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Elements of the healthy work environment

associated with lower primary care nurse burnout
Linda Y. Kim, PhD, MSN, RN, PHNa,b,*, Danielle E. Rose, PhD, MPHb,
David A. Ganz, MD, PhD, MPHb,c,d, Karleen F. Giannitrapani, PhD, MPHe,f,
Elizabeth M. Yano, PhD, MSPHb,g, Lisa V. Rubenstein, MD, MSPHd,g,h,
Susan E. Stockdale, PhD, MAb,i
a
Cedars-Sinai Medical Center, Los Angeles, CA
b
VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System,
Los Angeles, CA
c
Division of Geriatrics, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, CA
d
RAND Health, Santa Monica, CA
e
VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA
f
Department of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA
g
Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
h
Division of General Internal Medicine and Health Services Research, UCLA Geffen School of Medicine, Los Angeles, CA
i
Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, Los Angeles, CA

ARTICLE INFO ABSTRACT

Article history: Background: Little is known about the relationship between primary care nurses’
Received 6 December 2018 work environment and burnout, particularly in settings where patient-centered
Received in revised form medical homes (PCMH) have been implemented.
26 May 2019 Purpose: To investigate the relationship between PCMH nurses’ work environment
Accepted 21 June 2019 and burnout.
Methods: Multivariable analyses were performed using two waves of survey data
from PCMH registered nurses (RNs; n = 170) and PCMH licensed vocational nurses
Keywords: (LVNs; n = 181) in 23 primary care clinics.
Healthy work environment Findings: True collaboration was inversely associated with PCMH RN burnout
Interprofessional collaboration (b =
2.6, 95% confidence interval [CI] =
4.29,
0.08, p < .01). Meaningful recog-
Nurse burnout nition was inversely associated with PCMH LVN burnout (b =
5.1, 95%
Patient-centered medical home CI =
8.36,
1.82, p < .01). In models with all nurses, RN (vs. LVN) position was
Primary care nurses associated with higher levels of burnout (b = 6.2, 95% CI = 2.47, 9.84, p < .01).
Discussion: This study highlights the important role of the work environment in
reducing PCMH nurse burnout. Strategies to foster team collaboration and
meaningful recognition should be investigated to reduce PCMH nurse burnout.
Cite this article: Kim, L.Y., Rose, D.E., Ganz, D.A., Giannitrapani, K.F., Yano, E.M., Rubenstein, L.V., & Stock-
dale, S.E. (2019, xxx). Elements of the healthy work environment associated with lower primary care nurse
burnout. Nurs Outlook, 00(00), 1
12. https://doi.org/10.1016/j.outlook.2019.06.018.

Conflicts of interest: No conflicts of interest have been declared by the authors.

* Corresponding author: Linda Kim, Cedars Sinai, Nursing Research Department, 8711 W. 3rd Street, Los Angeles, CA 90048.
E-mail address: linyskim@ucla.edu (L.Y. Kim).
0029-6554/$ -see front matter Published by Elsevier Inc.
https://doi.org/10.1016/j.outlook.2019.06.018
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Introduction care activities with other members of the interprofes-

