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Using focus groups to identify characteristics of an ideal work environment for Advanced Practice Clinicians
Healthcare ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Using focus groups to identify characteristics of an ideal work environment for Advanced Practice Clinicians Robert J. Motley a,n, Richard J. Mazzaccaro b, David B. Burmeister c, Samuel D. Land d, Richard M. Boulay e, Heiwon Chung f, Lynn Deitrick g, Andrew D. Sumner h a
Department of Community Health, Lehigh Valley Health Network, 1628 W. Chew Street, Allentown, PA 18102, USA Department of Pediatrics, Lehigh Valley Health Network, Allentown, PA, USA c Department of Emergency Medicine, Lehigh Valley Health Network, Allentown, PA, USA d Department of Pathology and Laboratory Medicine, Lehigh Valley Health Network, Allentown, PA, USA e Department of Obstetrics & Gynecology, Lehigh Valley Health Network, Allentown, PA, USA f Department of Surgery, Lehigh Valley Health Network, Allentown, PA, USA g Department of Behavioral and Community Sciences, University of South Florida, Tampa, FL, USA h Center for Advanced Health Care, Division of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA b
art ic l e i nf o
a b s t r a c t
Article history: Received 6 November 2014 Received in revised form 31 July 2015 Accepted 20 October 2015
Advanced Practice Clinicians (APCs) in collaborative practice represent a diverse and valuable group of health care professionals, including nurse practitioners, physician assistants, nurse anesthetists, and nurse midwives. Because these healthcare professionals have been identified as part of the solution to physician shortages, it is critical for health networks to examine and address issues affecting collaborative relationships. We invited our network APCs to participate in focus group sessions to determine both attributes and barriers to an ideal work environment. Four major themes emerged: (1) compensation, (2) network representation, (3) employment structure, and (4) workplace culture. While issues relating to compensation and representation were prevalent, discussions also revealed the importance of relationships and communication. To ensure successful collaboration and, thereby, reduce clinician turnover, leaders must address gaps between the existing and ideal states in structural factors affecting job satisfaction (Themes 1–3) as well as the behavioral factors represented in workplace culture (Theme 4). & 2015 Elsevier Inc. All rights reserved.
Keywords: Allied health professionals Job satisfaction Work environment Focus groups Workforce
1. Introduction Advanced Practice Clinicians (APCs) in collaborative practice have become integral stakeholders in health care delivery within both inpatient and outpatient settings.1–3 The demand for APCs— nurse practitioners, physician assistants, nurse anesthetists and midwives—has accelerated recently, driven by legislative support, resident duty hour restrictions,4 expanding clinical complexity, and cost pressures. In Pennsylvania, legislation has been introduced to grant nurse practitioners independent practice authority, a privilege that 20 other states have already adopted. In a competitive marketplace, APC satisfaction is highly correlated with recruitment and retention.5 However, recent survey data has shown that up to 27% of nurse practitioners have expressed intent to leave their current positions.6 The loss of clinical team members disrupts patient access and continuity of care, and can also negatively affect efficiency, n
Corresponding author. E-mail address: [email protected] (R.J. Motley).
quality, and safety. Our health network, motivated to explore the APC work environment after the sudden loss of a group of 5 nurse practitioners from a single discipline, sought to identify and support an ideal work environment for APCs as one important strategy for maintaining a high-quality, collaborative workforce.
2. Study design and methods An interdisciplinary team of seven practicing physicians and one medical anthropologist convened to explore our network APCs' perception of an ideal work environment. We adopted a focus group format to elicit a wide range of participant concerns,7 seeking to identify both barriers and facilitators to an APC ideal work environment. Our goals were to inform clinicians and senior leaders, improve professional satisfaction, and reduce clinician turnover. Over the past 15 years, researchers have investigated issues of work environment and professional satisfaction among APCs,8–13 using surveys or semi-structured interviews with predetermined
http://dx.doi.org/10.1016/j.hjdsi.2015.10.007 2213-0764/& 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Motley RJ, et al. Using focus groups to identify characteristics of an ideal work environment for Advanced Practice Clinicians. Healthcare (2016), http://dx.doi.org/10.1016/j.hjdsi.2015.10.007i
R.J. Motley et al. / Healthcare ∎ (∎∎∎∎) ∎∎∎–∎∎∎
2
“I”
“It”
(personal attitudes, biases)
(aspects of work or job duties)
Autonomy Mutual Respect
Roles/ Reporting Structure Compensation
“We”
“They”
(close relationships-co-workers, teams, individual practice unit)
(attributes of the organization or health system)
Teamwork Communication Support/ Recognition
Network Representation Alignment of Strategies
External frames of reference
Internal frames of reference
designed to explore rewards and recognition within the context of a large health network).
