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Retention rates and burnout among medical assistants: an evaluation study

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Retention rates and burnout among medical assistants: an evaluation study

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Content BURNOUT AMONG MEDICAL ASSISTANTS 1

Retention Rates and Burnout Among Medical Assistants: An Evaluation Study
by
Timothy P. Seay-Morrison

A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

May 2019

Copyright 2019 Timothy P. Seay-Morrison

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Table of Contents
Introduction of the Problem of Practice .......................................................................................... 5
Organizational Context and Mission .............................................................................................. 5
Organizational Performance Goal ................................................................................................... 6
Stakeholder Group of Focus and Stakeholder Goal ........................................................................ 6
Organizational Performance Status ................................................................................................. 6
Purpose of the Project and Questions ............................................................................................. 7
Importance of Addressing the Problem .......................................................................................... 7
Review of the Literature ................................................................................................................. 8
Projected Shortage in the Workforce .......................................................................................... 8
Burnout ....................................................................................................................................... 9
Measurement of Burnout .......................................................................................................... 10
Burnout in Health Care ............................................................................................................. 11
Rationale to Reduce Burnout .................................................................................................... 11
Team Structure and Distribution of Work ................................................................................ 13
Knowledge, Motivation and Organizational Influences ............................................................... 14
Knowledge and Skills ............................................................................................................... 14
Motivation ................................................................................................................................. 16
Organizational Influences ......................................................................................................... 20
Summary ................................................................................................................................... 22
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Interactive Conceptual Framework ............................................................................................... 23
Data Collection and Instrumentation ............................................................................................ 26
Survey Instrument ..................................................................................................................... 26
Survey Procedures .................................................................................................................... 28
Participants ................................................................................................................................ 29
Data Analysis ................................................................................................................................ 30
Quantitative Analysis ................................................................................................................ 30
Qualitative Analysis .................................................................................................................. 33
Document Review ..................................................................................................................... 33
Results and Findings ..................................................................................................................... 33
Knowledge Influences .............................................................................................................. 34
Motivation Influences ............................................................................................................... 37
Organizational Influences ......................................................................................................... 38
Recommendations for Practice ..................................................................................................... 40
Improving Retention ................................................................................................................. 40
Improving Organizational Culture Related to Burnout ............................................................ 41
Medical Assistants as Role Models for Coping with Burnout .................................................. 43
Limitations and Delimitations ....................................................................................................... 44
Recommendations for Further Research ....................................................................................... 44
Conclusion .................................................................................................................................... 45
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References ..................................................................................................................................... 46
Appendix A: Participating Stakeholders with Sampling Criteria ................................................. 55
Appendix B: Survey ...................................................................................................................... 56
Appendix C: Assumed Influences and Measurement ................................................................... 61
Appendix D: Validity and Reliability ........................................................................................... 65
Appendix E: Ethics ....................................................................................................................... 67
Appendix F: Implementation and Evaluation Plan ....................................................................... 70
Implementation and Evaluation Framework ............................................................................. 70
Organizational Purpose, Need and Expectations ...................................................................... 70
Level 4: Results and Leading Indicators ................................................................................... 71
Level 3: Behavior ...................................................................................................................... 72
Level 2: Learning ...................................................................................................................... 75
Level 1: Reaction ...................................................................................................................... 76
Data Analysis and Reporting .................................................................................................... 77

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Introduction of the Problem of Practice
Burnout is increasing among health care professionals in the United States, and more than
50% of physicians reported burnout in 2017, increasing from 42% in 2013 (Benson et al., 2016;
McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011; Peckham, 2017; Shanafelt & Hasan et.
al, 2015). Many studies have examined physician burnout and change over time, but little
current research exists related to other health care professionals, such as medical assistants.
Medical assistants provide a bulk of the daily work in medical offices, supporting licensed
clinicians with administrative and clinical support tasks (Taché & Chapman, 2004). Medical
assistants have one of the fastest rates of job growth in California, one of the largest number of
job openings, and 46% of employers report difficulty recruiting ample candidates (Centers of
Excellence, 2014; Taché & Chapman, 2004). Internal data shows that burnout is increasing
among medical assistants employed at U Health System, and that the turnover rate for these
employees is higher than the state average for this profession (U Health System, 2018). This
problem is important to address because as California braces for a shortage of physicians by
2025, a shortage of medical assistants could further weaken access to care across the state (Spetz,
Coffman, & Geyn, 2017).
Organizational Context and Mission
U Health System, a large, academic medical center system in California provides a broad
range of health care services focused primarily on complex, specialty care. The organization
also offers primary care and family medicine services in four counties surrounding the health
system’s main campus. The mission of the organization combines a trio of priorities including
patient care, education and research, and the vision focuses on healing through a human-centered
approach.
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Organizational Performance Goal
U Health System’s goal was, by December 2018, to retain 100% of medical assistants for
at least 24 months. This goal was chosen by the leadership of the organization because of the
focus on team-based care as a foundation of health care practice. Additionally, the financial and
emotional cost of turnover are disruptive to team-based care and efficiency in the practice
settings. Human resources data will be used to determine retention rates.
Stakeholder Group of Focus and Stakeholder Goal
Each of the stakeholder groups is important in health care, but this evaluation focused on
the medical assistant. This stakeholder group was chosen because these professionals have not
been studied as robustly as other health care disciplines and constitute a large percentage of the
workforce. The stakeholder goal was to improve management of symptoms of burnout in 100%
of medical assistants by December 2018. This goal was determined by studying the reasons
physicians and others turnover at high rates in health care. Recent focus in health care has
challenged health systems to add physician and staff wellness to the aims of the work in addition
to quality, cost, and patient experience. Surveys have been administered to some physicians and
staff to understand the level of burnout, how it changes over time, and perceptions of team-based
care.
Organizational Performance Status
Turnover rate for medical assistants employed in U Health System was 14.65% for the
prior fiscal year and 13.44% for the current fiscal year (U Health System, 2019). These rates
were higher than the turnover rate for comparison health systems in the region and the entire
state. U Health System has surveyed a subset of the medical assistants over the last two years to
examine burnout and perceptions of teamwork using an adapted version of the Professional
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Fulfillment Index (Trockel et al., 2018). In the five clinics surveyed, participant responses were
paired at two separate time points, approximately 18 months apart. The average burnout score
for medical assistants increased for all clinics and the average burnout score for physicians
decreased in four of the five clinics (U Health System, 2018).
Purpose of the Project and Questions
The purpose of this project was to evaluate the degree to which U Health System is able
to retain medical assistants and improve management of symptoms of burnout among medical
assistants. The analysis focused on knowledge, motivation and organizational elements related
to achieving the organizational goals. The stakeholders of focus for this analysis were the
medical assistants. As such, the questions that guided the study were the following:
1. To what extent is U Health System meeting its goal of retaining medical assistants?
2. What is the medical assistants’ knowledge and motivation related to managing symptoms
of burnout?
3. What is the interaction between U Health System’s culture and context and medical
assistants’ knowledge and motivation?
4. What are the recommendations for organizational practice in the areas of knowledge,
motivation, and organizational resources?
Importance of Addressing the Problem
It is important to evaluate the organization’s performance in relationship to the
performance goal of 100% medical assistant retention for many reasons. If the organization fails
to retain staff, it will find itself unprepared for the anticipated increase in demand for health care
in the state (Spetz, Coffman, & Geyn, 2017). Competition for qualified physicians and staff is
likely to become a stressor for health care organizations as the predicted increase in demand is
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also paired with an expected gap of health care professionals to meet the needs of communities
(Centers of Excellence, 2014; Spetz, Coffman, & Geyn, 2017; Taché & Chapman, 2004).
Without improvement in teamwork and a reduction in burnout, U Health System risks facing a
lack of an adequate number of staff to meet the demands for health care in the community over
time. An evaluation enables U Health System to consider how to recruit and retain medical
assistants and to understand the impact of burnout on the medical assistant population.
Review of the Literature
Projected Shortage in the Workforce
Both California and the entire United States face a deficit in health care professionals to
meet the demands over the next decade (Centers of Excellence, 2014; Jacobsen & Jazowski,
2011; Spetz, Coffman, & Geyn, 2017; Taché & Chapman, 2004). By 2030, California expects to
have an increase of 12% to 17% above the current demand for primary care staff and is projected
to have a shortfall of more than 4,000 physicians to meet this demand by 2025 (Spetz, Coffman,
& Geyn, 2017). The Association of American Medical Colleges (AAMC) projects a shortage of
over 120,000 MDs across all specialties by 2025 citing reasons such as increased patient volume
driven by legislation like the Affordable Care Act, lack of financial incentives for people to enter
medicine, and increasing demands on the workforce (Jacobsen & Jazowski, 2011). Growth in
the demand for health care services has also placed increased demand for medical assistants. In
2014, the Centers of Excellence estimated that nearly 5,000 medical assistants would be needed
to fill vacancies in the following 12 months with 43% of employers stating that finding qualified
candidates was difficult. Burnout is associated with attrition for these workers and further
compounds the issue of having an adequate supply of replacement health care professionals in
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the years ahead (Alameddine, Saleh, El-Jardali, Dimassi, & Mourad, 2012; Shanafelt & Mungo
et al., 2016).
Burnout
Burnout is a dynamic experience for an individual caused by an interaction of exhaustion,
reduced engagement in work, and reduced productivity or accomplishment (Bakker & Costa,
2014; Hobfoll, 1989; Maslach, Schaufeli, & Leiter, 2001). The dimensions of burnout include
emotional exhaustion, depersonalization or cynicism, and inefficacy or reduced personal
accomplishment arising from exhaustion and cynicism (Maslach, Schaufeli, & Leiter, 2001).
Burnout is a cycle in which the restriction of resources such as tools, social support, and other
supportive work conditions causes maladaptive coping or a reduction in work performance
(Bakker & Costa, 2014; Hobfoll, 1989). The diminished performance increases the pressure in
the work environment which leads to further exhaustion (Bakker & Costa, 2014; Hobfoll, 1989).
Burned out workers may negatively impact their coworkers through disruptive behaviors,
turnover, or poor attendance and they may be at higher risk for substance abuse, family problems
and sleep disruption (Maslach, Schaufeli, & Leiter, 2001). Burnout among physicians and other
health care providers is associated with attrition for this segment of the workforce (Alameddine,
Saleh, El-Jardali, Dimassi, & Mourad, 2012; Shanafelt & Mungo et al., 2016). A cross-sectional
design study that surveyed all health providers in primary care clinics in Lebanon found that
40% of the respondents reported that they were likely to quit in the next few years (Alameddine,
Saleh, El-Jardali, Dimassi, & Mourad, 2012). Additionally, high levels of burnout on the
Maslach Burnout Inventory (MBI) were associated with an increased likelihood to quit
(Alameddine, Saleh, El-Jardali, Dimassi, & Mourad, 2012). A longitudinal study of physicians
in a large US health system found that increases in emotional exhaustion scores, decreases in
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satisfaction scores, and worsening burnout were all associated with the likelihood of reducing
work commitment over the next two years (Shanafelt & Mungo et al., 2016).
Measurement of Burnout
Burnout has been measured using inventories assessing the factors impacting a person’s
burnout across specific domains (Dolan et al., 2015; Maslach, Jackson, Leiter, Zalaquett, &
Wood, 1997; Trockel et al., 2018). The Maslach Burnout Inventory (MBI), a common tool to
measure burnout, defines burnout related to a person’s relationship with work and uses subscales
to measure exhaustion, cynicism, and personal efficacy (Maslach, Jackson, Leiter, Zalaquett, &
Wood, 1997). The MBI has been modified for use in human services and education, and there is
a general survey to accommodate professions outside of human services (Maslach, Jackson,
Leiter, Zalaquett, & Wood, 1997). Health care organizations are interested in modified tools that
are more easily accessible and address other factors for burnout and prevention (Dolan et al.,
2015; Trockel et al., 2018). Dolan et al. (2015) conducted a study that validated the Emotional
Exhaustion subscale of the MBI was a standalone burnout measure with Pearson correlation of r
= 0.79 between the subscale and the full MBI.
A limitation of the MBI is the lack of information gathered about well-being of the health
care professionals and factors that influence professional fulfillment (Trockel et al., 2018). The
Professional Fulfillment Index (PFI) is a 16-item instrument designed to address these gaps in
measurement (Trockel et al., 2018). In a study of 250 physicians who completed the PFI, the
MBI, and three other assessments, the PFI measures for burnout and professional fulfillment
correlated highly with MBI equivalents and the test-retest reliability estimates were 0.82 for
professional fulfillment (Trockel et al., 2018). The PFI offers information not only about the
burnout of the physician, but also provides information about professional fulfillment and team
BURNOUT AMONG MEDICAL ASSISTANTS 11

