Advanced Practice Provider Burnout in Primary Care: Insights from Virginia’s Joy in Healthcare Initiative

The Virginia Joy in Healthcare pilot is an initiative of the Virginia Task Force on Primary Care, staffed by the Virginia Center for Health Innovation, with funding support from the Commonwealth of Virginia. This report was developed by VCHI on behalf of the Task Force. Published February 9th, 2026.

Click Here to View the 2026 Virginia Joy in Healthcare Findings as a PDF

Introduction

Burnout is increasingly recognized as a threat to the stability of the U.S. primary care workforce, with evidence linking it to reduced clinical productivity, diminished patient access, and higher provider turnover.1, 2 Nearly half of U.S. physicians report working with inadequately staffed teams, which is associated with significantly higher odds of burnout and increased intention to leave the profession.3 As states face persistent physician shortages, Advanced Practice Providers (APPs), including Nurse Practitioners (NPs), Physician Assistants or Associates (PAs), and Certified Nurse Midwives (CNMs), have been increasingly relied upon to mitigate physician shortages.4 Recent data show that NPs comprise 47% of all US primary care clinicians and, together with PAs and CNMs, deliver a disproportionate share of care in rural and underserved communities.5 Yet, despite the expanding role of APPs, most burnout research remains focused on physicians, leaving gaps in the evidence on how APPs experience and respond to comparable systems-level pressures and the potential implications for future access to primary care.

Virginia’s Task Force on Primary Care (VTFPC) developed the Virginia Joy in Healthcare pilot as a collaborative, multi-system effort to measure clinician well-being with data from across the Commonwealth of Virginia. Implemented in partnership with the American Medical Association’s Joy in Medicine™ program, the pilot represents a first-in-the-nation initiative that aggregates clinician well-being data across multiple health systems to identify opportunities for statewide, system-level improvement. From its inception, the Task Force prioritized the inclusion of APPs, a critical and rapidly growing segment of Virginia’s primary care workforce. Between 2020 and 2025, the number of NPs per capita in Virginia rose from 106.7 to 153.2, and APPs accounted for all of the growth in primary care spending from 2022 to 2023.6 As APPs are increasingly relied upon to address primary care workforce shortages, they may also face unique challenges related to their scope of practice, training, and their own system-level pressures that can increase the risk of burnout in the absence of targeted support.

Methods

Five organizations, Ballad Health, Bon Secours Richmond, Carilion Clinic, Children’s Hospital of the King’s Daughters, and Trusted Doctors, administered a standardized organizational biopsy survey between November 2024 and February 2025. Across organizations, the response rate was 34.6%, yielding 1,274 clinician responses (i.e., 1,001 physicians and 273 APPs [including NPs, PAs, and other providers]).

“Primary care” was defined using the VTFPC’s four-quadrant approach, which incorporates a narrow and broad set of services and provider types. Based on this definition, the Joy in Healthcare analysis includes the following specialties, regardless of provider type, under primary care: “Family Medicine,” “General Practice,” “General Pediatrics,” “Internal Medicine, General- Primary Care,” “Obstetrics & Gynecology,” “Palliative Care,” and “Pediatrics.” Under this definition, the survey sample included 429 primary care physicians, 572 physicians from other specialties, 138 primary care APPs, and 135 APPs from other specialties.

The survey data were collected and reported at the organizational level, then aggregated to explore combined findings for the surveyed organizations. It is important to note that these pooled survey results are not structured to support statistical testing of comparisons between clinician groups in Virginia or to represent all of Virginia in comparisons with national results. The results are presented here as a data-informed starting point for further exploration of burnout and related concerns among advanced practice providers.

Key Findings

A note on the data:

In the data summaries that follow, the phrase ‘Virginia results’ refers to the pooled results from the five Virginia organizations surveyed in 2025. The phrase ‘national results’ refers to results collected from across the states as reported by AMA. The national results are referenced in selected sections and included in multiple appendix tables as context for considering the Virginia findings.

Burnout Symptoms

In the Virginia survey, APPs reported a high prevalence of burnout symptoms, as did physicians. This pattern was consistent across specialty groupings, with the highest reported rate observed among primary care APPs (52.9%).

  • All specialties: 50.2% for APPs, 45.0% for physicians
  • Primary care: 52.9% for APPs, 44.8% for physicians
  • Other specialties: 47.4% for APPs, 45.0% for physicians

The pattern observed in the Virginia results was generally consistent with national data from AMA for the same type of survey item in 2024. See Appendix A for more details on Virginia and national survey results.

Intention to Reduce Clinical Hours

The Virginia results indicate that more than one in four primary care clinicians surveyed reported an intent to reduce clinical care hours over the next year.

  • All specialties: 23.4% for APPs, 31.2% for physicians
  • Primary care: 29.7% for APPs, 28.4% for physicians
  • Other specialties: 17.0% for APPs, 33.2% for physicians

See Appendix B for more details on Virginia and national survey results.