Fig. 1. Ideal work environment themes in the “Ways of Knowing” framework: Domains of each quadrant of the model are listed in parentheses. Themes that emerged from the focus group analysis are presented in bold.
topics.8–10 To support the more qualitative nature of focus groups, we used Wilber's “Ways of Knowing” paradigm14 (Fig. 1) as a conceptual framework for organizing the themes from the published literature and to construct the focus group interview questions. “Ways of Knowing” is a four-quadrant model in a twoby-two design. On the “external” side is the work itself (“It”) and the larger system in which it takes place (“They”). On the “internal” side are the attitudes and motivations that health professionals bring to their work (“I”), as well as the team milieu (“We”) in which attitudes, behaviors and teamwork come to life. This conceptual model is a process for integrating data to the level of knowledge and understanding.15 Within healthcare, Stange and colleagues7,15 have used this four-quadrant approach to support mixed-methods research and knowledge development within generalist medicine. Process-wise, we sent internal email invitations to 273 randomly selected APCs within our health network. Thirty-nine responded, with approximately 10 participating in each of four separate sessions conducted in October and November 2010. The initial focus group session was moderated by a medical anthropologist with qualitative methods expertise; subsequent sessions were moderated by a research physician. Participants predominantly included nurse practitioners and physician assistants. The majority (64%) practiced primarily in outpatient settings. Of the 39 participants, 28% identified themselves as primary care clinicians; 72% practiced in sub-specialty fields. After collecting demographic information and obtaining consent, physicians facilitated the four focus group discussions with questions modeled from those previously used in validated surveys.9,11,16 Follow-up probe questions based on “Ways of Knowing”14 included the following:
What aspects of your work bring you the greatest satisfaction? (“I” quadrant, designed to explore attitudes, motivation).
How can doctors build healthy relationships with the APCs who
work with them? (“We quadrant, designed to explore working relationships within clinical teams”). If you could change one aspect of your job that would make it better for you, what would it be? (“It” quadrant, designed to explore aspects of the work itself). How are you recognized for your efforts? (“They” quadrant,
We recorded responses on flip charts and by audio; after transcripts were de-identified, all data were reviewed collectively by the physician team. Four dominant themes emerged and are described in the section below.
3. Primary themes
Theme 1. Compensation and Accurate Accounting of Work. A large part of the discussion in each of the focus groups centered on APC compensation, including both salary and accurate accounting of work performed. Participants reported perceptions that current salaries were below national averages,13,17 and that they had limited access to information about drivers of salary increases and incentives.10 Among other concerns were ambiguity in crediting relative value units (RVUs) for shared work with physicians and less available reimbursement of continuing medical education expenses than that of physicians.10 Theme 2. Network Advocacy. Although our health network supports an Advanced Practice Clinician Council whose mission is to support and integrate the professional interests of APCs within the network, several participants indicated uncertainty about the Council's role. Other concerns were the poor attendance at APC member meetings because of clinical duty conflicts or inconvenient meeting locations, lack of representation at the senior leadership level, and a perceived lack of communication about important changes affecting APCs within the network. Theme 3. Roles and Reporting Relationships. Focus group attendees said they valued collaborative relationships and saw their roles as complementary to those of physicians. However, many APCs felt there was a gap between the contracted job duties and the realities of what was expected within the team or practice unit. They noted being assigned time-consuming nonclinical tasks without adequate help from support staff.13 Some APCs could not identify their immediate supervisors, leaving them unsure as to whom to approach with professional or administrative concerns. For some, this was merely a nuisance until renegotiated within the practice, but for others, the lack of a “go-to” supervisor was disempowering. Theme 4. Workplace Culture and Behavior. Overall, most of our APCs reported satisfaction with their collaborative relationships. They specifically valued mutual respect,9,11 support from co-workers,8 dialogic communication and feedback, and team-based patient care mixed with personal autonomy.9,10,18 However, inadequate opportunities for emotional support, mentoring, and interaction with peers13 were noted as contributors to low morale. Several themes identified in our analysis are consistent with those previously published, as annotated in the points listed above. To our knowledge, the shared split billing issues in Compensation (Theme 1) and Network Advocacy (Theme 2) had not been previously identified.