dynamics attributable to interventions taking place in the work environment (Trockel et al.,
2018).
Burnout in Health Care
Numerous studies have examined the reasons for the high rates of burnout among
physicians and cite the main factors impacting burnout as control over work environment,
alignment with leadership, trust and belonging, workload distribution, and team communication
(Linzer et al., 2005; Shanafelt & Gorringe et al., 2015; Shanafelt & Mungo et al., 2016; Sinsky et
al., 2013). One study of over 4,000 physicians found that a 1-point positive increase in
perception of leadership correlated with a 3.3% decrease in likelihood to burnout and a 9%
increase in job satisfaction (Shanafelt & Gorringe, et al., 2015). There is less volume of research
examining other health care professionals’ burnout; however, the existing research shows levels
of burnout greater for physicians’ assistants, nurses, and nursing assistants than for non-medical
professionals (Benson et al., 2016; McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011;
Spinelli, Fernstrom, Galos, & Britt, 2016). Some findings in these studies of other professionals
are similar to those of the physicians where burnout is correlated to inadequate leadership
support, control over workload, and teamwork or community (Benson et al., 2016; Spinelli,
Fernstrom, Galos, & Britt, 2016).
Rationale to Reduce Burnout
Dr. Donald Berwick, former president of the Institute for Healthcare Improvement and
former Administrator for the Centers for Medicare and Medicaid Services described a “triple
aim” to improve health care in the United States which included the following goals: improving
patient experience, improving population health, and reducing costs (Berwick, Nolan, &
Whittington, 2008). The legislative and economic pressures to contain the rising costs of health
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care and improve outcomes is leading a change in medical practice where the relationship
between the patient and an entire care team is foundational (Berwick, Nolan, & Whittington,
2008; Ellner & Phillips, 2017; Glass, Kanter, Jacobsen, & Minardi, 2017; McDaniel, 2014).
Interventions such as the Patient Centered Medical Home and improved access through
technology have increased access to care driving up visits and the need for more staff to meet the
demands of increased utilization (Ellner & Phillips, 2017; Glass, Kanter, Jacobsen, & Minardi,
2017). Bodenheimer and Sinsky (2014) challenge Berwick’s definition of triple aim and exert
that we should move to also include provider wellness as burnout among primary care providers
increases.
Reducing burnout in a clinical practice can impact personal resilience of the staff and
physicians as well as reduce costs and improve quality of care (Bodenheimer & Sinsky, 2014;
Reid et al., 2010; Sinsky et al., 2013; Swensen & Shanafelt, 2017). Summarizing multiple
studies examining physician burnout, Swensen and Shanafelt (2017) suggest three outcomes of
reducing burnout and increasing joy in practice: (a) strengthen personal resilience, (b) eliminate
functional and structural drivers of burnout, and (c) satisfy the social and psychological needs of
the workforce.
Improving the quality of care provided and reducing harm to patients is associated with
lower physician burnout (Reid et al., 2010; Swensen & Shanafelt, 2017). A two-group, quasi-
experimental study of before and after metrics examined the benefits of a primary care practice
transformation to include team-based work, pre-visit planning, panel management, virtual care,
improved team communication, and structured management practices (Reid et al., 2010). Reid et
al. (2010) found that patient experience scores improved, clinical quality of the practice
improved, and reduced utilization produced a 1.5:1 return on financial investment. Additionally,
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the participants had significantly lower emotional exhaustion and depersonalization scores on the
MBI – Health Services survey compared to control clinic staff at 24 months after implementation
(Reid et al., 2010). Swensen and Shanafelt’s (2017) organizational framework to reduce burnout
examined multiple organizations targeting improved joy of practice and discovered that
physicians and staff involved in situations where harm occurred to a patient due to medical error
have risk for depression and burnout. Organizations with processes that focused on reducing
harm as well as supporting those professionals involved in a situation found improved resiliency
among staff and physicians (Swensen & Shanafelt, 2017).
Team Structure and Distribution of Work
Physician practices that have focused on improving the structure and culture of the team
as well as shifting work among team members have found reduced levels of burnout among the
members of the team (Bodenheimer & Smith, 2013; Reid et al., 2010; Willard-Grace & Dubé et
al., 2015; Willard-Grace & Hessler et al., 2014). Many services provided in a primary care clinic
do not require the expertise of licensure of a physician for effectiveness. Researchers have found
that dividing this work among other professionals can save up to 24% of primary care physician
time (Bodenheimer & Smith, 2013). A survey of approximately 500 primary care physicians and
staff found lower levels of exhaustion among staff when they reported higher levels of team
culture and working in a team-based structure.
Team structure, alone, did not impact exhaustion as much as strong team culture
(Willard-Grace & Hessler et al., 2014). Panel management is the proactive work of ensuring that
patients in the physicians’ panels are up to date on necessary tests and follow up interventions
which can typically be performed by a medical assistant with guidance from a physician
(Willard-Grace & Dubé et al., 2015). This work has been associated with improved rates of
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screening for illnesses and effective control of some chronic diseases. In a survey of
approximately 650 staff and physicians in primary care practices, high rates of panel
management were associated with lower cynicism scores on the five item Cynicism scale of the
MBI – General Survey (Willard-Grace & Dubé et al., 2015). Practices with high team culture
and high panel management had lower scores of cynicism and higher rates of “doability” of
primary care in a question designed for the study (Willard-Grace & Dubé et al., 2015).
Knowledge, Motivation and Organizational Influences
Knowledge and Skills
Knowledge and skills are one of the three important areas to assess when examining
causes of performance issues in organizations (Clark & Estes, 2008). These can be categorized
into types of knowledge to help inform the type of assessment methods to use to understand the
gaps that exist and potential solutions to address the gaps (Clark & Estes, 2008; Krathwohl,
2002; Mayer, 2011). Medical assistants need specific types of knowledge in order to combat
burnout. Conceptual knowledge is knowledge of the relationships between facts and how they
fit into an overall structure or concept (Krathwohl, 2002; Mayer, 2011). The following section
will explore literature focused on the conceptual knowledge influence of medical assistants’
understanding of an individual’s role on a team and effective communication strategies. An
additional knowledge type impacting burnout is metacognitive knowledge, the ability to be
aware and examine one’s own learning processes, knowledge obtained, and learning needs
(Mayer, 2011). The following section will also review relevant literature supporting the
importance of the metacognitive skill of understanding coping strategies to best manage
symptoms of burnout.
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Understanding an individual’s role on a team. A medical practice is made up of
physician and non-physician providers from the varying medical disciplines, and the practice
may also include a variety of support staff members who participate in the overall care of the
patients seeking care from the practice (American Association of Family Physicians, n.d.).
These may include physicians, nurses, medical assistants, administrators, and other health
professionals. Teamwork, and the conceptual knowledge associated with how to be on a team is
a knowledge influence impacting the success of these teams. In a study of four focus groups that
examined the factors influencing collaborative practice, van Dongen et al. (2016) found that the
factors were all interconnected. The interpersonal factors and organizational factors described
included the composition of the team, trust, respect, and knowing each other. O’Malley,
Gourevitch, Draper, Bond, and Tirodkar (2014) surveyed 63 people working in 27 different
primary care practices about the importance of teamwork on overcoming challenges of
productivity and satisfaction. This study found that the team members and clinics that used
practices associated with teamwork experienced more productivity and higher provider
satisfaction. This included concepts such as division of labor, role clarity, delegation of tasks,
and communication among the team. In another study of care coordinators, a group of
professionals and paraprofessionals who manage supportive tasks like medical assistants, found
that appropriate training on roles and responsibilities lowered the risk for burnout (Au, Kehn,
Ireys, Blyler, & Brown, 2018). Knowledge of the concepts of being on a team and how to
employ those skills impacts staff members’ collaboration in medical settings (O’Malley, et al.,
2014; van Dongen, et al., 2016).
Communication. Individual and team communication skills are an important factor in
successful teamwork and support reduced burnout and increased retention among health care
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professionals (Helfrich et al., 2013; Linzer et al., 2015; Sinsky et al., 2013; Stout et al., 2017;
Swensen & Shanafelt, 2017). Across several studies surveying physicians and other team
members, team behaviors such as standards for communicating, team meetings, huddles, and
team decision making are described as communication skills and strategies found to improve
burnout (Helfrich et al., 2013; Linzer et al., 2015; Sinsky et al., 2013; Stout et al., 2017; Swensen
& Shanafelt, 2017). Additionally, Linzer et al. (2015) found that interventions to improve
communication were associated with greater clinician satisfaction and retention.
Coping strategies to address burnout. Knowledge of coping skills and the use of
specific types of coping skills impact dimensions of burnout, and studies have shown that coping
skills can be taught to employees with positive outcomes (Bamonti et al., 2017; Jenaro, Flores, &
Arias, 2007; Rowe, 1999; Shin et al., 2014). Dysfunctional coping and emotion-focused burnout
strategies were found to positively correlate with higher burnout (Bamonti et al., 2017; Shin et
al., 2014). A meta-analysis of 36 studies involving over 9,000 human service and health care
professionals shows evidence that problem-focused coping strategies are correlated with lower
burnout (Shin et al., 2014). In a study of 188 health care providers, those who participated in a
six-week training on coping skills showed decreased burnout, and they showed continued
decreases in burnout over a two-year period if they participated in additional refresher sessions
(Rowe, 1999). While these strategies alone did not completely prevent burnout, they did show
correlation with reduced risk and possible improvement of employee retention (Jenaro et al.,
2007).
Motivation
Managing burnout requires time and attention from the medical assistants, fueled by their
individual and group motivation. Alexander, Schallert, and Reynolds (2009) explained that
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human learning is impacted by many aspects of our human nature. People can resist change,
learning is impacted by our emotions and reactions, and learning is an ongoing process
(Alexander et al., 2009). These principles that impact learning and change are what make up
human motivation to perform (Clark & Estes, 2008). Active choice, persistence, and mental
effort all impact the ability for change to occur and will impact the ability of the primary care
teams to modify from the current practice model to a new model (Clark & Estes, 2008). The
following discussion will review literature relevant to motivational theories and the impact of
motivation on managing burnout.
Perceived value of work. Motivation to change behavior can be explained by how
people perceive the value they will receive from engaging in the new behavior balanced with the
cost of engaging in the new behavior (Eccles, 2009). Eccles (2009) described the idea that
humans will evaluate the desire to perform the task based on attainment value, utility value, and
cost. Attainment value is the person’s assessment of how a change in performance will connect
to the self-image he or she has developed and wants to affirm through this behavior. Utility
value is the person’s assessment of how this behavior change fits into goals or fulfills needs
perceived by the person. Finally, the cost is the person’s perception of the emotional, physical,
time, and energy drain that may be felt by engaging in this task performance. Attainment value,
utility value, and cost are drivers of motivation for medical assistants to participate in team
culture and to remain in their current jobs with U Health System.
Expectancy of outcomes and linkage to self-image and ideology are identified as critical
factors for successful implementation of changes in team functioning (Ellard et al., 2016;
Lawrence & Frater, 2017; van Dongen et al., 2016). A study of four focus groups consisting of
experts and health care professionals mapped the factors influencing collaborative practice in
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primary care (van Dongen et al., 2016). The factors were all interconnected and spanned the
domains of patient-related, professional-related, interpersonal, organizational, and external. Both
intrinsic and extrinsic motivational factors were identified by the focus groups as influencing the
output of collaborative practice. In the van Dongen et al. (2016) study, the participants reported
that the intrinsic motivation was characterized as an internal desire to be collaborative on a team.
A similar finding by Lawrence and Frater (2017) was noted in a study of staff involved in
changing from a manual to automatic process in a hospital lab. The researchers used a model
developed by Hiatt (2006) examining awareness, desire, knowledge, ability, and reinforcement.
Among these participants, the study interpreted that more desire to change by an individual is
connected to higher capability of change and sustainment of the change. Desire was defined as
participants’ expectations for positive outcomes from the change and their motivation to perform
any tasks associated with this change. The attainment value perceived by participants impacts
overall motivation to engage in change and the cost of participating must also be examined.
The effort required to participate in behavior change impacts participants’ motivation to
continue as they weigh the cost of the change on their personal and professional situations
(Eccles, 2009). Ellard et al. (2016) interviewed non-physician clinicians and clinic leaders about
their experience as trainees in a three-month, competence-based training program. The trainees
reported positive experience in the training and in translating the training into practice.
Sustaining the changes proved difficult as trainees were disappointed if they were not able to
practice in appropriate facilities or if they lacked access to resources to perform their newly
trained skills. The Ellard et al. (2016) example highlighted a situation in which the utility value
would be low and could impact motivation to engage in future change activities. Additionally,
the cost of participating in the training program did not net all participants valuable outcomes.
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Eccles (2009) suggested that the likelihood of success is low when perceived cost does not
produce expected outcomes or support a person’s sense of attainment value.
Confidence in managing symptoms of burnout. Motivation is impacted by a person’s
self-efficacy beliefs or beliefs in one’s ability to learn and perform tasks in order to be successful
(Pajares, 2006). Self-efficacy beliefs are at the core of Bandura’s (2005) social cognitive theory
because they are linked to a person’s motivation. Pajares (2006) described the sources of self-
efficacy beliefs are mastery, vicarious experience, social feedback, and physiological responses.
People create a self-perception of their capabilities based on their experiences, feedback, and
interpretations of feedback and the outcomes of their performance. The level of self-efficacy for
a person impacts his or her motivation to engage in learning, exert effort and sustain focus on the
learning or task.
Confidence in one’s ability to employ coping strategies impacts burnout among health
care employees and may help improve retention (Elliott, Shewchuk, Hagglung, Rybarczyk, &
Harkins, 1996; Greenglass & Burke, 2002; Jenaro, Flores, & Arias, 2007; Shin et al., 2014). A
study of 211 human service professionals found that coping strategies alone did not prevent
burnout, but may help reduce employee turnover and higher perceptions of self-esteem and self-
efficacy correlate with high personal achievement, a factor impacted by burnout (Jenaro, et al.,
2007). Individual feelings of personal ability to manage stress and problems was predictive of
lower burnout scores among rehabilitation nurses surveyed about burnout, coping skills, and
stress (Elliott, et al., 1996). Similar results were found by a team studying burnout among
hospital employees experiencing restructuring (Greenglass & Burke, 2002). These researchers
noted that the personal resources of self-efficacy and coping skills resulted in lower burnout
(Greenglass & Burke, 2002).
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Organizational Influences
Organizational influences are the third of the three important areas to assess when
examining causes of performance issues in organizations (Clark & Estes, 2008). Culture, in an
organization, is comprised of basic assumptions and espoused values and beliefs (Schein, 2017).
This is also defined as a cultural setting or the pervasive understanding of how the world works
and the shared schema that guides the overall environment of the organization (Gallimore &
Goldenberg, 2001; Rueda, 2011). Organizational culture is also observed through the work
policies, processes, and work behaviors of the organization and the people within it (Clark &
Estes, 2008; Schein, 2017). These are defined as the cultural settings or the concrete ways in
which the organization’s culture is exhibited in daily practice (Gallimore & Goldenberg, 2001;
Rueda, 2011). Cultural models and cultural settings interact with one another and the
stakeholders of an organization (Rueda, 2011). Medical assistants’ burnout is impacted by the
cultural models and settings of U Health System. The following section will explore literature
focused on cultural models related to the organization’s understanding of burnout and the
cultural settings of U Health System’s support for the development of team culture, workload
distribution, and implementation of best practices to decrease burnout.
Understanding burnout. Burnout is impacting health care team members and driving
problems with retention among health care organizations (Alameddine, Saleh, El-Jardali,
Dimassi, & Mourad, 2012; Shanafelt & Mungo et al., 2016). Health care systems are challenged
to incorporate a focus on health care provider wellness and demonstrate a value in improving
burnout (Bodenheimer & Sinsky, 2014). One study that surveyed 2813 physicians found that
increases in leadership composite scores correlated with reduction in burnout (Shanafelt &
Gorringe et al., 2015). This study examined specific questions about the leadership qualities of
BURNOUT AMONG MEDICAL ASSISTANTS 21

