Burnout Predicts Clinician, Not Staff, Turnover

Diana Phillips

January 24, 2019

Mitigating burnout and improving employee engagement in primary care practices may help to reduce clinician turnover, but it might have less influence on the retention of other staff, new research suggests.

In a longitudinal cohort study of the relationship between burnout and workforce turnover in primary care, burnout and low employee engagement predicted turnover for clinicians (physicians, nurse practitioners, and physician assistants) but not for staff, Rachel Willard-Grace, MPH, of the Department of Family and Community Medicine, University of California, San Francisco, and colleagues report in the January/February issue of Annals of Family Medicine.

For the study, the researchers used survey data collected in 2013 and 2014 from primary care clinicians and staff in two San Francisco health systems and matched them to employment roster data from 2016. They measured burnout using two subscales from the Maslach Burnout Inventory General Survey: the five-item emotional exhaustion subscale, and the five-item cynicism subscale. Respondents with high scores on either subscale were classified as being burned out. Employee engagement was assessed from participants' response to the survey item asking the likelihood of recommending their clinic as a place to work.

Of 740 survey respondents included in the analysis, 252 were clinicians, and 488 were staff (registered nurses, medical assistants, administrative/front office personnel, and behavioral health professionals). As determined on the basis of the predefined criteria, slightly more than half of clinicians (53.2%) and staff (52.8%) were classified as being burned out. In contrast, about one third of each group (32% and 34.5%, respectively) were highly engaged. Turnover rates in both groups were high, with 30% of clinicians and 41% of staff no longer working in the same primary care system at follow-up.

Using logistic regression modeling, the researchers found the following:

  • Burned out clinicians were more than 50% more likely to leave their position in 2 to 3 years than those who were not burned out (adjusted odds ratio [aOR] = 1.57; 95% confidence interval [CI], 1.02 - 2.40).

  • The cynicism subscale score significantly predicted clinician turnover (aOR = 1.04 for each 1-point increase in the cynicism scale; 95% CI, 1.01 - 1.07), but the exhaustion subscale did not (aOR = 1.02; 95% CI, 0.98 - 1.05).

  • Low employee engagement was borderline significantly associated with clinician turnover (aOR with high engagement = 0.58; 95% CI, 0.33 - 1.04, P = .07).

  • Neither burnout nor employee engagement predicted turnover for staff.

  • Working full time (vs part time), being employed in an academic setting (vs the public system), and having worked at the clinical site for longer than 5 years were each significantly associated with a lower probability of staff turnover.

High rates of burnout, low employee engagement, and high turnover are "compelling" problems in primary care and have implications regarding cost and quality, according to the authors.

"Burnout is a symptom of distress and is associated with poor mental health. Continuity of care is one of the cardinal principles of primary care, but it is difficult to maintain in environments with frequent changes in clinician and staff," they write. "Turnover is also expensive for health care organizations because of the lost revenue caused by clinician vacancies and the expense of recruiting new personnel, estimated at upward of $500,000 per clinician."

Although the current study adds support to the assertion that burnout and engagement contribute to turnover among clinicians, the fact that the relationship does not extend to primary care staff suggests the likelihood of multiple contributing drivers.

Employee turnover "may reflect not only a negative 'push' of burnout but a positive 'pull' of career mobility and opportunities for professional growth," the authors write. "It may also be influenced by varying personal expectations about ideal tenure within an organization, competition among employers for skilled workers, and externalities such as local housing costs, school district quality, and commute times. These factors other than burnout may be particularly salient for staff."

Addressing high rates of turnover in the primary care setting may require differential approaches based on individuals' roles, the authors stress. "[H]ealth care organizations and policymakers concerned about employee turnover in primary care will need to understand its multifactorial causes to develop effective retention strategies for clinicians and staff," they note.

Funding for data collection for the study was provided by participating health systems. The authors have disclosed no relevant financial relationships.

Ann Fam Med. 2019;17:36-41. Full text

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