Project

ORIGINAL RESEARCH

Task Delegation and Burnout Trade-offs Among Primary Care Providers and Nurses in Veterans Affairs Patient Aligned Care Teams (VA PACTs) Samuel T. Edwards, MD, MPH, Christian D. Helfrich, MPH, PhD, David Grembowski, PhD, Elizabeth Hulen, MA, Walter L. Clinton, PhD, Gordon B. Wood, MS, Linda Kim, PhD, MSN, RN, PHN, Danielle E. Rose, PhD, and Greg Stewart, PhD

Purpose: Appropriate delegation of clinical tasks from primary care providers (PCPs) to other team members may reduce employee burnout in primary care. However, (1) the extent to which delegation occurs within multidisciplinary teams, (2) factors associated with greater delegation, and (3) whether delegation is associated with burnout are all unknown.

Methods: We performed a national cross-sectional survey of Veterans Affairs (VA) PCP-nurse dyads in Department of VA primary care clinics, 4 years into the VA’s patient-centered medical home initiative. PCPs reported the extent to which they relied on other team members to complete 15 common primary care tasks; paired nurses reported how much they were relied on to complete the same tasks. A com- posite score of task delegation/reliance was developed by taking the average of the responses to the 15 questions. We performed multivariable regression to explore predictors of task delegation and burn- out.

Results: Among 777 PCP-nurse dyads, PCPs reported delegating tasks less than nurses reported be- ing relied on (PCP mean � standard deviation composite delegation score, 2.97� 0.64 [range, 1– 4]; nurse composite reliance score, 3.26 � 0.50 [range, 1– 4]). Approximately 48% of PCPs and 35% of nurses reported burnout. PCPs who reported more task delegation reported less burnout (odds ratio [OR], 0.62 per unit of delegation; 95% confidence interval [CI], 0.49 – 0.78), whereas nurses who re- ported being relied on more reported more burnout (OR, 1.83 per unit of reliance; 95% CI, 1.33–2.5).

Conclusions: Task delegation was associated with less burnout for PCPs, whereas task reliance was associated with greater burnout for nurses. Strategies to improve work life in primary care by increas- ing PCP task delegation must consider the impact on nurses. ( J Am Board Fam Med 2018;31:83–93.)

Keywords: Cross-sectional Studies, Patient Care Team, Patient-Centered Care, Personnel Turnover, Primary Health Care, Professional Burnout, Veterans

Primary care involves an array of tasks including gathering patient history, screening, evaluation, in- tervention, health education, care coordination, and communication with patients outside of face-

to-face visits.1– 4 An underlying objective of team- based care models such as the patient-centered medical home (PCMH) is the development of an

This article was externally peer reviewed. Submitted 28 February 2017; revised 2 September 2017;

accepted 10 September 2017. From the Section of General Internal Medicine and the

Center to Improve Veteran Involvement in Care, VA Port- land Health Care System, Portland, OR (STE, EH); the Division of General Internal Medicine and Geriatrics and the Department of Family Medicine (STE), Oregon Health & Science University, Portland; the Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle,

WA (CDH, WLC, GBW); the Department of Health Ser- vices, University of Washington School of Public Health, Seattle (CDH, DG); the VA HSR&D Center for Study of Healthcare Innovation, Implementation & Policy, Greater Los Angeles Health Care System, Los Angeles, CA (LK, DER); the VISN 23 Patient Aligned Care Team Demon- stration Laboratory, Iowa City VA Health Care System, Iowa City, IA (GS); and the Department of Management, University of Iowa, Iowa City (GS).

Funding: This work was supported by the Patient Cen- tered Medical Home Demonstration Laboratory Coordina- tion Center (XVA-61– 041) of the U.S. Department of Vet- erans Affairs.

doi: 10.3122/jabfm.2018.01.170083 Task Delegation and Burnout Trade-offs in VA PACTs 83

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interdisciplinary team that shares primary care tasks and allows members to work at the top of their competence.5,6 However, differences in power and status, as well as a lack of clarity about who should do what, makes delegating tasks a chal- lenge.7–9 Teams struggle with poor role clarity and confusion over responsibility for clinical tasks.10 –15

Team struggles over who should do which tasks may contribute to work-related burnout, a psycho- logical state characterized by emotional exhaustion, lack of enthusiasm, and feelings of ineffective- ness.16,17 Burnout is common among primary care providers (PCPs)18,19 and primary care nurses20, with potentially negative implications for patient satisfaction21,22, patient safety18,23,24, and employee turnover.25 Clinical workload, unstable and inade- quate staffing26, and performing tasks that do not take advantage of a team members’ skills27 are as- sociated with increased burnout. By contrast, per- ception that a team culture exists is greater28 and more sharing of clinical and clerical tasks29, are associated with lower burnout among PCPs and staff. Improving task delegation among interdisci- plinary team members in a PCMH model may thus reduce burnout among PCPs and staff.

