Reasons Clinical Education Directors Intend to Leave their Jobs

doi:10.21203/rs.3.rs-1964318/v1

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Reasons Clinical Education Directors Intend to Leave their Jobs

https://doi.org/10.21203/rs.3.rs-1964318/v1

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Journal Publication

published 27 Feb, 2023

Read the published version in BMC Medical Education →

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Objectives

The goals of this study were to characterize clinical coordinators compared to other Physician Assistant (PA) faculty, and investigate factors associated with intent to leave their position, institution, and academia in the U.S.

Methods

This was a secondary analysis of data obtained from the 2019 PAEA Faculty and Directors Survey. We examined bivariate associations with faculty role and conducted multiple logistic regression to identify predictors of intent to leave among clinical directors.

Results

Clinical directors indicated an intention to leave their position more often than other faculty. Factors influencing intent to leave were a lack of satisfaction with professional development and moderate to high levels of burnout. Clinical directors with severe burnout had 27x the odds of intending to leave academia.

Conclusions

Our results suggest why clinical directors intend to leave and underscore the need for professional development opportunities and faculty mentoring. Faculty-centered work arrangements are needed to reduce burnout among clinical directors.

clinical director

clinical coordinator

education

intent to leave

satisfaction

burnout

Physician Assistant (PA) programs have had exponential growth in recent years; however, recruitment and retention of qualified faculty is emerging as a major limiting step in PA education [1]. According to the 2019 Physician Assistant Education Association (PAEA) Program Survey, there were 115 unfilled fulltime equivalent (FTE) positions with about 87 (21%) of PA programs reporting vacant FTEs [2]. Clinical Directors¹ (CD) are key members of the PA faculty team in supporting the clinical phase of PA programs. There have been anecdotal reports of high turnover of this group of faculty. This is especially important as issues of clinical sites, preceptors, and clinical coordination have become a daunting task as the number of PA programs continues to rise[2, 5-7]. The shortage of clinical sites has created significant difficulties in clinical coordination such as securing partnerships with health systems[8]. Increased demands in clinical coordination may lead to burnout and dissatisfaction, which ultimately impact faculty morale, retention, and student outcomes. Whether these factors also contribute to intention to leave remains to be established [3, 4]. Literature is still lacking on the factors influencing the CD’s role dynamics.

The goals of this study were to 1) describe features that characterize CDs compared to other faculty, and 2) investigate factors associated with intent to leave in CDs compared with other faculty. Findings from this study have far-reaching implications for PA program leadership and faculty teams as well as ensuring desired program outcomes and a qualified PA health workforce. To our knowledge this is one of the first studies that focuses on the CD group in PA programs, their characteristics, and their intent to leave their position, institution, and/or academia.

¹ May also be referred to as Clinical Coordinators

This was a secondary data analysis based on raw data obtained from the 2019 PAEA Faculty and Directors Survey. Only PA faculty who have been trained as PAs were included in this study. The survey response rate was 60.5% with representation from 97.9% of all programs. The Institutional Review Board at Charles R. Drew University of Medicine and Science approved the study.

In the current study, we assess the characteristics of CDs and their intention to leave academia, their institution, or their position compared to “other” PA faculty. “Other” PA faculty were defined as all other faculty not holding a CD role, except program directors or above (e.g. department chair, dean, etc) and medical directors who were excluded due to the exceptional conditions of those positions. Adjuncts and those with FTE < 50% were also excluded. We used descriptive, bivariate chi-squared tests and ANOVA to compare CDs and other faculty in terms of characteristics and potential predictors of intent to leave their jobs.

Features characterizing CDs that were examined were age, gender, representation in medicine, years in current position, academic rank, type of school, levels of satisfaction, and level of burnout. Representation in medicine categorizes those who identify as white or Asian as not under-represented, and all other racial/ethnic groups as under-represented. We excluded type of schools categorized as public/private hybrid or military, due to small numbers.

