restricted access Stress and Provider Retention in Underserved Communities
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Stress and Provider Retention in Underserved Communities

Workplace stress, provider retention, community health centers

Clinicians and staff in health care organizations experience stress and burnout due to both job conditions and unique pressures of the medical field. Stress and burnout have consequences not only for the health and wellness of employees but for patients through poor quality care. Health care organizations and systems are affected when it causes decreased productivity and even attrition. In safety net health centers, the loss of clinicians and staff and decreased productivity further strain an already resource-poor system, creating a vicious cycle as more demands are placed on those who remain. Acutely aware of this phenomenon, the Association of Clinicians for the Underserved (ACU) sought to better understand stress and burnout experienced by its members in hopes of developing strategies and interventions to break this cycle. This column describes the initial findings from a survey conducted to assess stress and burnout among ACU members.


Health care professionals commonly experience stress at their work site; contributory factors include heavy workload, understaffing, high intensity of work, job insecurity,1 and risk of injury or harm.2 Poor communication skills, especially among superiors, and unpleasant physical environments can also contribute to stress.3 Stress commonly arises in a variety of professions, including social work, occupational therapy, nursing, and medicine.4 Research on nurses has found sleep deprivation, ambiguity in work [End Page 597] roles, and time pressures to be linked to stress, while studies of physicians found links to unmet patient expectations, threats of litigation, interpersonal conflicts, and coping with the death of patients.2

Safety net health centers, like other health care delivery settings, can cause stress for their clinicians and staff. Due to limited organizational and systems resources, safety net providers face additional challenges such as severely inadequate patient care space and lack of essential supplies. Outside their own facilities, safety net providers lack systems resources such as specialists willing to see uninsured or underinsured patients. The recent economic downturn has caused a rise in uninsured patients seen by safety net clinics and further stretches their resources.5 Low literacy, poverty, and other socioeconomic challenges faced by patients also increase the workload for providers in such settings.

Despite the general lack of resources, safety net health centers and their staffs possess characteristics that make them resilient to some of the stressors. For example, safety net providers share a common mission to serve medically vulnerable communities and come into the setting with a systems perspective and are well-aware of potential challenges. Safety net health centers also self-select individuals with personal characteristics and skills suited to working with poor and underserved populations. For example, many have taken initiative to develop cultural competency skills as well as language skills specific to community needs.

Nevertheless, stress may lead to a wide range of effects for both workers and organizations. Negative health outcomes of stress include anxiety, depression, immune deficiencies, and cardiovascular problems.6 Stress has also been associated with occupational burnout, characterized by increased feelings of exhaustion, cynicism and inefficacy.7 Stress may directly and indirectly affect critical organizational measures such as job performance, absenteeism, errors in treatment, patient satisfaction, and turnover.4 Factors such as absenteeism and intentions of workers to quit all have an impact on the overall success of an organization, as the cost of recruiting and training adds additional financial burdens.

The negative consequences of stress and burnout place delicate health care systems for the poor and underserved at particular risk. In an effort to take the initial steps in developing a program to combat the problem, this study aimed to assess the degree of stress and burnout experienced by those who work in safety net settings as well as the characteristics of their practice environment.


ACU conducted an anonymous online survey of current members. Questions focused on perceptions, degree, and impact of stress, burnout, and workplace wellness. The survey also collected information about characteristics of staff, organizations, and any existing workplace wellness programs. Staff members of ACU constructed the survey in cooperation with a...