Please cite this article as: Motley RJ, et al. Using focus groups to identify characteristics of an ideal work environment for Advanced Practice Clinicians. Healthcare (2016), http://dx.doi.org/10.1016/j.hjdsi.2015.10.007i
R.J. Motley et al. / Healthcare ∎ (∎∎∎∎) ∎∎∎–∎∎∎
3
4. Network response
4.4. Workplace culture (Theme 4)
4.1. Network advocacy (Theme 2)
In response to our findings on workplace culture and behavior, members of our medical staff leadership started informal conversations with interdisciplinary groups that had low staff turnover rates. Their inquiries validated a presence of mutual respect and trust in which APCs were able to share ideas or get feedback in an environment of safety. A sense of team existed, characterized by gathering at mealtimes, open discussions, and assisting one other during busy times. In contrast, groups experiencing higher turnover lacked many of these attributes. Their workdays were driven with more hierarchical and inflexible roles, and the environment did not support open communication. Some of these groups have still been able to attract new employees by offering higher than average salaries, but turnover continues to be a problem. These issues are not unique to APCs—physician groups struggle with many of the same “cultural” issues. This process of informally engaging groups about their practice behaviors and traditions has prompted additional conversations among APCs in the network and has influenced other group practice leaders to assess their own unique environments.
By framing questions around the “ideal state,” we were able to describe aspects of the existing APC work environment and identify gaps. Our findings were presented to our network senior management council, who took action quickly to resolve the issues represented by the theme of Network Advocacy. Clearly, advocacy is impossible without adequate representation. APCs recognized that positive change was not possible without a stronger voice and a vote at the senior layer of the organization. An APC representative was appointed as a voting member of the senior management representative body, and APC councils within the network have been re-chartered for more broadly recognized representation. APCs are included in all communication channels aimed at clinicians, receiving clinical updates side-by-side with physician colleagues. They now have a dedicated section of the monthly medical staff newsletter, attend and offer input at network provider group meetings, and participate in quality and safety initiatives. Additionally, they have taken lead roles in patient engagement and the rollout of our newly implemented electronic medical record system (EMR). 4.2. Compensation (Theme 1) Progress has been slower with compensation issues. While a competitive salary helps with recruiting, it is but one of many drivers of job satisfaction. A review of network APC salaries relative to regional benchmarks did not reveal gaps. It is possible that perceptions of inadequate salaries could have been influenced by the issues described in the third theme of Roles and Reporting Relationships; additional administrative duties without remuneration can feel burdensome. Growth in patient volumes and an increase in collaborative clinical practice have also made it challenging to measure productivity within a shared billing model. Until the new institution-wide EMR enables better capture of shared billing, efforts have focused on educating physicians and coders about shared split billing criteria and documentation. Within private group practices, there is wide variation in salary policies and the criteria for revenue sharing and incentives. While some network-employed divisions have standardized salary and shared compensation policies, this remains a work in progress. Within certain high-demand specialties, annual network-recommended merit raise percentages are not always compared with salaries in the marketplace. A new hire sometimes prompts a salary correction for current employees. 4.3. APC roles (Theme 3) Regarding roles and reporting relationships within the practice unit, there have been disconnects at times between written job descriptions and the operational roles within practices. Upon closer inspection, we found that role clarity appears to depend on the relative strength of the groups' internal leadership and administrative skills. Physicians who lack a comprehensive understanding of the scope of practice for APCs often assign clinical and administrative tasks without critical analysis of priority or flow, resulting in duties that are not “top of license.” In both inpatient and outpatient settings, our network has engaged practice coaches to help educate physicians, identify system inefficiencies, and reengineer processes to reduce waste. Training in Toyota Lean principles19 is offered at several levels of the organization. A leadership fellowship is also offered to mid-career clinicians and administrators for improving leadership and administrative skills.
