
20–40 hours	188 (70.4)
40+ hours	57 (21.4)
State level scope of practice
Full (AZ, WA)	76 (28.3)
Reduced (NJ, PA)	51 (19)
Restricted (CA, TX)	142 (52.8)
Practice open on weekends
Yes	136 (50.8)
No	132 (49.2)
Practice has care coordination
Yes	182 (70.8)
No	75 (29.2)
Have own patient panel
Yes	211 (79.9)
No	53 (20.1)
Numbers of NPs in practice
1–2 NPs	88 (32.7)
3–5 NPs	95 (35.3)
6 or more NPs	86 (32)
Numbers of physicians in practice
0–2 physicians	112 (44.3)
3–7 physicians	86 (34)
8 or more physicians	55 (21.7)
Rural vs urban practice
Rural	44 (16.4)
Urban	225 (83.6)

Note. NP = nurse practitioner; CHC = community health center.

NP Practice Environment and Workforce Outcomes

Descriptive statistics of NP practice environment and workforce outcome measures are presented in Table 2. Over 89% of NPs reported being satisfied (i.e., very or somewhat satisfied) with their jobs. Approximately 30% of NPs reported being burned out (i.e., “I have one or more symptoms of burnout”, “the symptoms of burnout I experience won’t go away”, or “I feel completely burned out”). Approximately 25% of CHC NPs reported being likely or very likely to leave their current position in the coming year. Practice environment was measured by organizational-level score of the NP-PCOCQ subscales, where higher scores indicate better practice environment (range 1–4). The highest-rated subscale was Independent Practice and Support (M = 3.51, SD = 0.42); followed by NP-Physician Relations (M = 3.30, SD = 0.52); Professional Visibility (M = 3.19, SD = 0.61); and the lowest-rated subscale was NP-Administration Relations (M = 2.91, SD = 0.68).

Table 2.

Descriptive Statistics of NP Workforce Outcomes and Practice Environment

Variables	n (%)
Workforce Outcomes
Burnout
I enjoy my work. I have no symptoms of burnout	46 (17.2)
Occasionally under stress, but I don’t feel burned out	140 (52.4)
I have one or more symptoms of burnout	64 (24)
The symptoms of burnout I experience won’t go away	12 (4.5)
I feel completely burned out and wonder if I can go on	5 (1.9)
Job satisfaction
Very satisfied	124 (46.8)
Somewhat satisfied	113 (42.6)
Somewhat dissatisfied	22 (8.3)
Very dissatisfied	6 (2.3)
Turnover intention in the coming year
Very unlikely to leave current position	111 (41.4)
Unlikely to leave current position	91 (34)
Likely to leave current position	42 (15.7)
Very likely to leave current position	24 (9)
NP Practice Environment	m (SD)
Organizational level NP-PCOCQ score
Professional Visibility	3.19 (0.61)
NP-Administration Relations	2.91 (0.68)
NP-Physician Relations	3.30 (0.52)
Independent Practice and Support	3.51 (0.42)

Note. NP = nurse practitioner; CHC = community health center; NP-PCOCQ = Nurse Practitioner Primary Care Organizational Climate Questionnaire; NP-PCOCQ score range 1–4 (higher score is better practice environment).

Relationship between NP Practice Environment and NP Workforce Outcomes

Among the four practice environment subscales, the NP-Administration Relations subscale was associated with NPs’ job satisfaction and turnover intention (see Table 3). In the adjusted turnover intention model, a higher NP-Administration Relations score was associated with decreased odds of turnover intention (cumulative OR = 0.30; 95% CI [0.16, 0.57]; p-value = .0003); with a one-point increase in the NP-Administration Relations subscale, the odds of reporting higher likelihood of turnover intention decreased by 70%. In the adjusted job satisfaction model, a higher NP-Administration Relations score was associated with increased job satisfaction (cumulative OR = 4.45; 95% CI [2.20, 9.02]; p-value < .0001); with a one-point increase in the NP-Administration Relations subscale, the odds of reporting higher job satisfaction level increased to 4.5 times. There were no significant associations between practice environment subscales and burnout. Sensitivity analysis using linear regression demonstrated similar relationships between practice environment and outcomes.