Work stress and burnout are significant concerns in
nursing, as they not only affect individual nurses per-
sonally and professionally, but also the organizations in
which they are employed and the patients they care for
(Jennings, 2008). Nurse burnout has been linked to
lower quality of care, poorer patient safety and health
outcomes, and lower patient satisfaction (Cimiotti,
Aiken, Sloane, & Wu, 2012; McHugh, Kutney-Lee,
Cimiotti, Sloane, & Aiken, 2011; Poghosyan, Clark, Fin-
layson, & Aiken, 2010). Consequently, Bodenheimer
and Sinsky (2014) suggested that the Triple Aim—
national goals to optimize population health by (1)
enhancing patient experience, (2) improving population
health, and (3) reducing costs— expanded to the Qua-
druple Aim, adding the fourth goal of improving the
work life of health care providers, including nurses.
The American Association of Critical-Care Nurses
Healthy Work Environment (AACN HWE) Standards,
first issued in 2005 (Table 1), increased national and
international attention to the work environment’s
impact on nurse retention, team effectiveness, nurse
and patient outcomes, and burnout, particularly in
acute care settings (American Association of Critical-
Care Nurses, 2016). However, attention to these stand-
ards applied in other settings including ambulatory
care settings is also much needed, especially since the
various service/departments in which nurses work,
tasks performed, and the role played by the health care
staff as well as the type of patients treated, may impact
levels of nurse burnout (Monsalve-Reyes et al., 2018).
In primary care settings, nurses’ role differs from
that of acute care nurses, especially following imple-
mentation of patient-centered medical homes
(PCMH)—a team-based model of patient care delivery
that encompasses the core functions of primary health
care. Within the PCMH model, responsibility for
patients is shared by all team members in the PCMH,
in contrast to the traditional physician-centric
approach. The PCMH model also emphasizes continu-
ity and long-term relationships with patients, in con-
trast to acute care settings that focus on fixing what
“broke” and sending the patient back to primary care.
As such, primary care nurses practicing within a
PCMH model often share responsibilities for patient
sional team consisting of the primary care provider
and other health care professionals. They must also
undertake expanded roles including chronic illness
management, telephone triage, and coordination of
longitudinal and comprehensive patient care delivery
by initiating and informing referrals to other health
care professionals and participating in team-based
planning (Norful, Martsolf, de Jacq, & Paghosyan, 2017;
Smolowitz et al., 2015). With the increasing number of
primary care practices adopting the PCMH model of
care delivery, a better understanding of the relation-
ship between the PCMH practice environment and var-
ious burnout experienced by primary care nurses
practicing in these settings is urgently needed.
Much is already known about the relationship
between various practice environment factors on
nursing burnout in acute care settings (Dall’ora, Grif-
fits, Ball, Simon, & Aiken, 2015; Demir, Ulusoy, & Ulu-
soy 2003; Laschinger, Grau, Finegan, & Wilk, 2010;
McHugh & Ma, 2014). For instance, in acute care set-
tings, lower levels of nurse staffing, working night
shift, or shifts that last 12 hours or longer were linked
to increased nurse burnout (Dall’ora et al., 2015;
McHugh & Ma, 2014). Furthermore, higher levels of
burnout were reported by nurses who experienced
poor interprofessional relationships, including hori-
zontal/lateral violence and bullying by physicians as
well as other members of the nursing team (Demir
et al., 2003; Laschinger et al., 2010). On the other hand,
work environment factors including sufficient staffing,
authentic leadership that provides recognition and
support, participatory decision-making, and effective
nurse
physician relationships, all promoted through
workplace empowerment, were associated with lower
levels of nurse burnout (Laschinger, Finegan, & Wilk,
2011; Laschinger & Leiter, 2006; Leiter & Laschinger,
2006). These mitigating factors (e.g., true collaboration,
skilled communication, effective decision-making,
authentic leadership, meaningful recognition, and
appropriate staffing) are essentially the components of
the HWE endorsed by the AACN.
While several studies have examined various factors
associated with burnout in primary care, little is known
about the impact of the workplace environment on pri-
mary care nurse burnout, particularly those practicing
in PCMH settings (Helfrich et al., 2014; Kim et al., 2018;

Table 1 – AACN HWE Standards (AACN, 2016)