Factors in Maintaining Clinical Hours

Among surveyed Virginia APPs (all specialties) who reported intent to reduce clinical hours (n = 64), respondents identified multiple factors that would increase the likelihood of maintaining their current full-time equivalent (FTE) commitment. These include:

1.  Higher compensation (79.7%)

2.  Better workflow efficiency (54.7%)

3.  Less documentation/ work outside of work (53.1%)

4.  Consistent staffing (51.6%)

5.  Fewer electronic health record (EHR) hassles (i.e., less EHR work outside of office hours) (50.0%)

In comparison to the surveyed physicians reporting intent to reduce clinical hours (n=312), APPs placed greater emphasis on compensation (79.7% vs. 55.1%).  See Appendix C for more details on the Virginia survey results.

After-Hours EHR and Documentation

Virginia APPs practicing in primary care reported substantial levels of electronic health record (EHR) burden related to their workload outside of scheduled hours.

  • 13.0% of primary care APPs reported spending >8 hours per week in the EHR outside of scheduled patient contact hours, compared to 11.9% for other APP specialties.
  • 35.5% of primary care APPs characterized their after-hours EHR time outside of normal work hours as moderately high or excessive, compared with 23.0% for other APP specialties.
  • 27.3% of primary care APPs reported that EHR design limits effective task delegation to support staff compared with 20.2% for APPs practicing other specialties.

See Appendix D for more details on Virginia and national survey results.

Support Staff and Delegation

Access to Medical Assistants (MAs) or nurses for delegation was another notable concern among the surveyed Virginia APPs.

  • 48.9% of APPs in all specialties reported inadequate access to medical assistants (MAs) or nurses to whom routine clinical and administrative tasks can be delegated (e.g., order entry, medication review, visit note documentation, forms completion, or processing prescription renewals).
  • 51.5% of APPs in primary care reported inadequate access to MAs or nurses, compared to 45.5% of APPs in other specialties.
  • 19.7% of APPs in primary care reported barriers to effective delegation related to concerns about support staff training or reliability, compared to 21.2% in other specialties.

See Appendix E for more details on Virginia and national survey results.

Values Alignment with Organizational Leadership

Among surveyed Virginia APPs, reported alignment with the values of their organizations’ clinical leadership was generally comparable across respondents.

  • 68.1% of primary care APPs agreed or strongly agreed that their values align with clinical leadership, compared to 63.7% for APPs in other specialties.
  • 11.6% of APPs practicing in primary care disagreed or strongly disagreed that their values align with clinical leadership, compared with 15.6% for APPs in other specialties.
  • Similar proportions of APPs reported being neutral on values alignment (20.3% for primary care APPs and 20.7% for other specialty APPs).

See Appendix F for more details on Virginia and national survey results.

Feelings of Control Over Workload

Among the surveyed Virginia APPs, roughly one out of four reported only marginal or poor control over their workload.

  • 24.6% of primary care APPs reported marginal or poor control over their workload, compared to 27.4% for other specialties.
  • The rate for primary care APPs (24.6%) was essentially the same as the reported rate for primary care physicians (24.5%).

See Appendix G for more details on Virginia and national survey results.

Discussion

Survey findings indicate that APPs practicing in primary care report levels of burnout symptoms, administrative burden, and intent to reduce clinical hours that are generally comparable to those reported by physicians. These patterns suggest that system-level factors affecting clinician well-being are not limited to a single provider type. As APPs continue to assume a larger role in the delivery of primary care, these findings raise important considerations for how health systems, workforce planners, and other decision-makers can structure roles, workloads, and support mechanisms in the future.

Although the structure of the survey sample limits generalizability, the findings are nonetheless informative and shed light on priorities identified by APPs. Based on these findings, four considerations emerge for future exploration.

1. Recognize APP Burnout

The survey results indicate a high prevalence of reported burnout symptoms among APPs, particularly in primary care, alongside elevated administrative burden and limited access to support staff. While physician burnout has been extensively documented7, these findings indicate that APPs experience similar system-level pressures. The relative lack of APP-specific research at the national level may limit the ability of decision-makers to fully assess how these pressures affect retention, access to care, and workforce sustainability. Additional data collection and analysis focused on APPs may help clarify the scope and drivers of burnout within this growing segment of the workforce.

2. Adapt Workforce Planning

State and national workforce strategies have increasingly emphasized APPs as a solution to address physician shortages, particularly in primary care and in underserved communities or areas.4 However, the survey findings show substantial intent among primary care APPs to reduce clinical hours, suggesting that workforce expansion alone may not translate into sustained increases in care capacity. Prior research documenting higher turnover rates among primary care APPs relative to other settings further underscores the importance of aligning workforce planning with retention considerations.8, 9 These findings suggest that training pathways, role design, and practice environments may influence the effectiveness of APPs as a long-term workforce solution.