According to the PAEA survey description, individuals were asked to rate their level of satisfaction with a wide range of factors on a 4-point scale (Not satisfied-Very satisfied). Burnout was assessed in terms of how frequently participants felt burned out from their work, with response options ranging from Never to Every day. We further categorized level of burnout into low, moderate, and high, with low being monthly or less; more than monthly to weekly being moderate; and multiple times per week being high.

Intent to leave was characterized by three questions, which captured different levels of the intention. Participants were asked, “In the past 2 years, did you consider leaving your current position for another one within the same PA program?”, “In the past 2 years, did you consider leaving your current institution for another institution?”, and “In the past 2 years, did you consider leaving academia for a different job?” We treated each response as a separate outcome.

We performed multiple logistic regression separately among CDs and other faculty to determine predictors of intention to leave at each level (i.e. academia, institution, position), with listwise deletion and correcting for the characteristics mentioned above. Because there were many elements of satisfaction evaluated, to simplify analysis, we categorized satisfaction into four groups: Professional development, Job duties, Wellbeing & benefits, and Support & environment. While we recognize that these are arbitrarily chosen categories, we felt they reflected the broad domains of the factors that were asked about. These factors are summarized in Table 1. For each category, we calculated the average score. We present adjusted odds ratios, 95% confidence intervals, and p-values for the regression models. P < 0.05 is considered statistically significant for all analyses. All analyses were performed using SAS 9.4.

Table 1

Categorization of components of satisfaction
Category	Components
Professional development	Current academic rank
	Faculty development opportunities outside institution (e.g., conferences)
	Faculty development opportunities within institution (e.g., grant workshops)
	Promotion potential
	Research opportunities
	Tenure requirements
Job duties	Job responsibilities
	Teaching workload
	Clinical work arrangement
	Curriculum
Wellbeing & benefits	Autonomy and independence
	Departmental support for work/life balance
	Retirement benefits
	Salary amount
	Schedule flexibility
	Healthcare plan
	Fairness of salary relative to other faculty
Support & environment	Staff support
	Program management/leadership
	Institutional leadership
	Quality of students
	Didactic or clinical teaching environment
	Student to faculty ratio

Participant Characteristics

Table 2 shows the characteristics of all participants. About 22% of faculty were clinical directors. The mean age of all faculty was 44 years, and on average, participants had been in PA education for 2.6 years, at their program for 2.3 years, and in their position for 1.8 years. The sample was mostly female (73.6%), white (85.8%), and non-URIM (87.8%). Almost 18% of CDs held the rank of instructor/lecturer/other and 16% held the rank of associate professor or professor, while only 11% of other faculty had the rank of instructor/lecturer/other and 22% held the rank of associate or full professor. Although the majority of all participants did not have a doctorate degree (86.6%), CDs held almost half as many doctorates as other faculty.