Skilled communication
True collaboration
Effective decision-making
Appropriate staffing
Meaningful recognition
Authentic leadership
Note. AACN HWE, American Association of Critical-Care Nurses Healthy Work Environment.
Nurses must be as proficient in communication as they are in clinical skills
Nurses must be relentless in pursuing and fostering true collaboration
Nurses must be valued and committed partners in making policy, directing and evaluating
clinical care, and leading organizational operations
Staffing must ensure an effective match between patients’ needs and nurses’ competencies
Nurses must be recognized and must recognize others for the value each brings to the work
of the organization
Nurse leaders must fully embrace the imperative of a healthy work environment, authenti-
cally live it, and engage others in its achievement
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Lewis et al., 2012; Meredith et al., 2015, 2018; Nelson
et al., 2014; Reid et al., 2010). In one PCMH evaluation
study examining primary care tasks associated with
health care provider burnout, nurses were not included
in the study sample (Kim et al., 2018). In other studies
evaluating the impact of PCMH elements on health care
provider burnout, nurses were grouped with other
health care providers (Lewis et al., 2012; Meredith et al.,
2015, 2018), the proportion of nurses that was actually
included in the study sample is unclear (Reid et al.,
2010), and/or the studies do not provide a clear descrip-
tion of which PCMH practice environment elements
specifically impact primary care nurses (Helfrich et al.,
2014). The purpose of this study, therefore, is to investi-
gate the relationship between primary care nurses’
practice environment, following PCMH implementa-
tion, and their levels of burnout.
Methods
Setting and Sample
In 2010, the Veterans Health Administration (VHA)
adopted and implemented Patient-Aligned Care Teams
(PACT), a PCMH model of patient care delivery, in all pri-
mary care settings. Similar to other PCMH models,
PACT “teamlets” are comprised of a primary care pro-
vider such as a physician, nurse practitioner, or a physi-
cian assistant, and three supporting team members
including a registered nurse (RN) care manager, a
licensed vocational nurse (LVN), and a medical assis-
tant or a clerical staff member (Kim et al., 2018; U.S.
Department of Veterans Affairs, 2014). Multiple team-
lets are supported by ancillary staff from other disci-
plines, such as pharmacists, nutritionists/dieticians,
and social workers as well as mental health professio-
nals (e.g., psychiatrists, psychologists) who all work
together, with the ultimate goal of providing compre-
hensive, patient-centered, coordinated, high quality,
safe, and accessible care to patients and their caregivers
(Agency for Healthcare Research and Quality, n.d.).
The sample for this study included PACT nurses prac-
ticing in 23 practices within five health care systems
across Southern California and Nevada (Veterans Inte-
grated Service Network or VISN 22), who were included
in the larger evaluation study of the VA’s implementa-
tion of PACT. Analytic sample for this study included
170 PACT RNs and 181 PACT LVNs.
Data Collection
Data for this study come from two waves of surveys
(November 2011
March 2012 and August 2013
January
2014). The surveys were conducted by the RAND Corpo-
ration on behalf of the VHA, described in more detail
elsewhere (Meredith et al., 2015), and included approxi-
mately 130 items related to leadership involvement,
team decision-making, collaboration with members of
3
the team, and burnout. RN response rates for waves 1
and 2 were 81% and 32%, respectively; LVN response
rates were 67% and 33%, respectively. Both the VHA
and RAND Institutional Review Boards approved the
original study protocol.
Study Measures
Nurse burnout was measured using the emotional
exhaustion subscale (Appendix A) of the Maslach
Burnout Inventory (Maslach, Jackson, Leiter, Schaufeli,
& Schwab, 1996). Some scholars have argued that emo-
tional exhaustion is the first domain that manifests as
part of burnout and that variables such as job
demands are more strongly associated with emotional
exhaustion (Brenninkmeijer & VanYperen, 2003; Mas-
lach, Schaufeli, & Leiter, 2001; Meredith et al., 2015).
The nine items included statements such as “I feel
burned out from my work.” Response options for each
of the nine items ranged from “never” (0) to “every
day” (6), with a total score ranging from 0 to 54. This
scale was found to have high internal consistency
(a = 0.92) among nurses in this sample. The measure
was used as a continuous variable in the bivariate and
multivariable analysis to assess associations with
other variables. To facilitate interpretation and discus-
sion of the burnout scores, the responses were catego-
rized into three levels of burnout as used in previous
studies (Doulougeri, Georganta, & Montgomery, 2016):
low (0
16), medium (17
26), and high (27
54).
Although the AACN’s HWE framework was initially
created for the critical care settings, a recent study
by Connor et al. (2018) validates the use of the AACN
HWE Assessment Tool, across multiple health care
settings. The measures of the first five constructs of
the HWE were included in this study as described
below. The sixth construct, adequate staffing, was
not measured in our surveys. Response options for
each item ranged from “strongly disagree” (1) to
“strongly agree” (5). Survey items corresponding
with the HWE constructs were recategorized as
0 = “disagree” (response options 1
3) and 1 = “agree”
(response options 4
5) to facilitate interpretation
and discussion. A detailed description of the AACN’s
HWE constructs and definitions with corresponding
survey items is provided in Table 2, along with the
Cronbach’s alpha for the measures used in analyses.
Table 2 also shows the hypothesized relationships
between the HWE constructs and burnout.
In addition to HWE factors, the relationship between
primary care nurse burnout and nurse characteristics
was explored. Nurse characteristics included nurse type
(RN or LVN), age, gender, race/ethnicity (non-Hispanic
white vs. Asian, black, Latino/a, other), and tenure (num-
ber of years at this clinic). The relationship between pri-
mary care nurse burnout and clinic type (e.g., hospital-
based clinic, large community-based outpatient clinic
[CBOC] that services 8,000 or more primary care patients,
or small CBOC that services less than 8,000 primary care
patients CBOC), was also explored.