3. Implement Organizational Level Supports

Several of the factors identified in the survey—such as documentation burden, EHR usability, staffing adequacy, and workflow efficiency—are modifiable at the organizational level. Prior research has described structured approaches to supporting APP well-being, including models that emphasize leadership engagement, practice at the top of licensure, role clarity, professional development, and workload management.10 Research specific to the APP experience highlights that organizational strategies tailored to APP roles may differ from those developed primarily for physicians.11 The survey findings suggest that such organizational supports may be relevant to mitigating burnout risk and supporting retention among APPs.

4. State and Federal Policy Solutions

At the state and federal levels, several policy-relevant considerations may emerge, including:

  • Support for standardized onboarding and transition-to-practice programs for APPs entering primary care,
  • Workforce incentives that encourage sustained participation in primary care, particularly for early-career APPs, and investment in state-level infrastructure and evaluation efforts to assess APP well-being and workforce outcomes over time.

These policy approaches may complement organizational strategies by addressing system-level factors that influence APP practice environments.

Conclusion

The survey results indicate that APPs, particularly those practicing in primary care, report levels of burnout symptoms, administrative burden, and planned reductions in clinical effort that warrant attention in workforce planning discussions. These findings suggest that system-level pressures affecting clinicians persist across provider types. Addressing these pressures may require coordinated efforts at the organizational and policy levels to support both APPs and physicians and to promote a stable and effective primary care workforce.

Appendices

Sources

1. U.S. Department of Health and Human Services. (2022). Health Worker Burnout. https://www.hhs.gov/surgeongeneral/reports-and-publications/health-worker-burnout/index.html

2. NIHCM Foundation. (2025). The Future of Primary Care: Quality, Access, and Costs. https://nihcm.org/publications/the-future-of-primary-care-quality-access-costs

3. Rotenstein, L.S., Shah, P., Shanafelt, T., & Sinsky, C.A. (2025). Incomplete Team Staffing, Burnout, and Work Intentions Among US Physicians. JAMA Internal Medicine. 2025;185;(6):739-742. doi:10.1001/jamainternmed.2025.1679

4. McCain, J. & Flinter, M. (2025). Investing in Primary Care: The Nurse Practitioner Will See You Now. Milbank Memorial Fund. https://www.milbank.org/publications/investing-in-primary-care-the-nurse-practitioner-will-see-you-now/

5. Horstman, C. & Shah, A. (2025). The State of Rural Primary Care in the United States. The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2025/nov/state-rural-primary-care-united-states

6. Virginia Primary Care Investment Report. (2025). https://www.vahealthinnovation.org/virginia-primary-care-investment-report-2025/

7. American Medical Association. (2025). Measuring and Addressing Physician Burnout. https://www.ama-assn.org/practice-management/physician-health/measuring-and-addressing-physician-burnout

8. Powless, H., Villegas, J., & Buckler, L. (2025). APP turnover is more than an HR challenge – it’s an operational and financial reality. Sullivan Cotter. https://sullivancotter.com/advanced-practice-provider-turnover-cost/

9. Patel, E., & Fraher, E. (2025). Why Nurse Practitioners Leave and Stay: Diverging Factors in Hospital Vs. Primary Care Settings. Academy Health Annual Research Meeting. https://academyhealth.confex.com/academyhealth/2025arm/meetingapp.cgi/Paper/71702

10. Chan, G.K., Kuriakose, C., Blacker, A., Harshman, J., Kim, S., Jordan, L., & Tait, D.S. (2021). An organizational initiative to assess and improve well-being in advanced practice providers. Journal of Interprofessional Education & Practice. 2021; 25:2405-4526. https://doi.org/10.1016/j.xjep.2021.100469

11. Klein, C.J., Dalstrom, M., Lizer, S., Cooling, M., Pierce, L., & Weinzimmer, L.G. (2019). Advanced Practice Provider Perspectives on Organizational Strategies for Work Stress Reduction. Western Journal of Nursing Research. 2020 Sep;42(9):708-717. doi: 10.1177/0193945919896606

Acknowledgements

This report was prepared by:

Beth Bortz, MPP

President & CEO

Virginia Center for Health Innovation (VCHI)

 

Meredith Young, MSNP

Senior Researcher, Research Consortium @ VCHI

Virginia Center for Health Innovation (VCHI)

 

Zelda Hinkle

Director of Operations & Communications

Virginia Center for Health Innovation (VCHI)

 

We want to thank our colleagues at the American Medical Association, Nancy Nankivil, MD, Brittany Muston, Kyra Cappelucci, Nish Wise, and Samantha Cheney, for data preparation, expertise, and technical assistance. Thank you to our Virginia Joy in Healthcare Co-Chairs, Mark Greenawald, MD, and Riva Kamat, MD, for their leadership throughout the pilot. We would also like to thank Virginia Joy in Healthcare practice leads: Stephen Combs, MD (Ballad Health), Andreya Risser, MD (Bon Secours), Lisa Uherick, MD (Carilion Clinic), Douglas Mitchell, MD (Children’s Hospital of the King’s Daughters), and Sandy Chung, MD (Trusted Doctors). Thanks to Stephen Horan, PhD, at Community Health Solutions for additional content review and support.