supervisors in the organization and the perceived impact on the front-line staff levels of burnout
(Shanafelt & Gorringe et al., 2015). Group Health, a primary care collaborative in Seattle, found
improvements in patient experience, quality of care, and clinician burnout by implementing a
team-based model of care (Reid et al., 2010). This study reports that the investment by the
leadership in the new model of care and the goals to improve burnout were necessary to drive the
changes and promote success (Reid et al., 2010). U Health System’s understanding of burnout
will impact the interventions that support improvement for the medical assistants.
Teamwork and workload distribution. Value placed in team culture and teamwork is
likely to impact the primary care team members’ ability to improve burnout (Reid et al., 2010;
Swensen, & Shanafelt, 2017; Willard-Grace & Hessler, et al., 2014). A survey of over 500
primary care physicians and clinic staff members found that a greater sense of team culture was
connected to less exhaustion among the physicians and staff (Willard-Grace & Hessler et al.,
2014). These researchers conclude that an organization that works to build team culture may
help improve burnout for the team (Willard-Grace & Hessler et al., 2014). Reid et al. (2010)
report that the focus on and value of teamwork contributed to the improvements noted by Group
Health during the practice transformation of the primary care clinics. In a review of literature,
Swensen and Shanafelt (2017) provided an organizational framework recommendation to reduce
burnout in health care organizations. This framework suggested that organizations need to have
leaders who value teamwork and a culture that builds social community (Swensen & Shanafelt,
2017). The value of team culture and teamwork is one cultural model that impacts the cultural
settings, and therefore, the stakeholders’ ability to meet their goals.
Processes to implement best practices. A final representation of the organization’s
culture is the presence of systems to support team members in deploying best practices and
BURNOUT AMONG MEDICAL ASSISTANTS 22

improvement strategies (Linzer & Levine et al., 2013; Sinsky et al., 2013; Swensen & Shanafelt
et al., 2017; Willard-Grace & Dubé et al., 2015). A study of 23 primary care practices,
identified as high-functioning practices, found that implementation of the best practices to
support burnout reduction requires standard approaches and workflow mapping (Sinsky et al.,
2013). In the Group Health study, the researchers also noted that the practice transformation was
grounded in leadership commitment to change management and standardized management
approaches to implementing new processes (Reid et al., 2010). Supported by findings from
multiple researchers, the framework by Shanafelt and Swensen et al. (2017) proposed that
organizations need to have systems in place to support change management and implementing
solutions to improve practice. The presence of processes and procedures to help teams deploy
best practices is a cultural setting that will impact medical assistants’ reduction of burnout in
support of improving retention.
Summary
The purpose of this project was to evaluate the degree to which U Health System is
achieving its goal of retaining medical assistants and improving their ability to manage
symptoms of burnout. The bulk of available literature is focused on physicians and not on other
members of the primary care team. This study used information from the literature related to the
knowledge, motivation, and organizational influences on burnout to evaluate the impact on
medical assistants. Table 1 provides a summary of the knowledge, motivation, and
organizational influences that guided this study.

BURNOUT AMONG MEDICAL ASSISTANTS 23

Table 1
Knowledge, Motivation, and Organizational Influences on Burnout in Medical Assistants
Influence Influence Type
Medical assistants need to understand effective
communication strategies.
Knowledge: Declarative conceptual
Medical assistants need to understand role
expectations and how to engage in teamwork.
Knowledge: Declarative conceptual
Medical assistants need to understand effective
coping strategies to address burnout.
Knowledge: Metacognitive
Medical assistants need to feel there is value in
participating in team culture.
Motivation: Expectancy Value
Medical assistants need to feel confident that
they can manage symptoms of burnout.
Motivation: Self-Efficacy
Medical assistants need to feel that the benefits
of the job outweigh the costs.
Motivation: Expectancy Value
The organization needs to understand the causes
of and best practices associated with improving
burnout.
Cultural Model
The organization needs to support the
development of team culture and workload
distribution.
Cultural Model
The organization needs to have a process to
implement and support the best practices to
decrease burnout.
Cultural Setting

Interactive Conceptual Framework
A combination of the constructivist and pragmatic worldviews informed this study about
burnout among medical assistants (Creswell, 2014). In this study, the desire to understand how
to improve the outcome of burnout and retention of medical assistants relied on the interaction of
the team members and the meaning they individually and collectively gave to the influences on
burnout and retention.
The interaction of the knowledge, motivational, and organizational influences is a key
factor in reaching the stakeholder and organizational goals (Clark & Estes, 2008). This study
investigated research findings that the drivers of burnout among health care professionals are
BURNOUT AMONG MEDICAL ASSISTANTS 24

impacted by individual, team, organizational, and national factors (Shanafelt & Mungo et al.,
2016). As displayed in Figure 1, the organization must prioritize the problem and value the
interventions that support performance improvement. Leadership alignment with team
members’ values and actions that demonstrate organizational commitment to improvement will
impact burnout (Shanafelt & Mungo et al., 2016; Swensen & Shanafelt, 2017). The
stakeholders’, medical assistants, ability to meet the goal requires an investment by the
organization in the processes that support knowledge and motivational enhancement.
Additionally, the medical assistants influence each other and the performance of the team
through the interaction of their knowledge and motivation. The interaction of these influences
guided the interventions as well as the study questions to determine how well the stakeholders
are able to reach the goal and how this goal impacts the organization’s goal (Maxwell, 2013).
BURNOUT AMONG MEDICAL ASSISTANTS 25

Figure 1. The interaction of influences on reducing burnout among medical assistants.
BURNOUT AMONG MEDICAL ASSISTANTS 26