Table 2 – AACN HWE Constructs and Corresponding Veterans Assessment and Improvement Laboratory (VAIL) Survey Items
AACN’s HWE Constructs and
Definitions (AACN, 2016)
True collaboration: Nurses must be
relentless in pursuing and fostering
true collaboration.
Process in which unique knowl-
edge and abilities of each profes-
sional are respected to achieve
optimal, safe, and quality care for
patients. Skilled communication,
trust, knowledge, shared respon-
sibility, mutual respect, opti-
mism, and coordination are
integral to successful
collaboration.
Skilled communication: Nurses
must be as proficient in communica-
tion skills as they are in clinical skills.
Frequent, respectful interaction,
and two-way dialogue in which
nurses speak with knowledge and
authority related to patient care
Effective decision-making: Nurses
must be valued and committed part-
ners in making policy, directing and
evaluating clinical care, and leading
organizational operations.
Nurse involvement and full part-
nership with physicians and
4
VAIL Survey Items Cronbach’s Alpha for Hypothesized Relationship with Burnout
VAIL Survey Items
1. Overall, I am satisfied with how my teamlet a = 0.81 Total collaboration has an inverse relationship
members work together.* to burnout; that is, an increase in total collab-
oration score is associated with lower level of
burnout.
2. In this clinic, when I have a problem that
involves a coworker from a different clinical or
administrative discipline, I can access help to
resolve the problem.*
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3. In this clinic, coworkers from different clinical
or administrative backgrounds frequently
interact to solve quality of care problems.*
4. Our staff and clinicians have constructive work
relationships. (SOAPC)y
5. The staff and clinicians in this clinic operate as
real teams. (SOAPC)y
Total true collaboration score ranged from 0 to 5.
1. In this clinic, it is easy to speak up about what a = 0.87 Skilled communication has an inverse relation-
is on your mind. (LOS)y ship to burnout; that is, an increase in skilled
communication score is associated with lower
level of burnout.
2. People in this clinic are usually comfortable
talking about problems. (SOAPC)y
3. People in this clinic are eager to share informa-
tion about problems and disagreements. (LOS)y
4. When there is a conflict in this clinic, we usu-
ally talk it out and resolve the problem success.
(SOAPC)y
Total skilled communication score ranged from 0 to 4.
1. Staff and clinicians are involved in developing a = 0.80 Effective decision-making has an inverse rela-
plans for improving quality. (SOAPC)y tionship to burnout; that is, an increase in
effective decision-making score is associated
with lower level of burnout.
(continued on next page)
Table 2 – (Continued)
AACN’s HWE Constructs and
Definitions (AACN, 2016)
other health care professionals in
decisions that impact patient
care, including policy making,
directing and evaluating clinical
care, and leading organizational
operations.
Authentic leadership: Leaders must
fully embrace the imperative of a
healthy work environment, authenti-
cally live it and engage others in its
achievement.
Leaders are skilled communicators,
team builders, agents for positive
change, role models for collabo-
ration, and committed to service;
and are positioned within organ-
ization’s key operational and gov-
ernance bodies in order to inform
and influence decisions that
affect practice environments and
nursing practice.
Meaningful recognition: Nurses
must be recognized and must recog-
nize others for the value each brings
to the work of the organization.
Recognition (that is of value and
meaningful to the individual
nurse) for their unique contribu-
tion to the organization and com-
mitment to their patients.
VAIL Survey Items Cronbach’s Alpha for Hypothesized Relationship with Burnout
VAIL Survey Items
2. This clinic encourages staff and clinicians’
input for making changes and improvements.
(SOAPC)y
3. All of the staff and clinicians participate in
important decisions about clinical operations.
(SOAPC)y
Total effective decision-making score ranged from 0 to 3.
1. Provides measurable objectives for implement- a = 0.85 Authentic leadership has an inverse relation-
ing the strategy and vision within our clinic. ship to burnout; that is, an increase in skilled
(LN)y communication score is associated with lower
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level of burnout.
2. Is willing to try new clinical protocols. (ORCS)y
3. Works cooperatively with senior leadership/
clinical management to make appropriate
changes. (ORCS)y
4. Understands the difficulties and challenges
related to the implementation of patient-cen-
tered medical homes. (ORCS)y
Total authentic leadership score ranged from 0 to 4.
1. Recognizes and rewards progress in imple- a = 0.72 Meaningful recognition has an inverse relation-
menting change with our clinic. (LN)y ship to burnout; that is, an increase in mean-
ingful recognition score is associated with
lower level of burnout.
2. Encourages and supports changes in clinic pat-
terns to improve patient care. (ORCS)y
Total meaningful recognition score ranged from 0 to 2.
Not assessed (N/A) in this study. N/A N/A
(continued on next page)
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Analysis