In 2010, the US Department of Veterans Affairs (VA) began implementing its PCMH model through the Patient Aligned Care Teams (PACT) initiative in VA primary care clinics. Within the VA PACT model, a “teamlet” consists of 4 members: a PCP (physician, nurse practitioner, physician assis- tant), nurse care manager (registered nurse), clinical associate (licensed practical nurse/licensed vocational nurse), and administrative associate (medical assis- tant). While guidelines were distributed describing the role of each team member30, teams were given substantial flexibility in determining their own work- flows. Early in the implementation of PACT, signif- icant differences existed between PCP’s and nurses’ perceptions of responsibility for specific clinical tasks: PCPs reported they perform most clinical tasks alone, whereas nurses reported they were relied on for the same tasks.11 However, these discrepant findings may have occurred because PCPs and nurses were sur-

veyed separately, rather than analyzing responses from PCPs and nurses in the same team. In addition, it remains unknown how perceived task delegation relates to employee burnout.

In this study we surveyed PCPs and nurses 4 years into PACT implementation to examine whether PCP and nurse perceptions of task dele- gation were similar or different within matched PCP-nurse dyads (ie, PCPs and nurses in the same teamlet). We examined factors that might contrib- ute to perceptions of task delegation and whether task delegation was associated with employee burn- out.

Methods Our study is part of the national PACT Demon- stration Laboratory Initiative efforts to support and evaluate the VA’s transition to the PCMH model. This study is based on the 2014 national provider and staff survey, which was designed to assess pri- mary care personnel’s perceptions of work condi- tions during PACT implementation.

The survey was reviewed by national union lead- ers through VA Labor Management Relations to ensure that surveys were not coercive or a danger to employees. The study was considered a quality im- provement project by VA national primary care leadership and was exempt from institutional re- view board review.

Procedures and Participants The survey was administered online from August 4 through September 1, 2014, using Inquisit software (Millisecond Software, Seattle, WA). A survey link was sent via E-mail to national VA primary care leadership, who disseminated it to leaders of the regional networks and local facilities with a request for them to distribute the link to local primary care personnel. Three E-mail reminders were sent, and no incentives were used. The survey asked respon- dents to self-identify using a nationally designated primary care team identifier; the completed surveys did not include individual identifiers. Because the survey was disseminated electronically through leadership channels, we do not know the exact number of eligible employees who were contacted; that is, we do not have a true denominator with which to calculate a response rate. We estimated the individual response rate to be 21% based on the number of providers (physicians, nurse practitio-

Conflict of interest: none declared. Corresponding author: Samuel T. Edwards, MD, MPH,

Section of General Internal Medicine, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd. (R&D199), Portland, OR 97239 �E-mail: samuel.edwards@ va.gov�.

84 JABFM January–February 2018 Vol. 31 No. 1 http://www.jabfm.org

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ners, and physician assistants) who responded rel- ative to the number of providers in a panel man- agement database during the same period, which was the most reliable administrative data on per- sonnel nationally. Administrative records indicated that 8114 primary care teamlets existed in the VA at the time of our survey; 2809 teamlets had at least 1 respondent and 20.9% of active PCPs returned surveys. Our sample consisted of 721 PCPs and 598 nurses, who together compromised 777 PCP-nurse dyads in 554 teamlets.

Study Measures Employee Perceptions of Task Delegation/Reliance and Discordance We asked PCPs and nurses about how 15 common primary care tasks (Table 1) were performed. We asked PCPs, “To what extent do you rely on your teamlet to accomplish the following primary care activities?” We asked nurses, “To what extent does your teamlet/clinic team rely on you to accomplish the following primary care activities?” PCPs and nurses responded on a 4-point scale for each task: “not at all” (1), “slightly” (2), “somewhat” (3), or “a great deal” (4). We defined these measures as “task delegation” for PCPs and “task reliance” for nurses. We calculated the absolute value of the difference between PCP task reliance and nurse task reliance for each dyad; this was defined as “task discor- dance.” Two clinician researchers grouped the 15 tasks into 5