5. Project impact To reiterate, the APC feedback described herein has sparked discussion at all levels of our organization; the themes identified have focused attention on areas that require deeper analysis. Although culture change is dependent on many factors and can take years to achieve, tangible improvements have been made with billing and compensation, network representation, and processes within practice units. Looking forward, members of our APC Council leadership team are considering a survey of APCs to gather feedback on progress and continued areas of concern. There are several potential limitations to our project. Although APCs from all disciplines were invited to participate, our groups comprised mostly physician assistants and nurse practitioners. Because of the relatively low response rate (39 of 273), we did not have a representative sample. The conclusions drawn here may not be generalizable to other settings or APC professions. The themes identified may be unique to our network, although we were encouraged by the degree of congruence with those identified in existing literature. 5.1. Key lessons We were fortunate to have access to senior leaders and to garner their support for change within our organization. This was a key ingredient. Every healthcare system has its own culture and processes that influence the probability of success. Engaging senior management and those with influence and decision-making power was an important early step. With predicted physician shortages and expectations for high quality and reliability at reasonable cost, the face of the healthcare workforce is changing. APCs have become members of inpatient, outpatient, and complex care management teams. They contribute to all three components of the Triple Aim—enhancing patient experience, improving population health, and reducing costs.20 In return, APCs want fair remuneration with transparency around salary inputs, recognition of their scope of practice, and greater role clarity within their clinical teams. We learned that adapting to these evolving conditions requires proactive management, most effectively carried out at the practice unit level. The higher functioning practices we identified during our follow-up process demonstrated greater levels of commitment to understanding the changing landscape. These practices had leadership infrastructures
Please cite this article as: Motley RJ, et al. Using focus groups to identify characteristics of an ideal work environment for Advanced Practice Clinicians. Healthcare (2016), http://dx.doi.org/10.1016/j.hjdsi.2015.10.007i
R.J. Motley et al. / Healthcare ∎ (∎∎∎∎) ∎∎∎–∎∎∎
4
that promoted teamwork with greater task alignment and fostered cultures in which cooperation, recognition, and rewards were valued.21 It is in a health system’s strategic interest to identify and endorse these “best practices,” inviting practice leaders and their APCs to share experiences on a peer-to-peer basis. APCs want to be respected and to have their voices heard. Mutual respect, teamwork, and open communication are essential elements for collaborative care delivery.18 Moreover, these factors affect quality and the patient experience.22 Conditions in the work environment can be framed as internal service quality parameters that influence professional satisfaction, productivity, and retention, linking them to a healthier external service value—customer satisfaction and loyalty.23 In an era of HCAHPS scores24 and patient satisfaction surveys, attending to employee well-being supports better clinical performance and patient satisfaction. We found that asking APCs for input and giving them greater representation has built trust and started a multi-year journey of discovery that we believe has broad strategic value.
6. Conclusion In summary, our findings suggest that healthcare leaders working with inter-professional teams must attend to multiple sectors of the Ways of Knowing Paradigm: the external marketplace, the details of job roles and workflows within practice units, and the interpersonal dynamics and skills that support healthy work relationships. In addition to affecting productivity, satisfaction, and retention, these factors can influence a healthcare network's ability to achieve its patient/family-centered goals. Future studies should be conducted with larger, more diverse APC groups to further define the ideal APC work environment.
References 1. Hooker RS, Klocko DJ, Larkin GL. Physician assistants in emergency medicine: the impact of their role. Acad Emerg Med. 2011;18:72–77. 2. Hinkel JM, Vandergrift JL, Perkel SJ, Waldinger MB, Levy W, Stewart FM. Practice and productivity of physician assistants and nurse practitioners in outpatient oncology clinics at national comprehensive cancer network institutions. J Oncol Pract. 2010;6:182–187. 3. Britell JC. Role of advanced nurse practitioners and physician assistants in