Note. LN, leadership norms (Caldwell et al., 2008); LOS, Learning Organization Survey (Garvin et al., 2008); ORCS, Organizational Readiness to Change Survey (Helfrich, Li, Sharp, & Sales, 2009); SOAPC,
Responses from nurses from both waves (wave 1:
Hypothesized Relationship with Burnout

n = 220, wave 2: n = 131) were combined in the analyses

of burnout. A small number of nurses participated in
both waves (11 out of 351 observations) and were
included in the results of main analyses shown in the
paper. However, additional sensitivity analyses were
conducted controlling for clustering of responses among
those nurses who participated in both waves. The results
were similar with and without the 11 extra observations.
In addition to the univariate analysis to describe
nurse characteristics, levels of burnout, and nurses’
perceptions of the HWE elements, bivariate analyses
were performed to explore the potential relationship
between independent variables and nurse burnout.
Only the perceived HWE elements and covariates with
statistically significant associations (p  .05) to nurse
burnout in the bivariate analysis were included in the
multivariable linear regression analysis.
In the multivariable analysis, separate models were
Cronbach’s Alpha for

conducted for each perceived HWE element (models

VAIL Survey Items

1
5) and three models with all the HWE elements

(models 6
8): model 6 included the combined sample,
model 7 included RNs only, and model 8 included
LVNs only, controlling for respondent-level covariates.
All analyses were performed with Stata 14.0 (Stata
Corp LP, College Station, TX).

Results

Table 3 shows results for level of nurse burnout, per-

ceptions of the HWE, and respondent, clinic and health
Survey of Organizational Attributes for Primary Care (Ohman-Strickland et al., 2007).

care system characteristics. On average, RNs reported

a medium level of burnout (M = 22.1, SD = 14.3) while
LVNs reported a low level of burnout (M = 17.0,
y Previously validated survey items included in VAIL Survey.

SD = 13.3). Overall, RNs’ perceptions of the HWE were

slightly more favorable than LVNs’ (except perceptions
VAIL Survey Items

of authentic leadership); however, the differences

were not statistically significant. LVNs were younger
but had longer years of tenure as compared to RNs.
About one-third of the nurses identified as non-His-
panic white (37%) were female (75%) and were
employed in hospital-based clinics (44%).
Results from the bivariate analysis (Table 4) indi-
* New item created for VAIL Survey.

cated that nurse reports of each of the HWE elements

patient acuity, nurse competen-
Appropriate staffing: Staffing must

was inversely related to nurse burnout (p  .05). Nurse

ensure an effective match between

cies, and the status of the work

Staffing based on patient needs,

type (RN vs. LVN) was also significantly associated

the patients’ needs and nurses’
AACN’s HWE Constructs and

with nurse burnout (p  .05).

Definitions (AACN, 2016)

Multivariable linear regression analyses (Table 5) indi-

Table 2 – (Continued)

cate that nurse perceptions of each of the five HWE ele-

ments were inversely associated with nurse burnout in
environment.

separate models (models 1
5). When all five elements

competencies.

of the HWE were entered together in one model (model

6), perceptions of true collaboration (b =
1.3, 95% confi-
dence interval [CI] =
2.50, 0.00, p = .05) and perceptions
of meaningful recognition (b =
2.8, 95% CI =
5.64,
0.04, p = .05) were inversely associated with levels of
Table 3 – Nurse Characteristics and Perceptions of the Healthy Work Environment
Total (N = 351) Registered nurse (n = 170) Licensed vocational nurse (n = 181)
n (%) M (SD) n (%) M (SD) n (%) M (SD)
Nurse burnout (score 0
54)y 321 19.4 (14.0) 161 22.1 (14.3) 160 17.0 (13.3)
Perceptions of HWE*
True collaboration (score
-5) 334 2.9 (1.7) 167 2.9 (1.7) 167 2.8 (1.8)
Skilled communication (score 0
4) 335 2.1 (1.6) 167 2.2 (1.6) 168 2.0 (1.6)
Effective decision-making (score 0
3) 333 1.6 (1.2) 167 1.7 (1.2) 166 1.5 (1.3)
Authentic leadership (score 0
4) 331 2.3 (1.6) 166 2.2 (1.5) 165 2.3 (2.0)
Meaningful recognition (score 0
2) 330 1.0 (0.9) 165 1.1 (0.9) 165 1.0 (0.9)
Nurse characteristics*
Age (years) 302 47.7 (12.3) 147 50.2 (12.0) 155 45.5 (12.3)
Tenure (years) 311 5.3 (6.1) 147 5.0 (6.1) 164 5.6 (6.1)
Race/ethnicity
Non-Hispanic white 133 (37%) 72 (43%) 61 (32%)
Latino/a 19 (3%) 11 (2%) 8 (4%)