Data Collection and Instrumentation
Survey Instrument
The survey was created by combining questions developed for this study and an existing
survey, the Professional Fulfillment Index (PFI) designed by Trockel et al. (2018). The PFI is a
16-item self-report survey which was designed to examine physician’s burnout and professional
fulfillment and is scored on a 5-point Likert scale (Trockel et al., 2018). The PFI has six items in
the professional fulfillment/meaningfulness subscale, four items in the work exhaustion subscale,
and six items in the disengagement subscale (Trockel et al., 2018). The PFI has not been
validated with medical assistants, and this study allowed an opportunity to compare the
responses with those of physicians. For the purposes of this study, the professional
fulfillment/meaningfulness scale was adapted to match surveys previously used at U Health
System. The disengagement subscale was not used, and the work exhaustion scale was used to
describe burnout. To align with all of the knowledge, motivation, and organizational influences
of this study, 16 questions were added by the researcher, some of which were open-ended, and
some scored on a 5-point Likert scale. Five additional questions collected demographic data.
The survey protocol aligned with research questions, constructs, and potential analyses is
included in Appendix B.
Six scales were used in this study, and Table 2 presents the items that correspond with
each scale along with the reliability estimate, Chronbach’s alpha (α), for each scale. The work
exhaustion scale included the same items as the Trockel et al., (2018) study where α = 0.86.
Professional fulfillment/meaningfulness was most closely aligned with the professional
fulfillment scale (Trockel et al., 2018) where α = 0.92. Two survey items associated with the
BURNOUT AMONG MEDICAL ASSISTANTS 27

motivation influences that guided this study were not included in a scale: (a) I believe the
negative aspects of my job outweigh the positive, and (b) I prefer to work alone.
Table 2
Scales and Reliability Estimates
Scale and Items α
Work Exhaustion
Physically exhausted at work
A sense of dread when I think about the work I have to do
Emotionally exhausted at work
Lacking in enthusiasm at work

0.88
Professional Fulfillment/Meaningfulness
I enjoy helping my patients even when I am under time pressure.
My interactions with patients (or patient cases) are meaningful to me.
I am emotionally moved by my patients' experience even when I'm
stressed.
I help patients improve the quality of their lives.
My work is satisfying to me.
I feel in control when dealing with difficult problems at work.
I feel happy at work.
I feel worthwhile at work.

0.84
Control
The number of hours I work
The schedule I work
The volume of my patient load or panel size
Work interruptions (e.g. telephone calls, unscheduled patients)

0.84
Organizational Culture
Stanford Health Care has a process to avoid employee burnout.
I believe Stanford Health Care understands how to address burnout.
I can tell that Stanford Health Care is taking steps to prevent burnout
among medical assistants.
My manager can identify when an employee feels burned out.
My manager, or another leader, has supported my team in making sure
our work is divided up correctly.

0.91
Team Knowledge
I understand what is expected of me at work.
I understand my role on the team.
I know what information to share during huddle.
I believe Stanford Health Care values teamwork.
0.81
BURNOUT AMONG MEDICAL ASSISTANTS 28

Self-Efficacy
I feel confident I can manage my feelings of burnout or emotional
exhaustion at work.
I know what to do to prevent feeling burned out at work.

0.81

Survey Procedures
After approval from the Institutional Review Boards, the researcher gained access to the
employees by explaining the study rationale, sharing a short video description of the study, and
requesting permission from the Vice-Presidents and Executive Directors with oversight of the
medical assistants. In the fall of 2018, medical assistants received an email invitation to take the
Qualtrics survey that included brief information about the study, a hyperlink to the study, and a
QR code to scan to gain access to the survey via mobile device. This email was sent to all
employed medical assistants using U Health System’s tiered communication system in which the
direct supervisor of the employees sends the notification to their staff members. This allowed
the researcher to use direct supervisors for assistance in recruitment instead of using several
distribution lists. A single distribution list for medical assistants did not exist at the time of the
survey. To improve survey response and incentivize participation, the researcher created baskets
of snack foods that were placed in break rooms and common areas frequented by medical
assistants. The baskets contained cards with survey information, a survey link, and the QR code.
Flyers, with tear off sections containing the survey link, were also placed in the break rooms and
around the clinics. Finally, the researcher attempted to increase participation by walking through
clinics to explain the purpose of the study and potential value for the medical assistants. The
survey remained open for three week. This recruitment strategy allowed for the most
representative sample possible as all participants were provided access to the survey. Staff are
BURNOUT AMONG MEDICAL ASSISTANTS 29

used to being surveyed at different times of the year for questions about staff satisfaction,
quality, and improvement opportunities. Ethical issues related to this study and the recruitment
strategy are explained in Appendix E.
Participants
At the time of the survey, human resources reported that 505 people were employed as
medical assistants at U Health System. Survey data included surveys completed by 261 people,
a response rate of 51.6%. The organization reported similar demographic data about the total
population in gender identity and age. The other demographic items were not collected by U
Health System. A summary of the sample and population data is provided in Table 3.

Table 3
Demographic Characteristics of the Sample (n) and Total Population (N = 505)
Characteristic n % % of N
Participants 261
Gender Identity
Female
Male
Gender Queer/Non-Conforming
None of these
No response
198
20
2
3
38
75.9
7.7
0.8
1.1
14.6
89
11

Age
18 - 24
25 - 34
35 - 44
45 – 54
55 – 64
No response
15
126
40
7
5
58
5.7
48.3
15.3
6.5
1.9
22.2
9
57
23
8
2
BURNOUT AMONG MEDICAL ASSISTANTS 30

Characteristic n % % of N
Years of Experience
0 – 5
6- 10
11 – 15
> 16
No response
Education
CCMA
Bachelors
Masters
AA or other certification
Currently enrolled in program

92
65
33
17
54

183
38
3
36
28

35.2
24.9
12.6
6.5
20.7

70.1
14.6
1.1
13.8
10.7

Data Analysis
Data was exported from Qualtrics to SPSS for analysis. The data was cleaned by
removing 18 blank surveys and surveys where the respondent answered that they were not
employed by the U Health System or had previously completed the survey.
Quantitative Analysis
Descriptive statistics were used to examine the distribution of scales from the study.
Table 3 presents the descriptive statistics for these scales. Factor analysis with oblimin rotation
and Kaiser normalization was used to explore dividing the survey items into scales. Eigenvalues
greater than 1.0 suggested the retention of six components. High factor loadings in the principal
axis factoring, original scales used in the PFI, and face validity of the items provided scales for
reliability testing. Cronbach’s alpha was calculated to estimate internal consistency reliability
for the six scales: work exhaustion, professional fulfillment/meaningfulness of work, control,
organizational culture, knowledge of working on a team (team knowledge), and self-efficacy.

BURNOUT AMONG MEDICAL ASSISTANTS 31

Table 3
Descriptive Statistics of the Six Scales (n = 234)
Scale M SD
Work Exhaustion 2.32 1.04
Professional Fulfillment/Meaningfulness 4.08 0.67
Control 2.59 1.12
Organizational Culture 2.67 1.14
Team Knowledge 4.26 0.82
Self-Efficacy 3.41 1.04

Pearson’s r correlation coefficients were used to estimate correlation between the scales
listed above. All correlations were statistically significant (p < 0.001). Control and team
knowledge showed the least correlation with work exhaustion while perceptions of
organizational culture have the strongest correlation to work exhaustion. Self-efficacy and
professional fulfillment/meaningfulness have strong correlations with organizational culture.
Table 4 summarizes the Pearson’s correlations between the scales. Table 4 summarizes the
Pearson’s correlations between the scales.

Table 4
Inter-Item Correlation Matrix
Variables 1 2 3 4 5 6
1. Work Exhaustion -
2. Control -0.28 -
3. Organizational Culture -0.60 0.43 -
4. Team Knowledge -0.45 0.30 0.53 -
5. Self-Efficacy -0.53 0.40 0.61 0.42 -
6. Prof Fulfillment/Meaning -0.55 0.34 0.60 0.64 0.56 -
Note. All correlations are statistically significant (p < .001).
BURNOUT AMONG MEDICAL ASSISTANTS 32

Multiple regression analysis was used to test if control, organizational culture, team
knowledge, self-efficacy, and professional fulfillment/meaningfulness significantly predicted
work exhaustion. The results of the first regression model indicated that these five scales
explained 44.1% of the variance (R
2
= 0.441, F(5,228) = 36.01, p < 0.05). The data was
examined for multicollinearity and the variance inflation factor for all variables met the
assumption (VIF < 10). In this model, control (t = 0.61 and p = 0.54) and team knowledge (t = -
0.94 and p = 0.35) were not significant and were removed from the next model. The second, and
final regression model, indicated that organizational culture, professional
fulfillment/meaningfulness, and self-efficacy explained 43.8% of the variance (R
2
= 0.438,
F(3,230) = 59.83, p < 0.05). It was found that organizational culture is the strongest predictor of
work exhaustion (β = -0.34, p < 0.001), followed by professional fulfillments/meaningfulness (β
= -0.25, p < 0.001), and self-efficacy (β = -0.18, p < 0.01). A summary of the statistics for the
final model is included in Table 5.
Table 5
Hierarchical Regression Analysis for Variables Predicting Work Exhaustion (N = 261)

Model 2
Variable B SE B β t
Org Culture -0.31 0.06 -0.34* -5.04
Prof Ful/Meaning -0.38 0.10 -0.25* -3.81
Self-Efficacy -0.18 0.07 -0.18** -2.78
R
2
.438
59.83*

F for change in R
2

Note: *p < .001. **p < .01.

BURNOUT AMONG MEDICAL ASSISTANTS 33

Qualitative Analysis
Four open-ended questions were provided in the survey tool and analyzed by moving
from open codes to thematic codes to axial codes aligned with the knowledge, motivation, and
organizational influenced that guided this study (Corbin & Strauss, 2008; Harding, 2013). The
codes were informed by the literature review and influences that guided the study. The themes
and axial codes were reviewed with members of the dissertation committee and a research
consultant who provided coaching to the researcher during the analysis. The researcher kept a
log book which included analytic memos related to the coding process to support the validity of
the coding process (Corbin & Strauss, 2008; Harding, 2013). To further support the validity of
the qualitative data, it was triangulated around the data from the survey scales and the influences
that guided the study (Creswell, 2014).
Document Review
Human resources reports of demographics of medical assistants and the turnover rates of
medical assistants were reviewed to provide baseline and current information about the problem
of practice. U Health System has surveyed a subset of the medical assistants over the last two
years to examine burnout and perceptions of teamwork using an adapted version of the
Professional Fulfillment Index (Trockel et al., 2018). Summary reports of the findings from the
research team who conducted those surveys was reviewed to help frame the research questions in
this study.
Results and Findings
Burnout does not appear to be high among medical assistants within the U Health System
and is not likely a leading cause of problems with retention for the organization. Burnout, or
perceived work exhaustion, among medical assistants was found to be low (M = 2.32, SD =
BURNOUT AMONG MEDICAL ASSISTANTS 34

1.04). Perceptions of professional fulfillment and meaningfulness of work among medical
assistants was found to be high (M = 4.08, SD = 0.67). When the Likert Scale was rescored as 0
to 4 to match the original study of the PFI (Trockel et al., 2018), work exhaustion among medical
assistants (M = 1.32, SD = 1.04) was lower than that of physicians (M = 1.41, SD = 0.81).
Professional fulfillment/meaningfulness was compared to the most closely related scale of the
PFI (Trockel et al., 2018), professional fulfillment. In this comparison, professional fulfillment
among medical assistants (M = 3.08, SD = 0.67) was higher than that of physicians (M = 2.50,
SD = 0.80).
U Health System reported a slight decrease in turnover among medical assistants from
last fiscal year (14.65%) to the current fiscal year (13.44%). The turnover rate remained higher
than the organization’s target of 12%, but burnout may not be a leading contributor. The
following section will discuss other findings from the data related to the knowledge, motivation,
and organizational influences on burnout.
Knowledge Influences
Understanding an individual’s role on a team. Medical assistants reported a high
perception of knowledge of their role on the team and how to work on a team. The overall scale
score for team knowledge was the highest of the individual scales examined in this study (M =
4.26, SD = 0.82). Over 85% of the responses indicated completely true or very true to the
questions about knowledge of one’s role on the team: (a) I understand my role on the team, and
(b) I understand what is expected of me at work. Perceptions of an individual’s knowledge of
how to work on a team did negatively correlate with work exhaustion (r = -0.45, p < .001) and
also correlated with the other scales. Team knowledge had the strongest correlation with
perceptions of professional fulfillment (r = 0.64, p < .001) organizational culture (r = 0.53, p <
BURNOUT AMONG MEDICAL ASSISTANTS 35