Washington state. J Oncol Pract. 2010;6:37–38. 4. Moote M, Krsek C, Kleinpell R, Todd B. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual. 2011;26:452–460. 5. Shaver KH, Lacey LM. Job and career satisfaction among staff nurses: effects of job setting and environment. J Nurs Admin. 2003;33:166–172. 6. De Milt DG, Fitzpatrick JJ, McNulty R. Nurse practitioners' job satisfaction and intent to leave current positions, the nursing profession, and the nurse practitioner role as a direct care provider. J Am Acad Nurse Pract. 2011;23:42–50. 7. Stange KC, Miller WL, McWhinney I. Developing the knowledge base of family medicine. Fam Med. 2001;33:286–297. 8. Freeborn DK, Hooker PA. Satisfaction of physician assistants and other nonphysician providers in a managed care setting. Public Health Rep. 1995;110:714–719. 9. Misener T, Cox D. Development of the Misener nurse practitioner job satisfaction scale. J Nurs Meas. 2001;9:91–108. 10. Kacel B, Miller M, Norris D. Measurement of nurse practitioner job satisfaction in a midwestern state. J Am Acad Nurse Pract. 2005;17:27–32. 11. Wild P, Parsons V, Dietz E. Nurse practitioner's characteristics and job satisfaction. J Am Acad Nurse Pract. 2006;18:544–549. 12. Muus KJ, Geller JM, Williams JD, Ludtke RL, Knowlton DD, Hart LG. Job satisfaction among rural physician assistants. J Rural Health. 1998;14:100–108. 13. Faris JA, Douglas MK, Maples DC, Berg LR, Thrailkill A. Job satisfaction of advanced practice nurses in the veterans health administration. J Am Acad Nurse Pract. 2010;22:35–44. 14. Wilber KA. Theory of Everything. Boston. MA: Shambala Publications, Inc; 2000. 15. Stange KC. Ways of knowing, learning, and developing. Ann Fam Med. 2010;8:4–10. 16. Lynch MP, Cope DG, Murphy-Ende K. Advanced practice issues: results of the ONS advanced practice nursing survey. Oncol Nurs Forum. 2001;28:1521–1530. 17. Tri DL. The relationship between primary health care practitioners' job satisfaction and characteristics of their practice settings. Nurse Pract. 1991;16:46–55. 18. Way D, Jones L, Busing N. Implementation strategies: Collaboration in primary care–family doctors & nurse practitioners delivering shared care. Discussion Paper written for the Ontario College of Family Physicians (OCFP), OCFP, May 18; 2000. 19. Ohno T. Toyota Production System: Beyond Large-Scale Production. Portland, OR. Productivity Press; 1988. 20. Institute for Healthcare Improvement (IHI). IHI Triple Aim Initiative. Available at: 〈http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx〉; 2014. Accessed 15.07.15. 21. Beer M, Eisenstat RB, Spector B. Why change programs don’t produce change. Harv Bus Rev. 1990:158–166. 22. Kaplan GS. Respect: the foundation for quality care. Hospital Impact. Available at 〈http://hospitalimpact.org/index.php/2013/06/10/respect_the_foundation_ for_quality_care〉; 2013. Accessed 30.07.15. 23. Heskett JL, Jones TO, Loveman GW, Susser Jr. WE, Schlesinger LA. Putting the service-profit chain to work. Harv Bus Rev. 2008:118–129. 24. Centers for Medicare & Medicaid Services (CMS). HCAHPS: Patients' Perspectives of Care Survey. 〈https://www.cms.gov/Medicare/Quality-Initiatives-Patient-As sessment-instruments/HospitalQualityInits/HospitalHCAHPS.html〉. Accessed 31.07.15.
Please cite this article as: Motley RJ, et al. Using focus groups to identify characteristics of an ideal work environment for Advanced Practice Clinicians. Healthcare (2016), http://dx.doi.org/10.1016/j.hjdsi.2015.10.007i
Contents lists available at ScienceDirect
Healthcare journal homepage: www.elsevier.com/locate/hjdsi
Using focus groups to identify characteristics of an ideal work environment for Advanced Practice Clinicians Robert J. Motley a,n, Richard J. Mazzaccaro b, David B. Burmeister c, Samuel D. Land d, Richard M. Boulay e, Heiwon Chung f, Lynn Deitrick g, Andrew D. Sumner h a
Department of Community Health, Lehigh Valley Health Network, 1628 W. Chew Street, Allentown, PA 18102, USA Department of Pediatrics, Lehigh Valley Health Network, Allentown, PA, USA c Department of Emergency Medicine, Lehigh Valley Health Network, Allentown, PA, USA d Department of Pathology and Laboratory Medicine, Lehigh Valley Health Network, Allentown, PA, USA e Department of Obstetrics & Gynecology, Lehigh Valley Health Network, Allentown, PA, USA f Department of Surgery, Lehigh Valley Health Network, Allentown, PA, USA g Department of Behavioral and Community Sciences, University of South Florida, Tampa, FL, USA h Center for Advanced Health Care, Division of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA b
art ic l e i nf o
a b s t r a c t
Article history: Received 6 November 2014 Received in revised form 31 July 2015 Accepted 20 October 2015
Advanced Practice Clinicians (APCs) in collaborative practice represent a diverse and valuable group of health care professionals, including nurse practitioners, physician assistants, nurse anesthetists, and nurse midwives. Because these healthcare professionals have been identified as part of the solution to physician shortages, it is critical for health networks to examine and address issues affecting collaborative relationships. We invited our network APCs to participate in focus group sessions to determine both attributes and barriers to an ideal work environment. Four major themes emerged: (1) compensation, (2) network representation, (3) employment structure, and (4) workplace culture. While issues relating to compensation and representation were prevalent, discussions also revealed the importance of relationships and communication. To ensure successful collaboration and, thereby, reduce clinician turnover, leaders must address gaps between the existing and ideal states in structural factors affecting job satisfaction (Themes 1–3) as well as the behavioral factors represented in workplace culture (Theme 4). & 2015 Elsevier Inc. All rights reserved.