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Black/African American 39 (13%) 16 (10%) 23 (15%)
Asian 86 (23%) 48 (28%) 38 (19%)
Other 41 (12%) 17 (9%) 24 (14%)
Female 265 (75%) 137 (82%) 128 (69%)
Clinic characteristics
Hospital-based clinic 153 (44%) 76 (45%) 77 (43%)
Large CBOC (>8,000 patients) 114 (32%) 58 (34%) 56 (31%)
Small CBOC (<8,000 patients) 84 (24%) 36 (21%) 48 (26%)
Healthcare system characteristics
Healthcare system 1 105 (30%) 57 (34%) 48 (26%)
Healthcare system 2 65 (18%) 26 (15%) 39 (22%)
Healthcare system 3 52 (15%) 27(16%) 25 (14%)
Healthcare system 4 84 (24%) 38 (22%) 46 (25%)
Healthcare system 5 45 (13%) 22 (13%) 23 (13%)
Note. CBOC, community-based outpatient clinic; HWE, healthy work environment.
* Observations do not sum up to full sample (n = 351) due to missing data.

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Table 4 – Bivariate Analysis: Perceptions of Healthy Work Environment and Covariates Associated with
Nurse Burnout
b CI p
Perceptions of HWE
True collaboration (score 0
5)
2.6
3.5
1.7 <.001
Skilled communication (score 0
4)
2.7
3.8
1.7 <.001
Effective decision-making (score 0
3)
3.1
4.2
2.1 <.001
Authentic leadership (score 0
4)
2.2
3.3
1.1 <.001
Meaningful recognition (score 0
2)
4.4
6.4
2.3 <.001
Nurse characteristics
RN (ref: LVN) 5.1 1.3 8.8 .010
Age >45 years 3.0
0.4 6.3 .079
>6 years in clinic 1.9
2.8 6.7 .403
Non-Hispanic white (ref: Hispanic)
1.2
4.0 1.6 .393
Male (ref: female) 2.6
1.8 7.0 .235
Clinic characteristics (ref: VA Medical Center)
Large CBOC (>8,000 patients) 2.9
0.2 6.1 .067
Small CBOC (<8,000 patients) 0.2
4.0 4.4 .929
Healthcare system characteristics (ref: Healthcare System 1)
Healthcare system 2
0.1
4.5 4.3 .955
Healthcare system 3
0.7
4.6 3.1 .707
Healthcare system 4 0.3
4.2 4.8 .881
Healthcare system 5 0.9
4.8 6.7 .742
Wave (time)
2.0
6.4 2.4 .350
Note. CBOC, community-based outpatient clinic; HWE, healthy work environment; LVN, licensed vocational nurse; RN, registered nurse.

nurse burnout. Additionally, the RN (as compared to
LVN) position was associated with substantially higher
levels of burnout (b = 6.2, 95% CI = 2.47, 9.84, p < .01).
Results of the RN only model (model 7) showed that
perceptions of true collaboration were inversely associ-
ated with levels of RN burnout (b =
2.6, 95% CI =
4.29,

