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Background: Allocation of provider time across clinical, administrative,
educational, and research activities may influence job satisfaction, productivity,
and quality of care, yet we know little about what determines time allocation.
Aims: To investigate factors associated with time allocation, we
surveyed all mental health providers in one Veterans Health Administration
(VHA) network. We hypothesized that both facility characteristics (academic
affiliation, type of organization of services, serving as a “hub” for
treatment of severely mentally ill, facility size) and individual provider
characteristics (discipline, length of time in job, having an academic
appointment) would influence time allocation.
Methods: Eligible providers were psychiatrists, psychologists,
social workers, physician assistants, registered or licensed practical
nurses or other providers (psychology technicians, addiction therapists,
nursing assistants, rehabilitation, recreational, occupational therapists)
who were providing care in mental health services. A brief self-report
survey was collected from all eligible providers at ten VHA facilities
in late 1998 (N = 997). Data regarding facility characteristics were obtained
by site visits and interviews with managers. Multilevel modeling was used
to examine factors associated with three dependent variables: (i) total
time allocation by activity (clinical, administrative, educational, research);
(ii) clinical time allocation by treatment setting (inpatient vs. outpatient);
and (iii) clinical time allocation by type of care (mental vs. physical).
Licensed Practical Nurses (LPNs) were used as the reference group for
all analyses because LPNs were expected to spend the majority of their
time on clinical activities.
Results: Overall, providers spent most of their time on clinical
activities (77%), followed by administrative (11%), and educational (10%).
Surprisingly, research activities accounted for only 2% of their time.
Multilevel analysis indicated none of the facility-level variables were
significant in explaining facility variance in time allocation, but individual
characteristics were associated with time allocation. The model for predicting
time allocation by inpatient or outpatient settings explained 16-18% of
the variance in the dependent variable. In all models, provider discipline
and length of time in job played an important role. Having an academic
appointment was important only in the model examining total time allocation
by activity type.
Discussion: These simple models explained only a small amount of
variance in the three dependent variables which were intended to capture
issues related to time allocation; and the low number of facilities limited
our power to examine effects of facility-level factors. Our models performed
better in predicting allocation of clinical time to treatment setting
and type of treatment than in predicting overall time allocation. Discipline
and length of time in job were significant across all models. In contrast,
having an academic appointment was associated with allocating significantly
less time to clinical activities and more time to administrative activities
but not to any significant difference in time spent in either research
or education.
Implications: While a “gold standard” of optimal time allocation
does not exist, it is striking that research, a stated mission of the
VHA, accounted for so little of providers' time. The lack of involvement
of clinicians in research has implications for recruitment and retention
of high-quality mental health providers in this network and for the education
of future providers. Without involvement of clinicians, research conducted
in the network by nonclinicians may be less relevant to ``real-world''
clinical issues. Reductions of funds available to mental health, coupled
with increased clinical demands, may have prompted this pattern of time
allocation, and these findings attest to the challenges faced by large
institutions that are charged with balancing many often seemingly competing
missions.
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