Table 2

Characteristics of CDs compared with Other faculty
Characteristic	Total	Clinical Director	Other Faculty*
Characteristic	Total	(CD)	Other Faculty*
	n = 723	n = 156 (21.6%)	n = 567 (78.4%)
	Mean ± SD	Mean ± SD	Mean ± SD	p value
Age	44.2 ± 10.9	44.0 ± 10.3	44.2 ± 9.9	0.8013
Years in PA education	2.6 ± 1.3	2.6 ± 1.3	2.7 ± 1.3	0.6060
Years at program	2.3 ± 1.3	2.3 ± 1.3	2.3 ± 1.2	0.4885
Years at current position	1.8 ± 1.3	1.8 ± 1.3	1.7 ± 1.2	0.5567
	# (%)	# (%)	# (%)
Type of School				0.1576
Private, non-profit	438 (63.9)	100 (66.7)	338 (63.1)
Private, for-profit	31 (4.5)	10 (6.7)	21 (3.9)
Public	217 (31.6)	40 (26.7)	177 (33.0)
Gender				0.3893
Male	187 (26.4)	36 (23.7)	151 (27.2)
Female	521 (73.6)	116 (76.3)	405 (72.8)
Race/Ethnicity				0.9682
White	620 (85.8)	131 (84.0)	489 (86.2)
Asian	15 (2.1)	4 (2.6)	11 (1.9)
African American	29 (4.0)	6 (3.8)	23 (4.1)
Hispanic	27 (3.7)	7 (4.5)	20 (3.5)
NHPI/AIAN	5 (0.7)	1 (0.6)	4 (0.7)
Other or no answer	27 (3.7)	7 (4.5)	20 (3.5)
Under-represented status in medicine				0.7551
Non-UR in medicine	635 (87.8)	134 (90.5)	497 (91.4)
UR in medicine	88 (12.2)	14 (9.5)	47 (8.6)
Tenure status				0.2435
Not tenure track	588 (81.3)	130 (83.3)	458 (80.8)
Tenure track, not tenured	110 (15.2)	24 (15.4)	86 (15.2)
Tenured	25 (3.5)	2 (1.3)	23 (4.1)
Degree awarded at PA school graduation				0.0166
Certificate or Associate	77 (10.7)	25 (16.0)	52 (9.2)
Bachelor	182 (25.2)	30 (19.2)	152 (26.9)
Master	462 (64.1)	101 (64.7)	361 (63.9)
Academic Rank				0.0384
Instructor/lecturer/other	92 (12.7)	28 (17.9)	64 (11.3)
Assistant professor	480 (66.4)	103 (66.0)	377 (66.5)
Associate or full professor	151 (20.9)	25 (16.0)	126 (22.2)
Salary				0.4241
Median (104k) or below	460 (63.6)	95 (60.9)	365 (64.4)
Above median	263 (36.4)	61 (39.1)	202 (35.6)
Has a doctorate				0.0376
No	625 (86.6)	142 (91.6)	483 (85.2)
Yes	97 (13.4)	13 (8.4)	84 (14.8)
Ever published				0.1354
No	401 (57.0)	93 (62.4)	308 (55.6)
Yes	302 (43.0)	56 (37.6)	246 (44.4)
Received research funding in last 3 years				0.2603
No	631 (87.3)	132 (84.6)	499 (88.0)
Yes	92 (12.7)	24 (15.4)	68 (12.0)

Satisfaction and Burnout

Figure 1A and B summarizes satisfaction and burnout for all participants. There were no differences between CDs and other faculty in their satisfaction with any aspect of their position. However, 57.5% of CDs reported moderate or high levels of burnout compared to 42.7% of other faculty. About 20% of CDs had high levels of burnout compared to 12.7% of other faculty. Nearly half of all faculty indicated an intent to leave academia (Fig. 1C).

Faculty considering leaving their position

CDs were almost twice as likely to intend to leave their position as other faculty (Fig. 1C). Table 3 describes predictors of faculty intent to leave their position based on adjusted regression. In CDs, intent to leave was associated with moderate levels of burnout as well as dissatisfaction with professional development. CDs with moderate levels of burnout had 4 times the odds of those with low levels to consider leaving their position (95% CI, 1.15–13.92). CDs who were dissatisfied with professional development had 3.74 times the odds of intending to leave their position (95% CI, 1.09–12.84). In other faculty, there were no predictors significantly associated with intention to leave their position.

Table 3

Multivariable logistic regression for predictors of intention to leave position among CDs and Other faculty
	Considered leaving position
	Clinical Directors (n = 130)				Other Faculty (n = 488)
	AOR	Lower 95% CI	Upper 95% CI	pvalue	AOR	Lower 95% CI	Upper 95% CI	pvalue
Satisfaction with…
Professional development
Satisfied or very satisfied	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Not satisfied or marginally satisfied	3.74	1.09	12.84	0.0360	0.96	0.49	1.86	0.8965
Job duties
Satisfied or very satisfied	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Not satisfied or marginally satisfied	0.58	0.12	2.75	0.4895	1.51	0.7	3.28	0.2962
Wellbeing & benefits
Satisfied or very satisfied	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Not satisfied or marginally satisfied	0.71	0.12	4.21	0.7073	1.52	0.70	3.32	0.2953
Support & environment
Satisfied or very satisfied	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Not satisfied or marginally satisfied	1.58	0.38	6.62	0.5307	1.47	0.69	3.11	0.3175
Level of burnout
Low	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Moderate	4.00	1.15	13.92	0.0291	0.87	0.47	1.62	0.6621
High	3.84	0.89	16.46	0.0704	0.78	0.32	1.92	0.5864
*Adjusted for age, gender, representation in medicine, years in current position, academic rank, type of school