.001). Knowledge was not found to be a predictor of burnout, or work exhaustion, in the
multiple regression analysis (β = -0.06, p = 0.35).
Communication. U Health System medical assistants appeared to understand strategies
for successful communication among team members. Over 82% of the responses indicated that
medical assistants understand what information to share during team huddles, a short meeting to
share information about the day. In addition, of the 135 responses to the question “What do you
do to communicate effectively with your team?”, 47% of medical assistants reported using active
listening techniques, or using open and direct communication. To explain the knowledge as well
as the value of good communication, one medical assistant stated, “I have one-to-one chats with
teammates routinely and with respect and transparency, discuss what we did/do well and where
we can improve. My goal is to work effectively as a team and ensure I am doing everything I
can to support individuals' goals. By displaying these goals through consistency of follow-
through, I try to earn the trust of teammates, which helps improve communication.” Another
medical assistant shared their approach to listening by responding, “I check in with people in
person and ask questions. I also listen when someone has an idea and do my best to understand
their point of view.”
Another 39% of the responses indicated that medical assistants use the tools and systems
in place to communicate with their teams. These tools include email, team huddles, and
messaging applications. Another 12% of the responses indicated that the medical assistant
would ask for help or support in order to communicate well. This was summarized by one
medical assistants who reported, “We support each other as a team, communicate with each
other, troubleshoot and give each other feedback.” Only three (2%) of the 135 responses
indicated that they perceived that communication was not working well.
BURNOUT AMONG MEDICAL ASSISTANTS 36

Coping strategies. The medical assistants who completed the survey also appeared to
understand effective coping techniques when asked, “What do you do if/when you feel
emotionally exhausted by work?”. Of the 140 responses, 55% indicated that medical assistants
employ techniques to help them cope such as exercise, participating in hobbies, or taking a
break. Several medical assistants, 44 respondents, specifically identified taking a walk or a
quick break to help with feelings of emotional exhaustion. One response summarized this
approach by reporting, “I take a step back, take a break and go for a walk outside.” Of the 140
responses, 20% of the medical assistants reported relying on their relationships with friends,
family, and coworkers to help with feelings of emotional exhaustion. Evidence from the survey
also suggested that 13% of medical assistants used relaxation techniques, such as deep breathing
or a mindset shift to help with feelings of emotional exhaustion at work. One example of this
strategy was from a response that stated, “I would take a few deep breathes, make sure to remind
myself to continue breathing and take it one step at a time. Everything will be completed at a
steady pace.”
Only two responses indicated drinking alcohol or crying as a result of feeling exhausted
by work. One area for further exploration by U Health System was the finding that 5% of the
responses indicated that the medical assistant will “push through it” or “keep going” when
feeling emotionally overtaxed by their work. Although the medical assistants appeared to show
a high perception of their knowledge of teamwork skills, communication skills, and coping
skills, their perception of their ability to manage burnout was not as strong. The self-efficacy
findings will be discussed in the next section. All of these findings suggest that knowledge,
while not a predictor of burnout, is linked to the other influences that impact burnout and should
be considered when determining interventions to support decreasing burnout.
BURNOUT AMONG MEDICAL ASSISTANTS 37

Motivation Influences
Perceived value of work. Medical assistants who participated in this survey appeared to
place a high value on the work they do each day. In response to a question not included in any of
the scales, “I believe the negative aspects of my job outweigh the positive aspects,” 13%
reported this to be completely true and 8% reported this to be very true. The scale score for
professional fulfillment/meaningfulness of work was moderately high for the medical assistants
in this study (M = 4.08, SD = 0.67). Professional fulfillment/meaningfulness was highly
correlated with organizational culture (r = 0.60, p < .001) and team knowledge (r = 0.64, p <
.001), and perceptions of professional fulfillment/meaningfulness of work were significant
predictors of work exhaustion among medical assistants (β = -0.25, p < 0.001).
Confidence in managing symptoms of burnout. Medical assistants surveyed in this
study reported moderate perceptions of self-efficacy (M = 3.41, SD = 1.04) on the self-efficacy
scale which included two questions: (a) I know what to do to prevent feeling burned out at work,
and (b) I feel confident I can manage my feelings of burnout or emotional exhaustion at work.
This finding demonstrated a gap that exists between the medical assistants’ reported knowledge
of effective coping skills and their perception of their ability to cope with burnout. Self-efficacy
was also highly correlated with perceptions of organizational culture (r = 0.61, p < .001), and
perceptions of self-efficacy significantly predicted work exhaustion (β = -0.18, p = 0.006).
The survey findings, as noted in the correlation matrix in Table 4, indicated the link
between motivational influences and knowledge and organizational influences. In response to
the open-ended question, “What other things would help you to be an effective medical
assistant?”, some of the responses highlighted this correlation. Of the 132 responses to this
question, almost 12% of the responses indicated a desire to receive more professional
BURNOUT AMONG MEDICAL ASSISTANTS 38

development including avenues for professional growth and career progression. One medical
assistant wrote, “Allow for more growth opportunities,” and further stated, “By allowing growth,
this will allow more of a driving force for MAs to perform their best.” The combination of the
scale scores, contribution to variation in work exhaustion (R
2
= 0.438), and qualitative data
supported the impact of motivational influences on burnout among medical assistants.
Organizational Influences
Understanding burnout. The medical assistants reported low confidence in the
organization’s understanding of burnout. In response to the question, “I believe U Health
System understands how to address burnout,” 56% of responses indicated not at all true or
somewhat true. An additional 21.6% indicated moderately true in response to this question.
This question contributed to the scale, organizational culture, which investigated U Health
System’s understanding of and attention to burnout. The survey also indicated that 67.7% of
medical assistants did not believe, or were uncertain if, their manager could identify when an
employee feels burned out. The medical assistants reported a moderately low perception of the
organizational culture as it relates to burnout (M = 2.67, SD = 1.14). In response to the open-
ended question, “What other things would help you to be an effective medical assistant?”, 17%
indicated the need to improve leader behavior. Leader behavior incorporated the themes of
medical assistants feeling heard, observing consistent follow through by managers, and increased
displays of respect, recognition, support, and transparency. One response to this question
highlighted the impact of leaders on the staff: “Feeling heard by the higher ups such as managers
and directors, so we feel that we are a part of the quality of the hospital and not just workers.”
Another medical assistant explained that medical assistants would benefit from “Being
understood and seen as equal.”
BURNOUT AMONG MEDICAL ASSISTANTS 39

Teamwork and workload distribution. Perceptions of the value of teamwork in the
organization was high among medical assistants. In response to the question, “I believe U
Health System values teamwork,” 70% indicated this was true. Additionally, the responses
showed that 54% reported that managers in the organization supported staff in dividing up work
correctly. The medical assistants also appeared to value teamwork as 75% of those surveyed
responded that they do not prefer to work alone. This survey finding contrasted with some of the
responses to the open-ended question, “What other things would help you to be an effective
medical assistant?” Of the 132 responses to that question, 14% indicated a need to improve
teamwork and 14% also indicated the need to improve workload distribution. One medical
assistant explained the impact of unequal workloads on the perception of teamwork in the
following statement: “There are moments where I feel that some MA's can get away with having
a lot of downtime and have less responsibilities. I think all MA's should understand that
downtime means helping the other MA's that are struggling.” That person went on to state, “I
really care for the wellbeing of our team and I wish everyone had that same mindset.”
Processes to implement best practices. The survey findings from this study indicated
that over 61% of respondents do not believe that U Health System had processes in place to help
employees avoid burnout, and 57% of respondents are not able to tell if the organization is taking
steps to prevent burnout among medical assistants. Improved teamwork, improved
communication, and adequate resources were reported in 46% of the responses to the open-ended
question, “What other things would help you to be an effective medical assistant?” signifying
some of the organizational culture opportunities. Adequate resources to complete the work, such
as staffing ratios and appropriate coverage was reported by 17% of the respondents. These data
BURNOUT AMONG MEDICAL ASSISTANTS 40

reinforce the quantitative findings and suggest the importance of the organizational influence on
burnout.
This scale, organizational culture, indicated the strongest negative correlation to work
exhaustion (r = -0.60, p < .001) of all scales. Organizational culture also indicated high
correlation with self-efficacy (r = 0.61, p < .001), professional fulfillment/meaningfulness (r =
0.60, p < .001) and team knowledge (r = 0.53, p < .001). Additionally, perception of
organizational attention to burnout was found to be the strongest predictor of work exhaustion (β
= -0.34, p < .001). The strong prediction and high correlation with work exhaustion coupled
with the low mean score of the scale suggest that U Health System should focus on
organizational culture in order to improve burnout.
Recommendations for Practice
Improving Retention
This study did not provide evidence to suggest that burnout is a significant contributor to
the problem with retention at U Health System. Burnout, or perceived work exhaustion, among
medical assistants was found to be low, and perceptions of professional fulfillment and
meaningfulness of work among medical assistants was found to be high. While burnout is one
reason cited in the literature for turnover, turnover among paraprofessionals, like medical
assistants, has been linked to wage and job structure, and personal reasons such as family
changes or moves (Butler, Simpson, Brennan & Turner, 2010; Ghere & York-Barr, 2007).
Wages, hours and schedules account for the majority of reasons cited for leaving positions
(Ghere & York-Barr, 2007). In a study of personal assistant workers in home care, wages and
schedules accounted for 60% of the turnover of a paraprofessional team (Butler et al., 2010).
Based on the literature reviewed here and the findings from this study, U Health System should
BURNOUT AMONG MEDICAL ASSISTANTS 41

consider exploring other reasons that may be impacting turnover among medical assistants. The
organization may continue to survey the medical assistants, at various time intervals, to observe
if work exhaustion is changing over time and analyze the data with retention rates.
Improving Organizational Culture Related to Burnout
U Health System should take steps to create a culture of awareness around burnout and
deploy processes to prevent burnout among the employees. The findings indicated that
perception of organizational culture related to burnout was the strongest predictor of work
exhaustion, and that the medical assistants surveyed do not believe that U Health System
understands burnout or has processes in place to help employees avoid burnout. The
recommendation is for the organization to initiate a series of interventions that create attention to
burnout and display the priority of burnout reduction to U Health System:
1. The executive team should publish goals related to burnout reduction as part of
annual organization-wide goal deployment. As an example, executive leaders
should round in various departments and ensure that leaders have goals, at the
unit/clinic level, visible with action plans.
2. The leaders of U Health System should provide to leaders, at all levels, with
training that details the symptoms of burnout and the impact on the individual and
work environment. This should include the steps to help prevent burnout among
employees.
3. U Health System should establish a task force that reviews the best practices in
burnout prevention and monitors the implementation of those interventions across
the organization.
BURNOUT AMONG MEDICAL ASSISTANTS 42