Keywords: Allied health professionals Job satisfaction Work environment Focus groups Workforce
1. Introduction Advanced Practice Clinicians (APCs) in collaborative practice have become integral stakeholders in health care delivery within both inpatient and outpatient settings.1–3 The demand for APCs— nurse practitioners, physician assistants, nurse anesthetists and midwives—has accelerated recently, driven by legislative support, resident duty hour restrictions,4 expanding clinical complexity, and cost pressures. In Pennsylvania, legislation has been introduced to grant nurse practitioners independent practice authority, a privilege that 20 other states have already adopted. In a competitive marketplace, APC satisfaction is highly correlated with recruitment and retention.5 However, recent survey data has shown that up to 27% of nurse practitioners have expressed intent to leave their current positions.6 The loss of clinical team members disrupts patient access and continuity of care, and can also negatively affect efficiency, n
Corresponding author. E-mail address: [email protected] (R.J. Motley).
quality, and safety. Our health network, motivated to explore the APC work environment after the sudden loss of a group of 5 nurse practitioners from a single discipline, sought to identify and support an ideal work environment for APCs as one important strategy for maintaining a high-quality, collaborative workforce.
2. Study design and methods An interdisciplinary team of seven practicing physicians and one medical anthropologist convened to explore our network APCs' perception of an ideal work environment. We adopted a focus group format to elicit a wide range of participant concerns,7 seeking to identify both barriers and facilitators to an APC ideal work environment. Our goals were to inform clinicians and senior leaders, improve professional satisfaction, and reduce clinician turnover. Over the past 15 years, researchers have investigated issues of work environment and professional satisfaction among APCs,8–13 using surveys or semi-structured interviews with predetermined
http://dx.doi.org/10.1016/j.hjdsi.2015.10.007 2213-0764/& 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Motley RJ, et al. Using focus groups to identify characteristics of an ideal work environment for Advanced Practice Clinicians. Healthcare (2016), http://dx.doi.org/10.1016/j.hjdsi.2015.10.007i
R.J. Motley et al. / Healthcare ∎ (∎∎∎∎) ∎∎∎–∎∎∎
2
“I”
“It”
(personal attitudes, biases)
(aspects of work or job duties)
Autonomy Mutual Respect
Roles/ Reporting Structure Compensation
“We”
“They”
(close relationships-co-workers, teams, individual practice unit)
(attributes of the organization or health system)
Teamwork Communication Support/ Recognition
Network Representation Alignment of Strategies
External frames of reference
Internal frames of reference
designed to explore rewards and recognition within the context of a large health network).
Fig. 1. Ideal work environment themes in the “Ways of Knowing” framework: Domains of each quadrant of the model are listed in parentheses. Themes that emerged from the focus group analysis are presented in bold.
topics.8–10 To support the more qualitative nature of focus groups, we used Wilber's “Ways of Knowing” paradigm14 (Fig. 1) as a conceptual framework for organizing the themes from the published literature and to construct the focus group interview questions. “Ways of Knowing” is a four-quadrant model in a twoby-two design. On the “external” side is the work itself (“It”) and the larger system in which it takes place (“They”). On the “internal” side are the attitudes and motivations that health professionals bring to their work (“I”), as well as the team milieu (“We”) in which attitudes, behaviors and teamwork come to life. This conceptual model is a process for integrating data to the level of knowledge and understanding.15 Within healthcare, Stange and colleagues7,15 have used this four-quadrant approach to support mixed-methods research and knowledge development within generalist medicine. Process-wise, we sent internal email invitations to 273 randomly selected APCs within our health network. Thirty-nine responded, with approximately 10 participating in each of four separate sessions conducted in October and November 2010. The initial focus group session was moderated by a medical anthropologist with qualitative methods expertise; subsequent sessions were moderated by a research physician. Participants predominantly included nurse practitioners and physician assistants. The majority (64%) practiced primarily in outpatient settings. Of the 39 participants, 28% identified themselves as primary care clinicians; 72% practiced in sub-specialty fields. After collecting demographic information and obtaining consent, physicians facilitated the four focus group discussions with questions modeled from those previously used in validated surveys.9,11,16 Follow-up probe questions based on “Ways of Knowing”14 included the following:
What aspects of your work bring you the greatest satisfaction? (“I” quadrant, designed to explore attitudes, motivation).
How can doctors build healthy relationships with the APCs who
work with them? (“We quadrant, designed to explore working relationships within clinical teams”). If you could change one aspect of your job that would make it better for you, what would it be? (“It” quadrant, designed to explore aspects of the work itself). How are you recognized for your efforts? (“They” quadrant,
We recorded responses on flip charts and by audio; after transcripts were de-identified, all data were reviewed collectively by the physician team. Four dominant themes emerged and are described in the section below.