Table 3.

Relationship between NP Practice Environment in Community Health Centers and Workforce Outcomes^a

	Model 1 n = 253 Burnout		Model 2 n = 255 Turnover Intention		Model 3 n = 251 Job Satisfaction
Predictor	Cumulative OR (95% CI)	p-value	Cumulative OR (95% CI)	p-value	Cumulative OR (95% CI)	p-value
Practice Environment
Professional Visibility	0.954 (0.428, 2.128)	.908	1.094 (0.553, 2.165)	.796	0.883 (0.370, 2.106)	.779
NP-Administration Relations	0.592 (0.303, 1.158)	.126	0.301 (0.158, 0.573)	.0003*	4.452 (2.198, 9.017)	<.0001*
NP-Physician Relations	0.799 (0.405, 1.578)	.519	0.699 (0.387, 1.263)	.235	1.715 (0.821, 3.584)	.152
Independent Practice and Support	0.828 (0.315, 2.179)	.702	1.149 (0.496, 2.661)	.746	0.959 (0.338, 2.715)	.937
Age	1.003 (0.982, 1.024)	.812	0.985 (0.964, 1.007)	.185	1.008 (0.977, 1.040)	.613
Race
Non-White	1.127 (0.630, 2.016)	.696	1.563 (0.925, 2.643)	.095	0.785 (0.443, 1.391)	.407
White (Ref)
Ethnicity
Hispanic	0.988 (0.504, 1.935)	.971	1.085 (0.549, 2.144)	.814	0.856 (0.442, 1.655)	.644
Non-Hispanic (Ref)
Gender
Female	1.570 (0.752, 3.279)	.230	0.940 (0.453, 1.948)	.867	0.866 (0.405, 1.851)	.710
Male (Ref)
Marital Status
Married	0.743 (0.446, 1.237)	.253	0.967 (0.594, 1.574)	.893	0.951 (0.558, 1.621)	.852
Not married (Ref)
Hours Worked**
1–20 hours	0.369 (0.170, 0.801)	.012*
21–40 hours (Ref)
> 40 hours	1.816 (0.972, 3.392)	.061
Years licensed as NP**					1.040 (0.998, 1.084)	.062
Availability of care coordination**
Yes	0.709 (0.405, 1.243)	.230			1.327 (0.730, 2.411)	.354
No (Ref)

Note. OR = odds ratio; CI = confidence interval

^*= significant at p < .05

^**= not included in all models based on bivariate analysis results.

^aResults from proportional odds cumulative logit regression models with generalized estimating equation.

Discussion

We investigated the practice environment and workforce outcomes of 269 NPs practicing in CHCs. We found that CHC NPs reported generally favorable practice environment, rating support for their independent practice most favorably and their relationship with administration least favorably. We also found that NPs who practice in CHCs with favorable NP-administration relationships were more likely to be satisfied with their jobs and less likely to report intention to leave. Our study is the first to examine practice environment and workforce outcomes of NPs in CHCs, adding critical insights to optimize the staffing and well-being of this workforce.

Over 89% of CHC NPs in our study are satisfied with their jobs. In previous NP studies, 75% of the general primary care NP sample (i.e., NPs in practice settings beyond CHCs) reported job satisfaction (Poghosyan et al., 2020; Poghosyan & Aiken, 2015). Numerous factors may influence why CHC NPs are highly satisfied with their jobs. First, CHC NPs care for vulnerable populations and play a critical role in improving the health of underserved communities. Although CHC NPs work in challenging conditions, this meaningful work—or work that has positive meaning and contributes to the greater good (Steger et al., 2012)—may bring significant fulfillment and satisfaction in their jobs. Second, a sense of professional autonomy may also influence CHC NPs’ job satisfaction. We found that the score on the Independent Practice and Support subscale was rated as the highest practice environment subscale by NPs, and almost 80% of NPs have their own patient panel; independent patient panels allow NPs to autonomously deliver patient care. Indeed, autonomy has been shown to predict NP job satisfaction (Han et al., 2018).

