Title: Optimizing the Workforce and Patient Outcomes of Community Health Center Nurse Practitioners
Description: Many communities across the United States, including those from low-income and racial and ethnic minority groups, have less access to quality, timely, and preventative primary healthcare services. One factor contributing to this disparity is the shortage of primary care providers to meet demands in underserved areas. Nurse practitioners (NPs), or advanced-practice registered nurses trained to diagnose, treat, and manage health conditions, are a solution to meeting the nation’s primary care needs. Over the past decade, the NP workforce has grown significantly, doubling its number between 2010 and 2017. NPs frequently care for individuals from medically underserved communities, including those receiving care in community health centers (CHCs). CHCs are a network of safety-net healthcare organizations delivering comprehensive primary care in many rural and inner-city areas. However, the NP workforce can be further optimized in CHCs. Despite the growing national NP supply, CHCs struggle with adequate NP staffing.

Furthermore, providers working in CHCs and other safety-net settings report insufficient resources to care for patients, high workloads, and elevated staff turnover; these challenges may create poor practice environment and predispose CHC NPs to poor workforce outcomes, such as burnout and job dissatisfaction.Literature has demonstrated that poor clinician workforce outcomes, particularly burnout, negatively affect the safety and quality of care patients receive. Poor care and disease management may also result in disease exacerbation and, subsequently, preventable healthcare use by patients such as emergency department visits and hospital admissions. Preventable healthcare use increases the nation’s healthcare costs and may expose patients to harm. Despite the contributions of NPs to CHCs, little is known about how to optimize their staffing and workforce outcomes (e.g., reducing burnout, turnover intention, and improving job satisfaction) to assure positive patient outcomes. The overall purpose of this dissertation is to understand ways to optimize the NP workforce in CHCs to potentially improve outcomes for CHC patients.

Specific aims include: 1) examining factors that influence the recruitment and retention of NPs in underserved areas; 2) assessing the practice environment and workforce outcomes of NPs in CHCs; and 3) understanding the consequences of NP burnout on CHC patient outcomes. Dissertation Chapters and Findings The first chapter of this dissertation summarizes the background on the NP workforce and CHCs and details the problem under investigation. The second chapter is a scoping review examining the factors influencing recruitment and retention of NPs in underserved areas. Factors influencing recruitment and retention of NPs in underserved areas exist at various levels, from individual (e.g., growing up in underserved areas) to policy factors (e.g., autonomous scope of practice). However, current literature lacks rigorous, up-to-date, and NP-focused studies. The third chapter is a cross-sectional analysis of survey data from 269 CHC NPs. This chapter assessed the practice environment, job satisfaction, burnout, and turnover intention of NPs working in CHCs to better understand the current workforce conditions of CHC NPs; this chapter also examined the relationship between CHC NPs’ practice environment and workforce outcomes.

CHC NPs reported generally favorable practice environment and high job satisfaction. When CHC NPs report good relationships with their administration, they are more likely to report higher job satisfaction and lower intention to leave their jobs. The fourth chapter aimed to understand the implications of a negative workforce outcome (i.e., burnout) in the CHC setting. Through a cross-sectional analysis of merged NP survey and Medicare claims data, we examined the relationship between NP burnout and preventable hospitalization and emergency department use in patients. Patients receiving care in CHCs with higher NP burnout are more likely to use the emergency department for preventable reasons. The fifth and last chapter discusses the findings of this dissertation and its implications for policy, research, and practice.