3. Primary themes
Theme 1. Compensation and Accurate Accounting of Work. A large part of the discussion in each of the focus groups centered on APC compensation, including both salary and accurate accounting of work performed. Participants reported perceptions that current salaries were below national averages,13,17 and that they had limited access to information about drivers of salary increases and incentives.10 Among other concerns were ambiguity in crediting relative value units (RVUs) for shared work with physicians and less available reimbursement of continuing medical education expenses than that of physicians.10 Theme 2. Network Advocacy. Although our health network supports an Advanced Practice Clinician Council whose mission is to support and integrate the professional interests of APCs within the network, several participants indicated uncertainty about the Council's role. Other concerns were the poor attendance at APC member meetings because of clinical duty conflicts or inconvenient meeting locations, lack of representation at the senior leadership level, and a perceived lack of communication about important changes affecting APCs within the network. Theme 3. Roles and Reporting Relationships. Focus group attendees said they valued collaborative relationships and saw their roles as complementary to those of physicians. However, many APCs felt there was a gap between the contracted job duties and the realities of what was expected within the team or practice unit. They noted being assigned time-consuming nonclinical tasks without adequate help from support staff.13 Some APCs could not identify their immediate supervisors, leaving them unsure as to whom to approach with professional or administrative concerns. For some, this was merely a nuisance until renegotiated within the practice, but for others, the lack of a “go-to” supervisor was disempowering. Theme 4. Workplace Culture and Behavior. Overall, most of our APCs reported satisfaction with their collaborative relationships. They specifically valued mutual respect,9,11 support from co-workers,8 dialogic communication and feedback, and team-based patient care mixed with personal autonomy.9,10,18 However, inadequate opportunities for emotional support, mentoring, and interaction with peers13 were noted as contributors to low morale. Several themes identified in our analysis are consistent with those previously published, as annotated in the points listed above. To our knowledge, the shared split billing issues in Compensation (Theme 1) and Network Advocacy (Theme 2) had not been previously identified.
Please cite this article as: Motley RJ, et al. Using focus groups to identify characteristics of an ideal work environment for Advanced Practice Clinicians. Healthcare (2016), http://dx.doi.org/10.1016/j.hjdsi.2015.10.007i
R.J. Motley et al. / Healthcare ∎ (∎∎∎∎) ∎∎∎–∎∎∎
3
4. Network response
4.4. Workplace culture (Theme 4)
4.1. Network advocacy (Theme 2)
In response to our findings on workplace culture and behavior, members of our medical staff leadership started informal conversations with interdisciplinary groups that had low staff turnover rates. Their inquiries validated a presence of mutual respect and trust in which APCs were able to share ideas or get feedback in an environment of safety. A sense of team existed, characterized by gathering at mealtimes, open discussions, and assisting one other during busy times. In contrast, groups experiencing higher turnover lacked many of these attributes. Their workdays were driven with more hierarchical and inflexible roles, and the environment did not support open communication. Some of these groups have still been able to attract new employees by offering higher than average salaries, but turnover continues to be a problem. These issues are not unique to APCs—physician groups struggle with many of the same “cultural” issues. This process of informally engaging groups about their practice behaviors and traditions has prompted additional conversations among APCs in the network and has influenced other group practice leaders to assess their own unique environments.
By framing questions around the “ideal state,” we were able to describe aspects of the existing APC work environment and identify gaps. Our findings were presented to our network senior management council, who took action quickly to resolve the issues represented by the theme of Network Advocacy. Clearly, advocacy is impossible without adequate representation. APCs recognized that positive change was not possible without a stronger voice and a vote at the senior layer of the organization. An APC representative was appointed as a voting member of the senior management representative body, and APC councils within the network have been re-chartered for more broadly recognized representation. APCs are included in all communication channels aimed at clinicians, receiving clinical updates side-by-side with physician colleagues. They now have a dedicated section of the monthly medical staff newsletter, attend and offer input at network provider group meetings, and participate in quality and safety initiatives. Additionally, they have taken lead roles in patient engagement and the rollout of our newly implemented electronic medical record system (EMR). 4.2. Compensation (Theme 1) Progress has been slower with compensation issues. While a competitive salary helps with recruiting, it is but one of many drivers of job satisfaction. A review of network APC salaries relative to regional benchmarks did not reveal gaps. It is possible that perceptions of inadequate salaries could have been influenced by the issues described in the third theme of Roles and Reporting Relationships; additional administrative duties without remuneration can feel burdensome. Growth in patient volumes and an increase in collaborative clinical practice have also made it challenging to measure productivity within a shared billing model. Until the new institution-wide EMR enables better capture of shared billing, efforts have focused on educating physicians and coders about shared split billing criteria and documentation. Within private group practices, there is wide variation in salary policies and the criteria for revenue sharing and incentives. While some network-employed divisions have standardized salary and shared compensation policies, this remains a work in progress. Within certain high-demand specialties, annual network-recommended merit raise percentages are not always compared with salaries in the marketplace. A new hire sometimes prompts a salary correction for current employees. 4.3. APC roles (Theme 3) Regarding roles and reporting relationships within the practice unit, there have been disconnects at times between written job descriptions and the operational roles within practices. Upon closer inspection, we found that role clarity appears to depend on the relative strength of the groups' internal leadership and administrative skills. Physicians who lack a comprehensive understanding of the scope of practice for APCs often assign clinical and administrative tasks without critical analysis of priority or flow, resulting in duties that are not “top of license.” In both inpatient and outpatient settings, our network has engaged practice coaches to help educate physicians, identify system inefficiencies, and reengineer processes to reduce waste. Training in Toyota Lean principles19 is offered at several levels of the organization. A leadership fellowship is also offered to mid-career clinicians and administrators for improving leadership and administrative skills.