Organizational culture and core beliefs should be aligned with policies, procedures, and
communication within the organization (Clark & Estes, 2008). Health care systems are
challenged to incorporate a focus on health care provider wellness and demonstrate a value in
improving burnout (Bodenheimer & Sinsky, 2014). One study that surveyed 2,813 physicians
found that increases in leadership composite scores correlated with reduction in burnout
(Shanafelt & Gorringe et al., 2015). This study examined specific questions about the leadership
qualities of supervisors in the organization and the perceived impact on the front-line staff levels
of burnout (Shanafelt & Gorringe et al., 2015). Group Health, a primary care collaborative in
Seattle, found improvements in patient experience, quality of care, and clinician burnout by
implementing a team-based model of care (Reid et al., 2010). This study reported that the
investment by the leadership in the new model of care and the goals to improve burnout were
necessary to drive the changes and promote success (Reid et al., 2010).
A representation of the organization’s culture is the presence of systems to support team
members in deploying best practices and improvement strategies (Linzer & Levine et al., 2013;
Sinsky et al., 2013; Swensen & Shanafelt et al., 2017; Willard-Grace & Dubé et al., 2015). A
study of 23 primary care practices, identified as high-functioning practices, found that
implementation of the best practices to support burnout reduction requires standard approaches
and workflow mapping (Sinsky et al., 2013). Supported by findings from multiple researchers,
the framework by Shanafelt and Swensen et al. (2017) proposed that organizations need to have
systems in place to support change management and the implementation of solutions to improve
practice.
The findings and evidence from the literature support the recommendation that the
organization should dedicate attention and resources to understanding and preventing burnout.
BURNOUT AMONG MEDICAL ASSISTANTS 43

The presence of processes and procedures to help teams deploy best practices is a cultural setting
that will impact medical assistants’ reduction of burnout in support of improving retention.
Medical Assistants as Role Models for Coping with Burnout
The medical assistants of U Health System should be recognized as role models for
understanding how to cope with stressful work environments and avoid burnout. The findings
indicated that a majority of medical assistants are using effective tactics to manage feelings of
work exhaustion, but they reported a moderate sense of confidence in their ability to manage
burnout. The recommendation is to have medical assistants participate as team leaders or
teachers in the organization’s trainings related to burnout awareness and prevention. This could
take place in formal training sessions, during huddles or team meetings related to burnout
reduction, or by having medical assistants create job aids that detail coping skills to use to help
prevent feelings of work exhaustion.
Knowledge of coping skills and the use of specific types of coping skills impact
dimensions of burnout, and studies show that coping skills can be taught to employees with
positive outcomes (Bamonti et al., 2017; Jenaro, Flores, & Arias, 2007; Rowe, 1999; Shin et al.,
2014). In a study of 188 health care providers, those who participated in a six-week training on
coping skills showed decreased burnout, and they showed continued decreases in burnout over a
two-year period if they participated in additional refresher sessions (Rowe, 1999). This study’s
findings and evidence support the recommendation of training medical assistants and providing
ongoing training to support reducing the knowledge gap.
Confidence in one’s ability to employ coping strategies impacts burnout among health
care employees and may help improve retention (Elliott, Shewchuk, Hagglung, Rybarczyk, &
Harkins, 1996; Greenglass & Burke, 2002; Jenaro, Flores, & Arias, 2007; Shin et al., 2014). A
BURNOUT AMONG MEDICAL ASSISTANTS 44

study of 211 human service professionals found that coping strategies alone did not prevent
burnout but may help reduce employee turnover, and higher perceptions of self-esteem and self-
efficacy correlate with high personal achievement, a factor impacted by burnout (Jenaro, et al.,
2007). Individual feelings of personal ability to manage stress and problems was predictive of
lower burnout scores among rehabilitation nurses surveyed about burnout, coping skills, and
stress (Elliott, et al., 1996).
The findings and evidence from the literature support the recommendations to help
medical assistants gain confidence in their ability to manage symptoms of burnout by reinforcing
their past successes and leveraging them as the role models for the organization. An
implementation and evaluation plan for the organization is included in Appendix F.
Limitations and Delimitations
Some limitations of this study were threats to internal validity such as truthfulness of the
respondents, and the use of a survey tool designed for this study and not previously validated
(Price & Murman, 2004). The survey tool does not test for actual burnout or exhaustion, and is
limited by the respondents’ perceptions of the scales. In addition to these limitations, the
researcher chose a non-random sample of employees in one organization. The conceptual model
was based upon literature focused on physicians and adapted by the researcher for medical
assistants. The survey did not include all of the original questions and scales used in the study of
physicians by Trockel et al., (2018). These delimitations may prevent generalizability of the
study.
Recommendations for Further Research
Some leaders have started to offer a challenge to the concept of burnout as it relates to
physicians. Talbot and Dean (2018) state that the concept of burnout may be offensive to
BURNOUT AMONG MEDICAL ASSISTANTS 45

doctors and place blame on the physician for having any feeling characterized by traditional
burnout definitions. They suggest that physicians are experiencing distress that is more aligned
with a moral injury resulting from an inability to carry out the quality of care that aligns with
their values. While this study focused on the concept of burnout as work exhaustion, further
studies could examine the amount of moral distress or injury that is experienced by non-
physicians.
Conclusion
Burnout impacts healthcare professionals and poses a significant threat to maintaining a
stable workforce in the decade ahead. The medical assistants of U Health System demonstrated
that they are experiencing higher professional fulfillment and lower work exhaustion than their
physician colleagues. Healthcare organizations must be aware that the culture represented in the
organization has the most ability to impact the burnout of this group of employees. Medical
assistants are the largest segment of the workforce in medical office settings, and they are vital to
sustaining a robust health system for the future. Medical assistants’ strengths in communication,
teamwork, and coping skills can be used by all health professions to improve the work
environment and keep everyone healthy.
BURNOUT AMONG MEDICAL ASSISTANTS 46

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BURNOUT AMONG MEDICAL ASSISTANTS 55

Appendix A: Participating Stakeholders with Sampling Criteria
Participating Stakeholders
The stakeholders of interest are specific to one job type on the health care team. Because
of this, a non-random sampling method must be used to gather data from participants with
information relevant to the research questions (Johnson & Christensen, 2014; Merriam & Tisdell,
2016). Approximately 500 people were employed as medical assistants in several clinics in the
U Health System, and all of these team members were sought after for participation in the survey
data collection. To gain the most amount of information, the researcher used comprehensive
sampling and administered the survey to the entire sample through email invitation (Johnson &
Christensen, 2014). The criterion below describe the sampling strategy.
Criterion 1. Medical assistants were the first criterion for sampling. The entire
population of medical assistants is too large to study.
Criterion 2. Medical assistants employed by the U Health System were the second
criterion for sampling. The researcher was able to send the survey to approximately 500 medical
assistants employed by the U Health System at the time of the survey.

BURNOUT AMONG MEDICAL ASSISTANTS 56

Appendix B: Survey
Medical Assistant Survey

Thank you for taking this survey. Your answers will help U Health System understand how you,
and other medical assistants, are feeling about the current work environment. The survey should
take you about 15 minutes to complete.

We would like to understand a little about your role on the team and how you
communicate as a team.

How true do you feel the following statements are about you at work at the present time?

Q Not
at all
true
Somewhat
true
Moder
ately
true
Very
true
Completely
true
1 I understand my role on the
team.

2 I understand what is expected
of me at work.

3 I know what information to
share during huddle.

4 I prefer to work alone.
5 I believe U Health System
values teamwork.

6 My manager, or another
leader, has supported my team
in making sure our work is
divided up correctly.

7 What do you do to communicate effectively
with your team?

BURNOUT AMONG MEDICAL ASSISTANTS 57

Please check the box that best fits your opinion of your work situation at the present time.

How true do you feel the following statements are about you at work?

Q Not
at all
true
Somewhat
true
Moder
ately
true
Very
true
Completely
true
8 I feel happy at work
9 I feel worthwhile at work
10 My work is satisfying to me
11 I feel in control when
dealing with difficult
problems at work

12 My interactions with
patients (or patient cases)
are meaningful to me

13 I am emotionally moved by
my patients’ experience
even when stressed

14 I help patients improve the
quality of their lives

15 I enjoy helping my patients
when I am under time
pressure

In your clinic, how much control do you have over aspects of your work?

Q I have control over… No
Control
A little
control
Moderate
control
A lot of
Control
Complete
Control
16 The number of hours I
work

17 The schedule of hours I
work

18 Work interruptions (e.g.,
telephone calls,
unscheduled patients)

19 The volume of my
patient load or panel size

BURNOUT AMONG MEDICAL ASSISTANTS 58

We would like to understand more about any burnout you may experience at work.

20 What do you do if/when you feel
emotionally exhausted by work?

How true do you feel the following statements are about you at work at the present time?

Q Not at
all true
Somewhat
true
Moder
ately
true
Very
true
Completely
true
21 I know what to do to
prevent feeling burned out
at work..

22 I feel confident I can
manage my feelings of
burnout or emotional
exhaustion at work.

23 My manager can identify
when an employee feels
burned out.

24 I believe U Health System
understands how to
address burnout.

25 The organization has a
process to avoid employee
burnout.

26 I can tell that U Health
System is taking steps to
prevent burnout among
medical assistants.

27 I believe the negative
aspects of my job
outweigh the positive
aspects.

BURNOUT AMONG MEDICAL ASSISTANTS 59

To what degree have you experienced the following during the last two weeks?

Q During the past two
weeks I have felt…
Not at
all
Very little Moder
ately
Alot Extremely
28 A sense of dread when I
think about work I have to
do

29 Physically exhausted at
work

30 Lacking in enthusiasm at
work

31 Emotionally exhausted at
work

Please help us learn as much as we can about how to best support medical assistants at U
Health System.

32 What other things would help you to be an
effective medical assistant?

33 What feedback do you have about the
relevance and importance of the questions
in this survey?

BURNOUT AMONG MEDICAL ASSISTANTS 60

Thank you so much for completing this survey. The answers are anonymous and will help
us understand how to keep improving the workplace for medical assistants.

Please provide some information about yourself.

34 Are you currently employed as a
medical assistant with U Health
System?
Yes/No
35 Have you already completed this
survey?
Yes/No
36 My current gender identity is (select all
that apply):
Male
Female
Transgender Male
Transgender Female
Gender Queer/Gender Non-conforming
None of these
37 I have worked as a medical assistant for
______________ years.