0.84, p < .01). In the LVN only model (model 8), percep-
tions of meaningful recognition were inversely associ-
ated with LVN burnout (b =
5.1, 95% CI =
8.36,
1.82,
p < .01).
Discussion
The seminal article, From triple to quadruple aim: Care of
the patient requires care of the provider (Bodenheimer &
Sinsky, 2014) calls attention to the urgent need to
improve the work life of health care providers by
improving their practice environment and reducing
burnout so that in turn, they may help achieve the ulti-
mate goal of improving population health. Findings
from this study address this call and make several
important contributions to expand the current litera-
ture on nurse burnout in primary care settings.
This study is the first study to apply the AACN’s HWE
framework to assess the nursing practice environment
within a primary care setting with the PCMH model.
Findings from this study underscore the importance of
an HWE as a key factor associated with lower levels of
nurse burnout in the PCMH. All five HWE elements
showed a strong relationship with lower levels of pri-
mary care nurse burnout in the bivariate analysis.
Among HWE elements, perceptions of true
collaboration between members of interprofessional
PCMH teams were strongly associated with lower lev-
els of burnout for primary care RNs. True collaboration
that encompasses effective communication, knowl-
edge of each other’s role, shared responsibility, trust,
and mutual respect may be especially critical for pri-
mary care RNs who play a key role in coordination of
longitudinal and comprehensive patient care delivery
in team-based models.
Given the special importance of collaboration, a
comprehensive quality improvement program to
improve team collaboration may be an effective strat-
egy to reduce primary care RN burnout. Examples of
quality improvement initiatives aimed at improving
team collaboration include standardized task sharing
processes, workflow mapping, co-location of team
members, regular huddles and team meetings as well
as use of information technology such as instant mes-
saging, to share frequent and timely information (Sin-
sky et al., 2013). Other potentially effective strategies
to improve team collaboration include interprofes-
sional team training such as the Primary Care version
of Team Strategies and Tools to Enhance Performance
and Patient Safety (TeamSTEPPS) and the “Nurse for a
Day” nurse-shadowing program that pairs medical
residents with nurses acting as the resident’s precep-
tor with the ultimate goal of the nurse-resident dyad
developing a better understanding of each other’s
roles as well as improved communication and collabo-
ration (Jain, Luo, Yang, Purkiss, & White, 2012).
Buy-in and support from nurse leaders and managers
are crucial in order to promote successful adoption and
spread of evidence-based practices aimed at facilitating
PCMH team collaboration and preventing primary care
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1 2 9

RN burnout. In addition, for primary care nurses to func-

8 LVN only (n = 151) tion successfully as members of interprofessional PCMH
teams, nurse managers must be actively engaged in
daily functioning of PCMH teams (Giannitrapani et al.,
2019). Active involvement by nurse managers in daily

5.1**

6.5**

0.04

0.18
functioning of PCMH teams will promote efficient role-

1.4

1.4
1.2
Table 5 – Multivariable Linear Regression Analysis: Healthy Work Environment Elements and Covariates Associated with Nurse Burnouty

based care delivery that allows nurses to practice at the
top of their education, training, and scope and may also
improve the work life of primary care nurses through
7 RN only (n = 158)

promotion of true PCMH team collaboration and mean-

ingful recognition. In turn, primary care nurses can
improve the health of the patients they care for.
Findings from this study also showed a statistically sig-

2.6**

0.14
3.7*

nificant association between perception of meaningful

1.2
0.4

0.1
0.3

y Only statistically significant results (p < .05) from the bivariate analysis were included in the multivariable linear regression analysis.
recognition and lower levels of primary care LVN burn-
out. Meaningful recognition may come in various forms
including, but not limited to “thank you” notes, “Nurse
6 (n = 309)

Week” recognitions, advancement in the clinical ladder

24.2***
6.2**

0.87

0.17

1.3*

2.8*

(Kelly & Lefton, 2017), or other opportunities for profes-

1.4

0.4

sional and/or financial growth. Another way to recognize

LVNs may be through opportunities to participate in the
Daisy Award program that provides ongoing recognition
5 (n = 310)

for nurses’ clinical skill and compassion (Lefton, 2012).

4.5***

13.6***
5.3**

0.11

Further research should focus on the most effective

ways of recognizing the contributions of the LVN role in
patient care delivery and team functioning. More impor-
tantly, recognition should be delivered in a way that is
4 (n = 312)

meaningful to the “end user” (Lefton, 2012).

2.1***

12.9***
0.09
4.8*

Another important finding from this study was the

notable variation in the level of burnout (Tables 4 and 5)

between RNs and LVNs, with RNs reporting significantly
higher levels of burnout as compared to LVNs. Most
Notes. HWE, healthy work environment; LVN, licensed vocational nurse; RN, registered nurse.
3 (n = 312)

studies evaluate both groups of nurses as one combined

3.3***

28.7***
5.8**

0.12

sample even though RNs and LVNs experience organi-

zational and professional roles differently including (a)

diversified modes of care and expanded clinical duties;
(b) division of labor within PCMH teams; and (c) inter-
2 (n = 313)

professional status in the team (Stewart, Stewart,

2.9***

20.3***
6.1**

0.15

Lampman, Wakefield, Rosenthal & Solimeo, 2015).

