Employee turnover rates are an important indicator for healthcare organizations. The loss of employees to resignation places a high financial burden on employers, costing hospitals an estimated $268,000 to $957,000 for every physician and $40,300 to $64,000 for every RN who resigns.1,2 An academic medical center may spend as much as $17 to 29 million per year—or 5% of its annual operating costs—on employee turnover.3
The physician assistant (PA) profession represents a large portion of the healthcare workforce, with more than 130,000 PAs practicing in the United States in 2018.4 Despite generally high career satisfaction, PAs report rates of turnover similar to or higher than those of physicians.5 One study found that more than 40% of PA respondents had quit a job in the past because of stress; another 13% intended to quit because of workplace stress.6 Replacing a PA can cost 100% to 200% of their annual salary, giving PA turnover a hefty price tag.5,7
Understanding the reasons PAs leave their jobs is essential for healthcare leaders to address PA turnover and increase employee retention. Previous research reveals some insight into the factors associated with PA turnover. For instance, multiple studies have found that lower compensation and increased work hours are related to PAs' intent to leave their jobs.5,8 Interpersonal factors such as low levels of perceived respect and limited autonomy inversely correlate with PA job satisfaction; stimulating work and higher autonomy can help offset the dissatisfying elements of a particular job.8 However, a complete understanding of the most common reasons behind PA turnover has not been established.
This study sought to better quantify the reasons prompting PAs to leave their jobs in a given year.
The American Academy of PAs (AAPA) distributes a salary survey to all PAs who have provided an email address and who have not opted out of email communication. In 2019, this survey was directly distributed to about 97,550 PAs and also was announced via social media, website announcements, and through other AAPA email communications. This study focuses on a subset of responses to that larger survey.
The AAPA survey asked PAs if they had changed their employment status in the previous year. PAs who responded that they had changed jobs were asked a subsequent multiple-choice question related to the reasons behind this change.
Although previous versions of the AAPA salary survey followed a similar format, this 2019 iteration included additional and expanded answer choices for the follow-up multiple-choice question. The impetus for revising this question was a high percentage of previous survey respondents who had selected other as the reason they changed their jobs.
On previous surveys, respondents who selected this other option had the opportunity to provide a free-text written response explaining their choice. Using the previous years' written response data as a guide, our research team created new answer choices to recategorize the potential reasons for PAs' job changes (Table 1). The new options represented a more diverse array of potential answer choices than had been included on any previous version of the AAPA salary survey.
TABLE 1. -
Examples of free-text other
responses provided in the 2018 AAPA salary survey, yielding new 2019 salary survey multiple-choice response options
|The new categories provided (bold) are those that were added for the 2019 AAPA salary survey. The items below each category illustrate the responses PAs wrote in after selecting other for the reason they changed employers.
Better management/leadership/environment (reasons related to toxic/abusive environment)
“Bait and switch by employer”
“HR was not helping in a hostile work environment.”
“Previous employer bought out by a corporation and it became an intolerable work environment.”
Corporate or external factors forced job change (for example, closed, lost contract, restructuring, company failing)
“Company lost contract and new company took over but it is the same practice location.”
“Hospital did not renew contract with outside group so I joined the new group.”
“My practice was acquired.”
Personal reasons/life change
“Got married and moved”
Better management/leadership/environment (reasons unrelated to toxic/abusive environment)
“Change in old practice, bought by corporation, not well managed”
“Prior practice sold to new management that I didn't care for”
Left or joined military
“Left active duty to reserve status”
“Location: [redacted], active duty”
“Retired from active duty”
Multifactorial responses still categorized as other
“Moved; better work/life; better pay”
“Better benefits, more patient friendly, better work/life balance, better commute, better work environment”
“Better commute, coworkers, work/life balance, better leadership/boss”
The answer choices available on the 2019 survey were: better compensation/benefits, better professional/clinical responsibilities, better work/life balance, better commute, opportunity to switch to a new clinical focus/specialty, moved, reentered the workforce following sabbatical or extended leave, completed education or postgraduate program, better management/leadership/environment (reasons related to toxic/abusive environment), better management/leadership/environment (reasons unrelated to toxic/abusive environment), left the workforce to retire or take an extended leave of absence, corporate or external factors forced the job change (for example, closed, lost contract, restructuring, company failing), personal reasons/life change, and left or joined the military.
Respondents who felt that none of the available multiple-choice answer options represented their reason for leaving could select the response other and again had the option to explain their answer via a short free-text response. Only one selection was allowed per respondent.
This study was determined to be exempt from institution review board review in accordance with US Department of Health and Human Service's Policy for Protection of Human Research Subjects listed at 45 C.F.R. §46.104(d)(2)(ii).
The 2019 AAPA salary survey had 13,088 PA respondents. The response rate, though difficult to calculate due to the use of multiple modes of recruitment, is estimated at 16.4%. The overall margin of error is ±0.81% at the 95% confidence level; response rates and margins of error vary for individual questions on the survey. Table 2 presents the personal characteristics of the respondents, which are very similar to those of the known PA population.9 Of the 13,088 respondents to the 2019 AAPA salary survey, 1,261 (12.3%) reported changing employers during the previous year (Table 3). The most common reasons provided for leaving a job were: better work/life balance (n = 209, 16.8%), moved (n = 208, 16.7%), better management/leadership/environment (reasons related to toxic/abusive environment) (n = 170, 13.6%), and better compensation/benefits (n = 148, 11.9%). The rates of response for the complete set of answer choice options are provided in Table 3.