Faculty considering leaving their program

Fewer CDs intended to leave their program compared to other faculty (Fig. 1C). Table 4 describes predictors of faculty intent to leave their program. CDs with high levels of burnout had 14.65 times the odds of considering leaving their program (95% CI, 3.66–58.56). For other faculty, intent to leave was associated with moderate (p = 0.0003) or high levels of burnout (p = 0.0232), as well as dissatisfaction with professional development (p < 0.0001) and support and environment (p = 0.0009).

Table 4

Multivariable logistic regression for predictors of intention to leave program among CDs and Other faculty
	Considered leaving program
	Clinical Directors (n = 130)				Other Faculty (n = 488)
	AOR	Lower 95% CI	Upper 95% CI	pvalue	AOR	Lower 95% CI	Upper 95% CI	pvalue
Satisfaction with…
Professional development
Satisfied or very satisfied	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Not satisfied or marginally satisfied	1.67	0.41	6.76	0.4699	3.18	1.91	5.28	< .0001
Job duties
Satisfied or very satisfied	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Not satisfied or marginally satisfied	2.49	0.49	12.67	0.2722	1.64	0.87	3.08	0.1255
Wellbeing & benefits
Satisfied or very satisfied	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Not satisfied or marginally satisfied	3.92	0.56	27.36	0.1686	1.81	0.91	3.61	0.0897
Support & environment
Satisfied or very satisfied	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Not satisfied or marginally satisfied	1.65	0.36	7.6	0.5217	2.84	1.53	5.28	0.0009
Level of burnout
Low	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Moderate	0.86	0.23	3.15	0.8139	2.5	1.53	4.08	0.0003
High	14.65	3.66	58.56	0.0001	2.36	1.12	4.94	0.0232
*Adjusted for age, gender, representation in medicine, years in current position, academic rank, type of school

Faculty considering leaving academia

More CDs reported an intent to leave academia compared to other faculty (Fig. 1C). Table 5 describes predictors of faculty intent to leave academia. Intent to leave academia was associated with moderate or high levels of burnout, as well as dissatisfaction with professional development, for both CDs and other faculty. CDs with moderate and high levels of burnout had respectively 6.14 times the odds (95% CI, 2.08–18.13) and 27.13 times the odds (95% CI, 6.05-121.61) of considering leaving compared to those with low levels of burnout. A strong association between burnout and intent to leave was also observed in other faculty (moderate burnout: AOR = 5.21, 95% CI, 3.25–8.36; high burnout: AOR = 12.89, 95% CI, 5.42–30.68). CDs who were not satisfied with professional development opportunities had 4.39x the odds of considering leaving academia (95% CI, 1.12–17.33) than those who were satisfied, while other faculty had 2x the odds of considering leaving academia (95% CI, 1.21–3.58). Dissatisfaction with support and environment was also associated with other faculty’s intent to leave (p = 0.0104).

Table 5

Results of multivariable logistic regression for predictors of intention to leave academia among CDs and Other faculty
	Considered leaving academia
	Clinical Directors (n = 130)				Other Faculty (n = 488)
	AOR	Lower 95% CI	Upper 95% CI	pvalue	AOR	Lower 95% CI	Upper 95% CI	pvalue
Satisfaction with…
Professional development
Satisfied or very satisfied	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Not satisfied or marginally satisfied	4.40	1.12	17.33	0.0343	2.08	1.21	3.58	0.0079
Job duties
Satisfied or very satisfied	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Not satisfied or marginally satisfied	0.75	0.15	3.69	0.7192	1.78	0.9	3.52	0.0992
Wellbeing & benefits
Satisfied or very satisfied	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Not satisfied or marginally satisfied	8.37	0.42	168.37	0.1653	1.11	0.53	2.31	0.7904
Support & environment
Satisfied or very satisfied	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Not satisfied or marginally satisfied	1.33	0.29	6.21	0.7157	2.4	1.23	4.83	0.0104
Level of burnout
Low	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Moderate	6.14	2.08	18.13	0.001	5.21	3.25	8.36	< .0001
High	27.13	6.05	121.61	< .0001	12.89	5.42	30.68	< .0001
*Adjusted for age, gender, representation in medicine, years in current position, academic rank, type of school