5. Project impact To reiterate, the APC feedback described herein has sparked discussion at all levels of our organization; the themes identified have focused attention on areas that require deeper analysis. Although culture change is dependent on many factors and can take years to achieve, tangible improvements have been made with billing and compensation, network representation, and processes within practice units. Looking forward, members of our APC Council leadership team are considering a survey of APCs to gather feedback on progress and continued areas of concern. There are several potential limitations to our project. Although APCs from all disciplines were invited to participate, our groups comprised mostly physician assistants and nurse practitioners. Because of the relatively low response rate (39 of 273), we did not have a representative sample. The conclusions drawn here may not be generalizable to other settings or APC professions. The themes identified may be unique to our network, although we were encouraged by the degree of congruence with those identified in existing literature. 5.1. Key lessons We were fortunate to have access to senior leaders and to garner their support for change within our organization. This was a key ingredient. Every healthcare system has its own culture and processes that influence the probability of success. Engaging senior management and those with influence and decision-making power was an important early step. With predicted physician shortages and expectations for high quality and reliability at reasonable cost, the face of the healthcare workforce is changing. APCs have become members of inpatient, outpatient, and complex care management teams. They contribute to all three components of the Triple Aim—enhancing patient experience, improving population health, and reducing costs.20 In return, APCs want fair remuneration with transparency around salary inputs, recognition of their scope of practice, and greater role clarity within their clinical teams. We learned that adapting to these evolving conditions requires proactive management, most effectively carried out at the practice unit level. The higher functioning practices we identified during our follow-up process demonstrated greater levels of commitment to understanding the changing landscape. These practices had leadership infrastructures
Please cite this article as: Motley RJ, et al. Using focus groups to identify characteristics of an ideal work environment for Advanced Practice Clinicians. Healthcare (2016), http://dx.doi.org/10.1016/j.hjdsi.2015.10.007i
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that promoted teamwork with greater task alignment and fostered cultures in which cooperation, recognition, and rewards were valued.21 It is in a health system’s strategic interest to identify and endorse these “best practices,” inviting practice leaders and their APCs to share experiences on a peer-to-peer basis. APCs want to be respected and to have their voices heard. Mutual respect, teamwork, and open communication are essential elements for collaborative care delivery.18 Moreover, these factors affect quality and the patient experience.22 Conditions in the work environment can be framed as internal service quality parameters that influence professional satisfaction, productivity, and retention, linking them to a healthier external service value—customer satisfaction and loyalty.23 In an era of HCAHPS scores24 and patient satisfaction surveys, attending to employee well-being supports better clinical performance and patient satisfaction. We found that asking APCs for input and giving them greater representation has built trust and started a multi-year journey of discovery that we believe has broad strategic value.
6. Conclusion In summary, our findings suggest that healthcare leaders working with inter-professional teams must attend to multiple sectors of the Ways of Knowing Paradigm: the external marketplace, the details of job roles and workflows within practice units, and the interpersonal dynamics and skills that support healthy work relationships. In addition to affecting productivity, satisfaction, and retention, these factors can influence a healthcare network's ability to achieve its patient/family-centered goals. Future studies should be conducted with larger, more diverse APC groups to further define the ideal APC work environment.
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Please cite this article as: Motley RJ, et al. Using focus groups to identify characteristics of an ideal work environment for Advanced Practice Clinicians. Healthcare (2016), http://dx.doi.org/10.1016/j.hjdsi.2015.10.007i