TABLE 2. -
Characteristics of PA respondents to the 2019 AAPA salary survey
|Percentages may not total 100 because of rounding. Individual question response totals may be less than 13,088 because respondents did not respond to all questions.
| American Indian and Alaskan Native
| Native Hawaiian and other Pacific Islander
| Two or more races
| Not Hispanic
| Under 30
| 30 to 34
| 35 to 39
| 40 to 44
| 45 to 49
| 50 to 54
| 55 to 59
| 60 to 64
| 65 and older
| 0 to 1
| 2 to 4
| 5 to 9
| 10 to 14
| 15 to 19
| 20 or more
TABLE 3. -
Primary reasons PAs changed employers, 2019
|Individual question response totals may be less than 13,088 because respondents did not respond to all questions.
Changes in career in 2018
| I did not have any changes in my role, my employer, my setting, or my specialty
| Changed my role
| Changed my employer
| Changed my setting
| Changed my specialty
Reasons for changing employer
| Better work/life balance
| Better management/leadership/environment (reasons related to toxic/abusive environment)
| Better compensation/benefits
| Better professional/clinical opportunities
| Corporate or external factors forced job change (for example, closed, lost contract, restructuring, company failing)
| Opportunity to switch to a new clinical focus/specialty
| Completed education or postgraduate program
| Personal reasons/life change
| Better management/leadership/environment (reasons unrelated to toxic/abusive environment)
| Better commute
| Reentered workforce following extended leave (for example, unemployment, sabbatical)
| Left workforce to retire or take extended leave of absence
| Left or joined military
| Other (please specify)
A thorough understanding of the reasons behind PA turnover could have significant value for institutions and organizations that employ PAs. The 2019 AAPA salary survey provided the most expansive data to date to address this question.
The most common reason PAs reported changing employers was for better work-life balance. The idea of a work/life balance is nebulous, complex, and may involve many factors outside the control of an employer or organization. Although employers can attempt to provide flexibility to clinicians to balance their time spent at work, at home, and at leisure, this may be limited by the demands of an industry tasked with providing around-the-clock patient care.
The second-most common reason for PAs changing employers was that they geographically moved. Like work-life balance, this is largely out of the control of employers. Geographic relocation is difficult for employers to predict and address due to the variety of specific circumstances that may cause an individual or family to move their home.
However, the third-most common choice, better management/leadership/environment (reasons related to toxic/abusive environment), represents both a significant reason for PA turnover (13.6% of responses) and an opportunity for potential employer intervention.
The idea that a toxic workplace environment can lead to poor outcomes in healthcare settings is well established. Although it lacks standard terminology and definitions, toxicity/rudeness/incivility is pervasive in healthcare settings.10,11 Previous research has associated toxic workplace behavior with poor outcomes in healthcare workers, including burnout, anxiety, and depression.12,13 It has been linked to poor productivity, absenteeism, and the desire to quit.13,14 Research also has established a connection between toxic behavior/environments and employee turnover in healthcare professions.14,15 Bullying has been linked to RN turnover; bullied physicians are more likely to take sick leave, reduce their work hours, and report an intention to leave medicine altogether.14,15
Perhaps most concerning of all is the growing body of evidence that rude or toxic behavior has a significant effect on patient care and patient outcomes, especially in acute, high-stakes settings. Retrospective data have linked poor work environments in hospitals to increased patient mortality.16 Two randomized, controlled trials have shown that rude behavior has a profound, negative effect on clinician performance in simulated neonatal resuscitations and OR emergencies.17,18
How toxic work environments affect PAs is unknown, because much of the existing research focuses on outcomes among physicians and RNs. However, given the similar work environment and stressors shared by PAs and other healthcare professions, we suspected that toxic environments played a greater role in PAs' decisions to leave their employer than had been captured in previous surveys. Our review of previous surveys' open-ended responses provided valuable insight and early confirmation that workplace toxicity may play a major role in PA retention and turnover.
Our results suggest that the link between toxic environments and turnover seen in RNs and physicians likely extends to the PA profession. Given the size of the PA workforce, the economic advantages of employing and retaining PAs, and the cost of replacing them, healthcare organizations and institutions should examine the effect of toxic behavior on their entire clinician workforce—including PAs—and consider interventions to reduce the prevalence of and tolerance for toxic behaviors that may drive healthcare professionals away.
Any survey research has the potential for nonresponse bias and sample representativeness. However, 8,988 responses are needed for a 1% margin of error and 95% confidence interval, and our research sample included more than 13,000 PAs, representing about 10% of the entire PA population. Our sample also had similar characteristics to the National Commission on Certification of Physician Assistants' PA demographic data collected the same year.9 As such, there should be confidence in the sample established within this work. In terms of nonresponse bias, there is a chance that PAs who were more or less likely to change their employer in the past year responded to the survey. Using unpublished data, the AAPA was able to confirm that these 2019 findings are similar to those found over the past several years in the same survey instrument.
Additional limitations to this research include the chance of social desirability affecting respondents' answers. The respondents may not have felt comfortable providing honest responses to the questions. Specifically, social stigma may be associated with reporting some of the options, such as better management/leadership/environment (reasons related to toxic/abusive environment). Similarly, measuring a construct such as work-life balance poses an inherent challenge, because it may be conceptually defined but operationally variable and dependent on an individual's priorities, values, expectations, and more.
The survey also limited respondents to only the single most significant reason for change. Those with more than one reason for change, or multifactorial reasons, were not captured in this or previous versions of the AAPA salary survey. PAs may be more likely to select the simplest or easiest-to-articulate reason regardless of the complexities of their decisions.
Given the potential to address multiple important outcomes—including healthcare worker wellbeing, employee turnover, and patient outcomes—additional research should be done to examine the prevalence and effects of workplace toxicity as it affects PAs and other healthcare workers. Research should also explore the utility and effects of interventions to improve workplace behavior and culture.
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