Faculty turnover is one current limitation to expanding the PA workforce. Our study revealed that nearly half of all PA faculty indicated an intent to leave academia. Among these educators, CDs hold a very important role in coordinating the clinical year of the PA program. Compared to other faculty, CDs generally have worked in PA education, their program, and their position about the same length of time. CDs more often hold the rank of instructor/lecturer and have less doctorate degrees compared to other faculty.

CDs indicated an intention to leave their position almost 2x that of other faculty. Key factors influencing intent to leave were a lack of satisfaction with professional development and burnout. Our results underscore the importance of supporting CDs in reducing burnout and creating more opportunities for professional development and faculty mentoring.

Based on our results, burnout is always a factor for CDs intent to leave their position, their program, or academia. Similar observations have been noted in prior studies in the intent to leave and burnout, as well as a relationship between depression, burnout, and professional outcomes among clinically practicing PAs [9–15]. In our analyses, very few other faculty indicated an intention to leave their position, despite 43% also reporting moderate-high levels of burn out. Much higher levels reported an intention to leave their program or leave academia altogether.

Another main contributor to intent to leave in both CDs and other faculty was dissatisfaction with professional development opportunities. In CDs, this dissatisfaction contributed to an intention to leave their position or academia, while in other faculty, this dissatisfaction contributed to an intention to leave their program or leave academia. This result may suggest that without a path to advancement, all faculty may intend to leave academia for a different career.

Furthermore, at least 60% of those in each faculty role reported being satisfied with the various aspects of their jobs, suggesting that PA faculty are overall satisfied with their role, despite high levels of burn out. The current study was based on findings pre-pandemic and we have witnessed a major shift in PA burnout rates and resignations. Unique to health profession education, there have been significant challenges in accessing training and clinical sites and preceptors during the COVID-19 pandemic. This has made the job duties of CDs more difficult, so further studies are needed to explore burnout and faculty retention post COVID-19 pandemic.

Limitations:

This was a cross-sectional study prior to the pandemic, and PA education, specifically clinical coordination efforts and duties, have changed rapidly during the pandemic, which would likely increase burnout and intent to leave. The main outcome variable measured intent to leave, but how this intention translates into actual faculty turnover remains to be investigated through longitudinal studies.

Faculty turnover is a major limiting factor in PA education as approximately 50% of all PA faculty intend to leave academia in the next 2 years. We found that clinical coordinators in particular are more likely to intend to leave compared to other faculty. In both CDs and other faculty, intent to leave was significantly associated with a lack of satisfaction with professional development, and moderate to high levels of burnout; however, only in CDs were these specifically associated with intention to leave their current position. This study underscores the importance of mentoring and providing faculty development opportunities to the PA professoriate. Longitudinal and qualitative research are needed to investigate the unique characteristics of CDs and assess changes after the pandemic period.

AAPA: American Academy of Physician Assistants; Physician Assistant/Associate; PAEA: Physician Assistant Education Association. FTE: Fulltime equivalent; CD: Clinical Directors; PA: Physian Assistant/Associate

Ethics approval and consent to participate

This study was approved by The Institutional Review Board at Charles R. Drew University of Medicine and Science. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declared that they have no competing interest.

Funding

This study was not supported by external funding.

Author’s contributions

These authors contributed equally to this work: GK, AK, LK, and KS contributed to the design of the research, the development of methodology, and the conduct/analysis of data. All authors read and approved the final manuscript.

Acknowledgements

The Institutional Review Board at Charles R. Drew University of Medicine and Science approved the study. We want to acknowledge the Physician Assistant Education Association for providing access to the de-identified raw data.

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No competing interests reported.

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Reasons Clinical Education Directors Intend to Leave their Jobs

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