Previous work has examined the relationship between

specific tasks performed by other health care providers
and burnout (Helfrich et al., 2014; Kim et al., 2018).
Although this study did not examine the level of involve-
1 (n = 313)

2.7***

27.6***
5.7**

ment in PCMH teams and specific tasks performed by

0.15

RNs vs. LVNs, these factors may also impact the level of
burnout nurses may experience. Hence, further evalua-
tion of the distinct roles various nurses have on PCMH
teams and the specific patient care tasks that RNs and
Effect. decision-making (score 0
3)

Meaningful recognition (score 0
2)

Skilled communication (score 0
4)

LVNs perform in relation to the levels of burnout they

Authentic leadership (score 0
4)
with Nurse Burnout (score 0-54)

True collaboration (score 0
5)

experience is needed. The findings from these studies

Models with HWE Elements

could promote more efficient role-based care delivery,

and Covariates Associated

*p  .05, **p  .01, ***p  .001.

where nurses can practice at the top of their education,

training, and scope.
Nurse characteristics
Perception of HWEy

Limitations
RN (ref: LVN)

This study has limitations. The data were cross-sectional

survey and thus causality between the HWE factors and
nurse burnout could not be determined. A longitudinal
R2
F

study evaluating the relationship between the primary

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care nurses’ practice environment and burnout would
help extend findings from this and future studies.
Second, previous studies investigating PCMH imple-
mentation have found that the VHA primary care clin-
ics and providers were representative of primary care
settings in other studies (Helfrich et al., 2014, Nutting
et al., 2011). Nonetheless, findings from this study
should be interpreted with some caution when gener-
alizing to non-VHA primary care clinics, especially
those located in international settings, as this study
sample was limited to primary care clinics within one
VHA region in the United States.
Another limitation is that the survey was not specifi-
cally designed to measure the constructs of the AACN’s
HWE, which may potentially impact internal validity;
however, the measured constructs (leadership, commu-
nication, team process and satisfaction, and shared deci-
sion-making) mapped closely with those in the AACN’s
HWE and the internal consistency of the measured con-
structs was high. In addition, one of the six constructs—
appropriate staffing—was not measured here, and its
exclusion may have impacted the strength and direction
of the relationships between the HWE constructs and
burnout. Recent studies, including the study by Helfrich
et al. (2014), have demonstrated the association of having
a fully staffed PCMH team and lower levels of burnout.
Future research using validated instruments to measure
the primary practice environment such as the Practice
Environment Scale of the Nursing Work Index (Lake,
2002) specifically modified for the primary care setting is
needed so that findings from such studies can guide
nursing and other organizational leaders in implementa-
tion of targeted strategies to improve nursing and patient
outcomes, particularly in primary care settings.
collaboration between members of interprofessional
PCMH teams in reducing primary care RN burnout and
meaningful recognition in reducing primary care LVN
burnout. Nursing and other organizational leaders
should seek to achieve the Quadruple Aim (Boden-
heimer & Sinsky, 2014) by implementing evidence-
based strategies to foster an HWE in primary care set-
tings.
Acknowledgments
Funding for this project was supported through a grant
from the VA Veterans Assessment and Improvement
Laboratory for Patient-Centered Care (VAIL-PCC) and
Patient Aligned Care Team (PACT) Demonstration Lab
(#XVA 65-018) and VA Locally Initiated Project (LIP
#65162). Dr. Kim’s time was covered by the Quality
Scholars Program funded through the VA Office of Aca-
demic Affiliations (#TQS 65-000) and Dr. Yano’s time
was covered by a VA HSR&D Senior Research Career
Scientist Award (Project # RCS 05-195). The views
expressed in this article are those of the authors and
do not necessarily reflect the position or policy of the
Department of Veterans Affairs.
Supplementary materials
Supplementary material associated with this article
can be found in the online version at doi:10.1016/j.out
look.2019.06.018.

Conclusion
Appendix A. Maslach’s Burnout Inventory
(Emotional Exhaustion Subscale)
The results of this study highlight the important role of
a healthy work environment, particularly, true

Never A few Times Every A few Times Every A few Times Every
a Year Month a Month Week a Week Day
(a) I feel emotionally drained from my work.
(b) I feel exhilarated when I accomplish some-
thing at work.
(c) I feel used up at the end of the workday.
(d) Working with people all day is really a strain
for me.
(e) I feel burned out from my work.
(f) I feel fatigued when I get up in the morning
and have to face another day on the job.
(g) I have accomplished many worthwhile
things in this job.
(h) I feel frustrated by my job.
(i) I feel I’m working too hard on my job.
(j) Working with people directly puts too much
stress on me.
(k) I feel like I’m at the end of my rope.
(l) In my opinion, I am good at my job.
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