38 I am _________________years old.
39 I have completed the following
education (check all that apply):
GED, High School Diploma
MA Certification (CCMA)
Bachelors Degree
Masters Degree
Doctoral Degree
Other Professional Certification
40 I am currently enrolled in an academic,
vocational, or professional training
program.
Yes/No

BURNOUT AMONG MEDICAL ASSISTANTS 61

Appendix C: Assumed Influences and Measurement

Research
Question/
Data Type
KMO
Construct
Survey Item (question and
response)
Scale of
Measurem
ent
Potential
Analyses
Reliability –
Sample
Confidence
NA Are you currently a medical
assistant employed with U Health
System? (Yes, No)
NA
NA
Reliability –
Sample
Confidence
NA Have you already completed this
survey? (Yes, No)
NA
NA
Demographics
– Sample
Description
NA I have worked as a medical assistant
for ____ years.
Interval
Percentage,
Frequency,
Mode,
Median, Mean,
Standard
Deviation,
Range
Demographics
– Sample
Description
NA I am: Male Female
Nominal Percentage,
Frequency
Demographics
– Sample
Description
NA I am ______ years old.
Interval Percentage,
Frequency,
Mode,
Median,
Mean,
Standard
Deviation,
Range
Demographics
– Sample
Description
NA I have completed the following
education (check all that apply):
GED, High School Diploma, MA
Certification (CCMA), Bachelors
Degree, Masters Degree, Doctoral
Degree, Other Professional
Certification
Nominal Percentage,
Frequency
Demographics
– Sample
Description
NA I am currently enrolled in an
academic, vocational, or
professional training program. (Yes,
No)
Nominal Percentage,
Frequency
Medical
assistants need
to understand
effective
communication
strategies.
K-DC What do you do to communicate
effectively with your team?
Qualitative Open
Coding
BURNOUT AMONG MEDICAL ASSISTANTS 62

Medical
assistants need
to understand
effective
communication
strategies.
K-DC I know what information to share
during huddle. (Not at all true,
Somewhat true, Moderately true,
Very true, Completely true)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Medical
assistants need
to understand
role
expectations
and how to
engage in
teamwork.
K-DC I understand my role on the team.
(Not at all true, Somewhat true,
Moderately true, Very true,
Completely true)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Medical
assistants need
to understand
role
expectations
and how to
engage in
teamwork.
K-DC I understand what is expected of me
at work. (Not at all true, Somewhat
true, Moderately true, Very true,
Completely true)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Medical
assistants need
to understand
effective
coping
strategies.
K-M I know what to do to prevent feeling
burned out at work. (Not at all true,
Somewhat true, Moderately true,
Very true, Completely true)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Medical
assistants need
to understand
effective
coping
strategies.
K-M What do you do when you feel
emotionally exhausted by work?
Qualitative Open
Coding
Medical
assistants need
to feel there is
value in
participating in
team culture.
M-EV I prefer to work alone. (Not at all
true, Somewhat true, Moderately
true, Very true, Completely true)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
Medical
assistants need
to feel
confident that
they can
manage
M-SE I feel confident I can manage my
feelings of burnout (emotional
exhaustion) at work. (Not at all true,
Somewhat true, Moderately true,
Very true, Completely true)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
BURNOUT AMONG MEDICAL ASSISTANTS 63

symptoms of
burnout.
Medical
assistants need
to feel that the
benefits of the
job outweigh
the costs.
M-EV I believe the negative aspects of my
job outweigh the positive aspects.
(Not at all true, Somewhat true,
Moderately true, Very true,
Completely true)
Ordinal Percentage,
Frequency,
Mode,
Median,
Range
The
organization
needs to
understand the
causes of and
best practices
associated with
improving
burnout.
O-CM My manager can identify when an
employee feels burned out. (Not at
all true, Somewhat true, Moderately
true, Very true, Completely true)

Ordinal Percentage,
Frequency,
Mode,
Median,
Range
The
organization
needs to
understand the
causes of and
best practices
associated with
improving
burnout.
O-CM I believe U Health System
understands how to address burnout.
(Not at all true, Somewhat true,
Moderately true, Very true,
Completely true)

Ordinal Percentage,
Frequency,
Mode,
Median,
Range
The
organization
needs to
support the
development of
team culture
and workload
distribution.
O-CM I believe the organization values
teamwork. (Not at all true,
Somewhat true, Moderately true,
Very true, Completely true)

Ordinal Percentage,
Frequency,
Mode,
Median,
Range
The
organization
needs to
support the
development of
team culture
and workload
distribution.
O-CM My manager, or another leader, has
supported my team in making sure
our work is divided up correctly
(Not at all true, Somewhat true,
Moderately true, Very true,
Completely true)

Ordinal Percentage,
Frequency,
Mode,
Median,
Range
The
organization
needs to have a
process to
O-CS The organization has a process to
avoid employee burnout (Not at all
true, Somewhat true, Moderately
true, Very true, Completely true)
Ordinal Percentage,
Frequency,
Mode,
Median,
BURNOUT AMONG MEDICAL ASSISTANTS 64

implement and
support the
best practices
to decrease
burnout.
Range
The
organization
needs to have a
process to
implement and
support the
best practices
to decrease
burnout.
O-CS I can tell that U Health System is
taking steps to prevent burnout
among medical assistants (Not at all
true, Somewhat true, Moderately
true, Very true, Completely true)

Ordinal Percentage,
Frequency,
Mode,
Median,
Range
The
organization
needs to have a
process to
implement and
support the
best practices
to decrease
burnout.
O-CS What other things would help you to
be an effective medical assistant?
Qualitative Open
Coding

BURNOUT AMONG MEDICAL ASSISTANTS 65

Appendix D: Validity and Reliability
The PFI was tested for reliability and validity as an instrument to measure burnout
compared to previously validated tools (Trockel et al., 2018). In a study of 250 physicians who
completed the PFI at two different time points, the MBI, and three other assessments, the PFI
measures correlated highly with the MBI equivalents (r ≥ 0.50) which provides confidence for
test-retest reliability (Salkind, 2017; Trockel et al., 2018). Additionally, the PFI was found to
have test-retest reliability for the three burnout subscales of professionally fulfillment, work
exhaustion, and disengagement (Trockel et al., 2018). Cronbach’s alpha was found to be α =
0.91, α = 0.86, and α = 0.92 for the subscales respectively and α = 0.92 for overall burnout
(Trockel et al., 2018). The strength of reliability shown in the Trockel et al. (2018) analysis
provided support for use of PFI for this study (Creswell, 2014; Salkind, 2017).
Content validity for the survey tool was managed by reviewing the survey questions with
dissertation committee and peers (Salkind, 2017). Feedback about the questions was solicited to
test linkage of the question with the knowledge, motivation, and organizational influences that
the question was intended to explore. Modifications were made based on this feedback.
Criterion and construct validity was managed in a few ways. More than one question per
influence was administered and analyzed for internal consistency reliability (Salkind, 2017).
Questions with high degrees of discrepancy are discussed in the analysis. Because little research
was available related to burnout among medical assistants, this researcher compared survey
results with results from the literature on physicians and other health professionals. This allowed
for some testing of construct validity and offered additional analysis around similarities and
differences in burnout among medical assistants (Salkind, 2017).
BURNOUT AMONG MEDICAL ASSISTANTS 66

Sample confidence was managed by the executive leader sending to those in that job
class on email distribution list and validated by the managers in those areas. The survey tool
asked two questions to further provide confidence in the sample: “Are you a medical assistant
employed in the U Health System?” and “Have you already completed this survey?” Answers to
those questions supported data cleaning as discussed previously. The sample size, where C >
0.95, allowed for sufficient analysis for the purposes of this study (Johnson & Christensen,
2014). Related to bias inherent in non-response, the researcher assumed that there was a
percentage of non-response due to survey fatigue or disinterest. The researcher analyzed data
returned as a representative sample of the participants surveyed.

BURNOUT AMONG MEDICAL ASSISTANTS 67

Appendix E: Ethics
Researchers have a responsibility and ethical duty to protect the participants from harm,
insure privacy, and rigorously assess that informed consent has been given to be studied (Glesne,
2011; Rubin & Rubin, 2012). Because of the complexities of relationships, the interaction
between humans, and the changing nature of the questions in qualitative inquiry, ethical
dilemmas for the researcher are common and require contemplation before embarking on the
data collection (Glesne, 2011). The following section will describe the complexities and ethical
considerations associated with this study and for this researcher.
My role as an administrative leader with U Health System posed challenges that required
ethical consideration and mitigation to protect the participants and the project. The medical
assistants in some of these clinics were directly in my line of operational and supervisory
responsibility. While I did notsupervise them directly, I supervised their leadership team and
worked closely with the physician leadership team that governs the physicians. Most staff and
physicians would know my name and responsibilities, even if we have not met in person.
Additionally, I had accountability for the operational and financial performance of these clinics.
The success of improvement initiatives, staff engagement, patient satisfaction, and volume or
financial stability of the clinics directly impacted my job performance appraisal. For these
reasons, I used a survey to allow anonymity in the data collection process.
A power differential existed for the employees being surveyed because of our respective
roles in the organization. The medical assistants may have felt pressured to complete the survey
or concerned about confidentiality if they were aware that I was the researcher. Even with the
informed consent process using an information sheet, the employees may have felt that their
responses would be attributed to them as individuals and could harm their employment. They
BURNOUT AMONG MEDICAL ASSISTANTS 68

may also have provided information in the survey that they believe I would want to hear or that
would not show problems or negative feelings about the workplace. Employees may have
thought that disclosing any negative feelings about the work might suggest they should not have
this job.
Managing the concerns about confidentiality and power took place during the recruitment
process. Participants were asked to participate in the survey via email. The email detailed that
the survey would not be linked to them in anyway and that the researcher would not be aware of
who opened the email, who responded to the survey, and who chose not to respond to the survey.
This recruitment email was explicit about the fact that none of their responses would be
attributed to individual or group work performance, and no action related to individual or group
performance would be taken as a result of the survey responses. Also in this recruitment email, I
explained that their responses would help offer feedback and information about how to improve
the work environment.
The informed consent process is especially important because this study took place
within the participants’ place of work. It allowed them to understand the nature of their
participation as voluntary and not connected to their work performance in any way. Informed
consent allows participants to understand the confidentiality of their participation, their ability to
withdraw at any time without penalty, and the nature of the study and how their responses will be
used (Glesne, 2011). The informed consent process took place within the emails, flyers, and
survey tool, Qualtrics, in the form of an information sheet. The information sheet explained the
purpose of the study, my contact information, a phone number to obtain information about
participant’s rights, and contact information for the dissertation chair in case a participated
wanted to seek more information from the research team. To further protect the identity of the
BURNOUT AMONG MEDICAL ASSISTANTS 69

participants, the survey feature that collects IP addresses was disabled. Data from the survey
was stored on a password protected, encrypted cloud-based drive that was only accessible to the
research team.
My assumptions and biases were important to examine throughout the study and
evaluation process. Similar to an example cited by Merriam and Tisdell (2016) where a Dean is
surveying students, I cannot eliminate the fact that I was in a leadership role in the organization
and had motivation for programs to succeed. However, I was able to represent myself
transparently and describe the difference between research questions and operational issues. I
attempted to insure participants that no harm would come to them as a result of participating, but
my perceptions of the clinic operations and how that informed my overall practice could be
impacted (Merriam & Tisdell, 2016; Rubin & Rubin, 2012). Participants were also made aware
that they might ultimately benefit from the information shared as it will inform U Health System
executives about how their individual work could be made better to support the organization’s
goals. This example of reciprocity was made explicit, carefully, so as not to bias the participants
to provide overly positive or negative information (Patton, 2015).