NPs’ relationship with administration significantly influenced NP job satisfaction and turnover intention. This finding demonstrates that administrators can improve the satisfaction and decrease turnover intention of their NP workforce through promoting collegial NP-administration relationship, which include ensuring NPs feel valued, NPs are informed of changes in the practice, NPs and physicians are treated equally, and NPs’ concerns and contributions are acknowledged (Poghosyan, Nannini, Stone, et al., 2013). Yet, CHC NPs ranked NP-administration relations as the lowest practice environment subscale. Knowing the influence that NP-administration relationships have on NP workforce outcomes—and subsequently, staffing and patient care—this relationship is in need of improvement.

NPs’ favorable rating of their professional visibility, relationship with physicians, and independent practice may be attributed to the nature of how CHCs operate. One example might be the difference in reimbursement for NP services in CHCs compared to other primary care settings. In private primary care practices, NP services are reimbursed by Medicare at 85% of the physician fee (Center for Medicare and Medicaid Services, 2016); CHCs have adopted all-inclusive per-visit payment, where NPs bill at the same rate as other providers (Center for Medicare and Medicaid Services, 2021). Equal payment recognizes NPs’ contribution to patient care and independent practice. CHCs also heavily rely on NPs and team-based care to expand access to care for their patients (Hing et al., 2011; Ku et al., 2015). Due to their well-established roles in CHCs, NPs in this setting may be better recognized for their contribution by their physician colleagues, which may also lead to increased trust and practice independence between NPs and physicians. CHCs should be lauded for creating favorable practice environments for their NPs and should continue these NP-supportive practices. CHCs should also consider advertising this NP-supportive environment when recruiting NPs for their practices.

While our study provides insights about the CHC NP workforce, our findings also highlight areas for future research. First, the relationship between NP workforce outcomes and quality of patient care has not been established in the CHC setting. Researchers may want to further explore whether CHC NPs’ workforce outcomes, among other factors, contribute to better patient care and outcomes. Studies should also further examine what factors in CHCs contribute to NPs’ high job satisfaction and favorable practice environments; findings may help other practices improve their NP workforce outcomes.

Limitations

We recognize several limitations to our study. This study is a secondary analysis of existing data and we were limited to the variables available in the dataset. We did not comprehensively control for other factors that may influence CHC NP workforce outcomes (e.g., salary, panel size). Our study is affected by the limitations of the parent study as well. The parent study surveyed NPs in six states, findings may not be generalizable to the national population. The parent study produced self-reported data; self-report may introduce errors such as recall and social desirability bias. In addition, this data is cross-sectional in nature and determining causation is not possible. Our response rate of 22% is low, however, it is typical of healthcare provider survey responses (Cho et al., 2013) and the demographic characteristics of NP respondents in the data are generally similar to national CHC NP studies (e.g., majority female, White, and non-Hispanic) (Kurtzman & Barnow, 2017). Lastly, practice setting was self-reported by NPs in the parent survey; we do not have information to determine CHC type (e.g., federally qualified health center, look-alike), which may have different practice characteristics and policies.

Conclusion

Despite working in low-resource and high workload healthcare settings, CHC NPs are highly satisfied with their jobs and report generally favorable practice environments. When CHC NPs report good relationships with the administration, they are more likely to report higher job satisfaction and lower intention to leave their jobs. CHC administrators may be able to improve the quality of patient care and staffing within their practices through ensuring good relationship with NPs, such as fostering effective communication and supporting NPs’ ability to deliver high quality care to patients.