BURNOUT AMONG MEDICAL ASSISTANTS 70

Appendix F: Implementation and Evaluation Plan
Implementation and Evaluation Framework
Evaluation is necessary when an organization seeks to implement improvement activities
because it allows the organization to examine the transfer of learning and behavior to results and
to assess for the value demonstrated by the program (Kirkpatrick, J. & Kirkpatrick, 2016). The
New World Kirkpatrick Model (Kirkpatrick, J. & Kirkpatrick, 2016) will guide the integrated
implementation and evaluation plan presented in the following section. This framework employs
four levels in the training evaluation model. The fourth level is an examination, at the highest
level, of the results of the change effort by studying the leading indicators that are tied to the
desired outcomes. The next level below is that of behavior change where the organization
examines the critical behaviors of the stakeholders involved in the change process. These
behaviors are those that are most linked to the anticipated results. Additionally, the third level
evaluates the systems that are put in place to monitor the critical behaviors and reinforce
performance. The second level is and evaluation of learning in which the amount of information
and skills about the task, participants’ perception of the value of the tasks, and self-efficacy and
persistence regarding the task are all assessed. Finally, the first level is an assessment of the
reaction or participants’ satisfaction with the overall training experience (Kirkpatrick, J. &
Kirkpatrick, 2016). The four levels of this model will be used to assess the recommendations to
improve burnout and retention of medical assistants at U Health System.
Organizational Purpose, Need and Expectations
U Health System seeks to improve the retention of medical assistants in order to control
overall cost and insure that the organization can continue to meet the community demand for
medical care by having appropriate staff in place. The stakeholders of focus are the medical
BURNOUT AMONG MEDICAL ASSISTANTS 71

assistants, a large percentage of the front-line workforce in outpatient clinics. The stakeholder
goal is to improve management of symptoms of burnout, which may be a cause of turnover,
increased cost, and increased patient safety risks. The goal was selected because medical
assistant turnover is above the target turnover rate for U Health System, and studies have shown
that burnout is also increasing among healthcare professionals. Recommendations to decrease
burnout among medical assistants include increasing the organization’s commitment to
improving burnout and leveraging the knowledge strengths of the medical assistant population to
support the organization and improve the self-efficacy of the medical assistants.
Level 4: Results and Leading Indicators
U Health System may notice outcomes of efforts to reduce burnout through improved
patient satisfaction, improved access to care, improved quality of care, reduced cost of care, and
improved employee satisfaction. Table 6 provides a summary of external and internal leading
indicators, metrics, and methods to collect the outcome data. In the area of improved patient
satisfaction, U Health System will use current patient satisfaction survey tools to monitor
increased top box and percentile rank scores on specific indicators. To monitor improved access
to care, U Health System will use measures that show reductions in time to access care for
patients seeking care in U Health System. U Health System will measure improved quality of
care through ongoing quality performance metric monitoring and will use human resources data
to monitor turnover of employees and the cost of turnover. Finally, to examine employee
satisfaction, U Health System will utilize quarterly employee engagement surveys and annual
physician satisfaction surveys. Through these standard measurement methods, U Health System
will be able to monitor the metrics that have been set as indicators of the positive outcomes of
the changes that are implemented.
BURNOUT AMONG MEDICAL ASSISTANTS 72

Table 6

Outcomes, Metrics, and Methods for External and Internal Outcomes

Outcome Metric(s) Method(s)
External Outcomes
Improved
patient
satisfaction.
Increased top box and percentile
ranking of patient satisfaction
survey indicators:
1. Likelihood to recommend
the practice.
2. Staff worked well together
to coordinate my care.
3. Our sensitivity to your
needs.
4. Concern the nurse/assistant
showed to your problem.
Department of Patient Experience
provides monthly and quarterly patient
satisfaction survey results to leaders.
Improved new
patient access
to care.
1. Decrease time to third next
available appointment.
2. Increase percent of patients
receiving appointment
within seven days of
appointment request.
Clinic Operations collects and monitors
access metrics in all operational
departments.
Internal Outcomes
Improved
patient quality
of care.
1. Improved population health
measures.
2. Decreased medical errors.

Clinical Operations and the Quality
Department collect and monitor
performance on population health
metrics and medical error rates.
Reduced labor
costs.
Decreased turnover rate at one year
and two years of employment.
Human Resources reports on turnover
by role and links to finance calculation
on turnover cost per employee.
Improved
employee
satisfaction.
1. Improved employee
engagement scores.
2. Improved physician
satisfaction scores.
Human Resources collects employee
engagement scores by department and
role. Clinic Administration collects
physician satisfaction scores annually
via survey.

Level 3: Behavior
Critical behaviors. The New Work Kirkpatrick model (Kirkpatrick, J. & Kirkpatrick,
2016) identifies the importance of outlining the few, key behaviors that are most able to drive the
BURNOUT AMONG MEDICAL ASSISTANTS 73

organization’s desired performance results. Linking the leading indicators described in Table 6
with the recommendations for improvement, they key behaviors to improve burnout are those
that will exhibit the organization’s commitment to reducing burnout. After the executive team
articulates the importance of reducing burnout and publishes and organization-wide goal,
managers will need to also take action to continue cascading the goals throughout the
organization. Table 7 summarizes two critical behaviors to help drive improvement: (a)
managers will need to launch and display efforts to reduce burnout in their clinics or units, and
(b) medical assistants will need to participate in these teams.

Table 7

Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s)
Method(s)
Timing
1. Managers will lead
projects focused on
burnout reduction or
prevention with a
documented target
goal that links to the
organizational goal.
100% of clinics/units will
display project plan on
visibility board.
Directors will
validate
compliance with
goal.
Monthly
2. Medical assistants
will participate in
burnout reduction
project teams.
100% of clinic/unit project
teams will include at least
one medical assistant.
Directors will
validate
compliance with
goal.
Upon
establishment
of project
team

Required drivers. Success of the critical behaviors is dependent on key drivers to
support and monitor the work (Kirkpatrick, J. & Kirkpatrick, 2016). U Health System has many
systems in place to monitor cascaded goals and interventions and should rely on those processes
for encouraging and monitoring the critical behaviors described above. Table 8 provides a
summary of the required drivers and links to the critical behaviors. To support the self-efficacy
of the managers in leading these projects and of the medical assistants in educating others about
BURNOUT AMONG MEDICAL ASSISTANTS 74

coping skills, leaders in the organization need to provide ongoing coaching and reinforcing of
these behaviors. Additionally, the organization must exhibit its commitment to the goals by
reinforcing the behaviors through holding managers accountable, providing resources and time to
complete the work, and recognizing the successes achieved in the process.

Table 8
Required Drivers to Support Critical Behaviors
Method(s) Timing
Critical
Behaviors
Supported
1, 2, 3 Etc.
Reinforcing

Managers will provide time away from
assignments for medical assistants to
participate in projects.
Weekly 2

Organizational burnout task force will
share best practice examples with
managers.
Monthly 1, 2
Encouraging

Directors and executives will provide
coaching to managers as they develop
projects.
Monthly 1, 2
Rewarding
Executives will share unit/clinic success
stories in organization-wide meetings.
Monthly 1, 2
Medical assistants will receive points
toward career ladder progression by
participating in project group.
Annual evaluation 2
Monitoring
Executives will monitor progress during
rounding times.
Quarterly 1, 2
Directors will review project plans with
managers.
Monthly 1, 2

BURNOUT AMONG MEDICAL ASSISTANTS 75

Level 2: Learning
Learning goals. Following completion of a burnout training, leaders, of all levels, will
be able to:
1. Articulate the contributors to burnout and work exhaustion;
2. Explain the impact of burnout on work groups and systems;
3. Identify signs and symptoms of burnout within their employee teams;
4. Develop a project plan to assess burnout within their team and implement targeted
interventions; and
5. Describe benefits of reduced burnout specific to their teams.

Program. U Health System has systems in place to provide organization-wide training
on priority topics. The organization could use semi-annual trainings for leaders that focus on
specific topics and incorporate the content into new leader orientation. The organization also
uses standard performance improvement methodology and leaders will be reinforced to use those
tools as they develop individual action plans for their units and clinics. Because a gap identified
in this study was organizational culture and commitment to burnout, this training should be
conducted in person and allow for executives to share the importance of the topic and goals. The
sessions should allow time for feedback among participants and processing the ability to transfer
this knowledge via discussions.
Evaluation of the components of learning. Table 9 summarizes the activities that U
Health System will use to evaluate the learning of participants who participate in the burnout
awareness and prevention training sessions. The evaluation should assess knowledge and skill
development as well as participants’ perceptions of the value of the training and their ability to
implement learning in their work environment (Kirkpatrick, J. & Kirkpatrick, 2016).
BURNOUT AMONG MEDICAL ASSISTANTS 76

Table 9
Evaluation of the Components of Learning for the Program.
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”
Pre- and post-test survey items focused on contributors to burnout,
signs and symptoms of burnout, and benefits of reducing burnout
During training session
Procedural Skills “I can do it right now.”
Director observation of managers implementing project plans in
clinics and units
Within one month of
training session and
monthly
Attitude “I believe this is worthwhile.”
Pre- and post-test survey items addressing participants’ perceptions
of the importance of this training and relevance to their work
During training session
Confidence “I think I can do it on the job.”
Pre- and post-test items that address participants’ perceptions of
their ability to lead a project focused on burnout reduction
During training session
Commitment “I will do it on the job.”
Action plan to launch project team and project plan At the completion of the
training session

Level 1: Reaction
Level One evaluation is designed to measure the extent to which participants of a training
found the experience to be engaging, relevant, and enjoyable (Kirkpatrick, J. & Kirkpatrick,
2016). Table 10 summarizes the feedback surveys, completion rates, attendance, and instructor
observations that will be used to measure reactions to the program.

Table 10
Components to Measure Reactions to the Program.
Method(s) or Tool(s) Timing
Engagement
Instructor or small group leader observations of engagement During training session

Completion rate of training Following training session
and monthly summary
BURNOUT AMONG MEDICAL ASSISTANTS 77

Relevance
Session feedback survey At the conclusion of
training session
Customer Satisfaction

Session feedback survey At the conclusion of
training session

Data Analysis and Reporting
Kirkpatrick, J. and Kirkpatrick (2016) state the importance of using data during the
training process to inform any necessary adjustments and ongoing to evaluate if the program is
meeting expectations of the organization. The data from the blended evaluation tools
(Kirkpatrick, J. & Kirkpatrick, 2016) will be analyzed by the training team following the
sessions so that modifications can be made to improve participant learning and reaction.
Summary information from the training sessions will be provided to the executive team who
sponsors this program and initiative. To assess compliance with the organizational goals and
desired critical behaviors, a dashboard will be created to inform the leadership about the progress
the organization is making to achieve targets for the critical behavior and required drivers. This
information will be connected to the organizational goals that were set to reduce burnout and
reported alongside the Level Four outcomes that were identified related to this program.

Abstract (if available)

Abstract Burnout among physicians is increasing and the country braces for a shortage of doctors to meet the public’s demand in the decade ahead. Medical assistants, the key professionals supporting physician practices have not been studied regarding burnout and retention. This study used a tool previously validated with physicians, the Professional Fulfillment Index (Trockel et al., 2018) and new survey items to investigate the knowledge, motivation and organizational influences on burnout (work exhaustion) among medical assistants in a large academic health system. The study validated the tool for use with this population and validated three additional scales to examine as they relate to work exhaustion. Work exhaustion was found to be low among medical assistants in this population (M = 2.32) and professional fulfillment/meaningfulness of work was found to be high (M = 4.08). Organizational culture, professional fulfillment, and self-efficacy were found to be predictors of work exhaustion (R² = 0.438) with negative perceptions of organizational culture found to be the strongest predictor of work exhaustion among medical assistants (β = -0.34). These data and the qualitative findings provided the recommendations that the organization should deploy a set of interventions to demonstrate broad organizational commitment to burnout reduction and should leverage the medical assistants as role models within the organization.

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Asset Metadata

Creator Seay-Morrison, Timothy Patrick (author)

Core Title Retention rates and burnout among medical assistants: an evaluation study

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 04/15/2019

Defense Date 03/21/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Burnout,medical assistants,OAI-PMH Harvest,organizational culture,work exhaustion

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Hirabayashi, Kimberly (committee chair), Brown-Johnson, Catherine (committee member), Seli, Helena (committee member)

Creator Email seaymorr@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-139096

Unique identifier UC11675678

Identifier etd-SeayMorris-7194.pdf (filename),usctheses-c89-139096 (legacy record id)

Legacy Identifier etd-SeayMorris-7194.pdf

Dmrecord 139096

Document Type Dissertation

Format application/pdf (imt)

Rights Seay-Morrison, Timothy Patrick

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA