The Model Study On The Relationship Between Job Satisfaction, Career Burnout And Turnover Intention Among Physicians From Urban State-owned Medical Institutions

Objective:State-owned medical institutions are the main power to maintain health service undertaking public welfare. Motivating working morale of medical personnel effectively is the indispensable factor to enhance subject status of state-owned medical institutions and promote the further development of medical system reform, among which the incentive for physicians is more crucial. However, because of professional specialty and system anomie, the working and emotion status of current physician groups is worth worrying, such as job dissatisfaction rising, mental burnout increasingly serious, quitting even refusing medical career, which bring negative effect to physician's physical and mental health, the quality of health service and physician-patient relationship. At present, most of the domestic researches on job satisfaction, career burnout or quitting medical career are the theory elaboration or typical survey, large-scale empirical researches especially for clinical physicians from state-owned medical institution are relatively less, and systematic research on whole structure relation among the three concepts is still blank. Besides, most of the existing researches adopted foreign mature scale directly, which often lack of characteristic elements of Chinese physicians. Furthermore, the control of confounders and measurement error is the disadvantage in the methods used by previous researches.In view of this, we conducted the investigation in order to understand the present situation and distribution difference on working attitude of physicians from urban state-owned medical institution in the process of medical reform, to inspect the path relations among job satisfaction, career burnout and turnover intention, and to build a comprehensive potential structure model. Meanwhile, we also intended to mine the deep mechanism about relevant factors, and predict the scenario mode of physicians' working attitude, finally put forward some countermeasures to enhance physicians' working motivation and stability as a reference for making related policy.Methods:This research used the method of logical analysis combined with empirical research, descriptive analysis combined with explanatory research, the quantitative study combined with qualitative analysis, the present condition analysis combined with scenario anticipation. First, we used the literature inductive method to construct the theoretical framework guiding this study, then deduced this structure model into concrete hypothesis according to the research objectives.Quantitative Questionnaire survey:In reference to related literatures, we compiled the questionnaire of physicians' job satisfaction, career burnout and turnover intention as a tool through interview, expert consultation and initial survey. Hubei Province in central China, where the number of doctors per thousand population is average, was determined as the source site of sample. From the data of this initial investigation, the sample size in the actual survey was calculated to be no fewer than 1445 individuals. A method of multistage stratified random sampling was adopted to acquire the study group, using the socioeconomic development level among cities and the grade of state-owned medical institutions as stratification standards at the first two stages. A cross-sectional survey was carried out in March and April 2010 in three urban areas (Wuhan, Shiyan, and Jingmen) of Hubei Province, covering 67 state-owned medical institutions (9 third grade,18 second grade, and 40 first grade). All investigators underwent training together in advance. Participants who were not informed of the specific hypothesis of this study were surveyed anonymously with the self-administered questionnaire. Data was accepted for final analysis after invalid questionnaires were rejected. Of the 1600 physicians surveyed in the three urban areas, 1497 responded. Of those responses,1451 valid questionnaires were finally acquired, yielding an effectiveness rate of 96.9%. The data was analyzed with SPSS 16.0 and AMOS7.0.The statistical methods used in this paper mainly included exploratory and confirmative factor analysis, statistical description (x, s,%), single-factor analysis (t test, one-way ANOVA,x2 test, Kruskal-Wallis test), multiple-factor analysis (Mixed Model, General Linear Model, non-condition logistic regression model), Structural Equation Modeling (SEM) and and Multi-group invariance test.Qualitative Interview Survey:The objects participating in the in-depth individual interview included some physicians, agency managers, and officials from health administrative department. Interview outlines were made according to different objects. Semi-structured interview was carried out using certain interviewing skills. The interviewees covered 24 clinical physicians,14 managers of medical institutions and 7 officials from health administrative department. Focus group discussions mainly aimed at the physicians. Nine-times group discussions were completed according to the interview outlines formulated in advance, in which the quality control of interview was emphasized. Interviewing materials were sorted and interpreted through reading text, coding, and concepts classification for providing some information on further explaining the results of quantitative study and exploring deep-rooted reasons of related factors and anticipating future situation. Qualitative interview survey was conducted in October and November 2010. Result:(1) The basic characteristic of study sample:66.2% were males and 77.7% were married; average age was 35.3; 54.2% had a bachelor's degree; attending physicians and below accounted for 76.3%; departments of internal medicine and surgery accounted for 54.7%, gynecology and obstetrics 9.1%, and pediatrics 3.4%; 37.0% reported an income between?1.53 and ?3.04 per month,29.6% between?3.05 and?4.56; 82.2% physicians were formal; 594 physicians were from third grade institution,489 second grade,368 first grade.(2) Exploratory factor analysis showed that job-itself satisfaction (58.79%) contained three factors which were job matching, professional characteristics and autonomy; job inner-circumstance satisfaction (60.38%) contained three factors which were interpersonal relationship, job condition and supportive system; job reward satisfaction (61.83%) contained two factors which were payment and allocation, and career development; organization management satisfaction (63.86%) contained two factors which were institution construction and leadership; practicing environment satisfaction (62.79%) contained three factors which were macro health-policy, public opinions and physician-patient communication; career burnout (57.33%) contained three factors which were emotional exhaustion, depersonalization and reduced personal accomplishment; turnover intention (65.17%) contained one factor.Confirmative factor analysis showed that the simple five factors Model A2'(13 indexes) of physicians' job satisfaction can be supported by sample data (GFI=0.933, RMSEA=0.075, RMR=0.024). The fitting effect of second-order measuring Model A3 on the basis of Model AT didn't decrease significantly (?CMIN=10.163, P>0.05; RMSEA=0.086, RMR=0.025). The adjusted three factors Model B2 (11 indexes) of career burnout met the fitting standard (GFI=0.965, RMSEA=0.068, RMR=0.047). The second-order measuring Model B3 was equivalent to Model B2. The simple factor measuring Model C (3 indexes) of turnover intention was saturated model.Reliability test showed that Cronbach's a coefficients of job satisfaction, career burnout and turnover intention were 0.910,0.848 and 0.766, respectively; Cronbach's a coefficients of every dimension of job satisfaction ranged between 0.798 and 0.924, and every dimension of career burnout ranged above 0.75.(3) Attitude status of physicians from urban state-owned medical institutions showed that the average score of overall job satisfaction was 2.98; job-itself satisfaction scored higher (3.61) while social practicing environment satisfaction (2.62) and job reward satisfaction scored lower (2.64). There were statistically significant difference on job-itself satisfaction, organization management satisfaction and medical practicing environment satisfaction among physicians from regions with different socio-economic development levels (P?0.01 or P?0.05). There were statistically significant difference on job inner-circumstance satisfaction, job reward satisfaction and practicing environment satisfaction among physicians from institutions of different grades (P?0.01 or P?0.05). Emotional exhaustion (3.45) and depersonalization (3.56) of physicians scored high, while psychological experience in reduced personal accomplishment (2.16) was low. Detectable rate for burnout in these three dimensions were 67.0%,68.6% and 5.8%, respectively. Of overall career burnout, severe burnout accounted for 3.2%, moderate burnout 48.2%, mild burnout 35.4% and zero burnout 13.2%. Emotional exhaustion, depersonalization and overall career burnout had statistically significant difference among physicians from regions with different development levels and institutions of different grades (P?0.01). Reduced personal accomplishment of physicians from the first-grade institutions was higher. The average score of turnover intention (3.18) was slightly higher than medium value. There was statistically significant difference among physicians from regions with different development levels (P?0.01), but there was no statistically significant difference among physicians from institutions of different grades.(4) The simple effect analysis of socio-demographic factors showed that gender had significant difference on social practicing environment satisfaction (P?0.01); age had significant difference on every dimension of job satisfaction and overall job satisfaction (P<0.01) with U tendency which descended first and ascended afterwards; education background had significant difference on both job inner-circumstance satisfaction and social practicing environment satisfaction (P?0.01); technical position had significant difference on job-itself satisfaction, job inner-circumstance satisfaction, job reward satisfaction and overall job satisfaction (P?0.01 or P?0.05); attending physicians scored lowest on the five dimensions of job satisfaction and overall job satisfaction; department had significant difference on job-itself satisfaction and social practicing environment satisfaction (P?0.01 or P?0.05); average monthly income had significant difference on job reward satisfaction, social practicing environment satisfaction and overall job satisfaction (P?0.01 or P?0.05); employment mode had significant difference on overall job satisfaction and the other dimensions of job satisfaction except job-itself satisfaction (P?0.01 or P?0.05), which is causal physicians had higher job satisfaction than formal physicians. The results showed that gender, age, education background, technical position, department and employment mode had significant difference on both emotional exhaustion and depersonalization (P<0.01). Reduced personal accomplishment had significant difference on the other socio-demographic factors except marital status (P?0.01 or P?0.05). Besides, turnover intention had significant difference among physicians of different gender, age and average monthly income. Physicians aged between 31 and 40 scored highest and male physicians scored higher than female.(5) It showed that leadership (0.310), job matching (0.231), payment and allocation (0.196), institution construction (0.183), physician-patient communication (0.144), job condition (0.092), macro health-policy (0.085) and autonomy (0.084) were significant determinants of overall job satisfaction under the control of age, technical position, average monthly income and employment mode, which became no longer significant. The estimate value (variance uoj) of institution difference in random effect model was 0.0013 (P=0.571) and showed no data aggregation.It showed that job-itself satisfaction (-0.166), job reward satisfaction (-0.084), and medical practicing environment satisfaction (-0.096) had a statistically significant effect on emotional exhaustion (R2=0.350), when all socio-demographic variables were controlled with technical position and department still significant; job-itself satisfaction (-0.056), job reward satisfaction (-0.150), and medical practicing environment satisfaction (-0.319) had a statistically significant effect on depersonalization (R2=0.511) under the control of socio-demographic variables with age, education status, technical position and department significant; job-itself satisfaction (-0.355) had a statistically significant effect on reduced personal accomplishment(R2=0.398) with marital status and technical position significant. Stepwise logistic regression Model H3 showed that job-itself satisfaction (OR=0.687), job reward satisfaction (OR=0.709), and medical practicing environment satisfaction (OR=0.475) had statistically significant impact on overall career burnout with department significant. Besides, department and overall job satisfaction had interaction on physicians' overall career burnout (Model H4).It showed that job-itself satisfaction (-0.060), medical practicing environment satisfaction (-0.075), job return satisfaction (-0.084), and organization management satisfaction (-0.142) were proved to be negative predictors of turnover intention (R2=0.297), when all socio-demographic variables were controlled; after the burnout syndrome variables were added, only the emotional exhaustion (0.135) among them was a significant positive predictor of turnover intention with job-itself satisfaction no longer significant and the estimated parameter on job rewards satisfaction smaller (-0.073). Besides, Model K4 (R2=0.456) showed that overall job satisfaction (-0.193), and the easy-acquirability of job (-0.642, high easy-acquirability as control group) were identified as significant negative predictors of turnover intention. Furthermore, Model K6 (R2=0.468) showed interactions between overall job satisfaction and the easy-acquirability of job, age and overall job satisfaction. It also showed that overall career burnout of physician was identified as a significant positive predictor of turnover intention (0.189).(6) SEM Model R showed that as comprehensive potential concepts, job satisfaction (gamma11=-0.70) had a significant direct effect on occupational burnout (SMC=0.62); job satisfaction (gamma21=-0.32) and occupational burnout (beta21=0.18) had a significant direct effect on turnover intention (SMC=0.47). Moreover, there was still a significant indirect effect (gamma11×beta21=-0.13, P<0.01) of job satisfaction on turnover intention through occupational burnout as a mediator. The integral model-fit effectiveness of Model RT on both total sample and single sample of areas met the acceptable level with small variance (total sample: GFI=0.908, CFI=0.911, RMR=0.053, RMSEA=0.077). In addition, the multi-group invariance test showed that the factor-loading parameters (?%2=21.528,?DF=16, P>0.05) and structural path weights (?x2=14.207,?DF=6, P>0.05) among these three samples met invariance, while structural covariance, structural residuals and measurement residuals didn't meet it (P<0.05).(7) Qualitative investigation on physicians' turnover and staying:A total of 13 physicians (18.84%) answered that they had the ideas of turnover before or in the current.10 physicians (76.92%) mentioned the aspect of hospital management system and leadership,9 physicians (69.23%) mentioned that the salary and welfare were poor, followed by the limited space on career development (7,53.85%). The reasons on physicians' staying:41 physicians (59.42%) expressed that this job was stable,27 physicians (39.13%) considered that their income and working conditions were acceptable,24 physicians (34.78%) mentioned that it was hard to hunt a new job.(8) Scenario anticipation analysis of physicians' working attitude:Management ability of agency leaders, income level and distribution rationality, optimizing work attributes and career development and improving practicing environment are the four key elements that affect physicians' work attitude in urban public medical institutions. Trend judgments were made based on the related-policy analysis. Four kinds of scenario development mode on physicians' work attitude were constructed, which were optimistic, slow improvement, maintaining the status quo and pessimistic. According to the experts' comprehensive anticipation, the probability of these four types of scenarios was 0.17,0.42,0.31, and 0.10, respectively. It is known that slow improvement scenario will be the most likely to occur.Conclusions:?The reliability and validity of the questionnaire formulated by this study about job satisfaction, career burnout and turnover intention of physicians from urban state-owned medical institutions are in accordance with the requirements of psychological measurement. The questionnaire is worthy to be promoted in physicians.?There is certain ascending space for overall work morale of physicians from urban state-owned medical institutions. The situation on physicians' psychological health is not optimistic and physicians' staying is a little low but not as low as expected. In job attitude, there're some differences among physicians from regions with different development levels or institutions of different grades. However, the distribution of job attitude is not completely consistent and not enough to explain correlation.?Compared with individual factors, external factors such as leadership behavior, job matching degrees, salary payment, system construction and physician-patient relationship have an obvious decisive effect on the physicians' overall job satisfaction. Among those factors, organization management satisfaction has the closest relation with overall job satisfaction. Physicians aged between 31 and 40 and with intermediate title have the lowest job satisfaction.?Physicians from the department of obstetrics and gynecology, pediatrics and emergency are more likely to generate career burnout. Job-itself satisfaction, job reward satisfaction and social practicing environment satisfaction can significantly predict physicians' career burnout. Department can adjust the relation between physicians' overall job satisfaction and career burnout.?Individual factors, attitude toward work and organization, and external market factors' have a combined effect on turnover intention. Male physicians aged between 31 to 40 have higher level of turnover intention. Physicians' career burnout plays an intermediary role between job-itself satisfaction, job reward satisfaction and turnover intention. Age and the easy-acquirability of job can adjust the relation between physicians' overall job satisfaction and turnover intention.?As comprehensive latent concepts, physicians' career burnout plays partial intermediary role between job satisfaction and turnover intention. The influence may mainly come from emotional exhaustion dimension of career burnout despite the low sensitivity of the mode.?Management ability of agency leaders, income level and distribution rationality, optimizing work attributes and career development and improving occupational environment are the four key elements that affect physicians' work attitude in urban state-owned medical institutions. Four kinds of scenario development modes on physicians' work attitude may appear in future, which are optimistic, slow improvement, maintaining the status quo and pessimistic. It is predicted that slow improvement has larger possibility.Policy recommendations:?Government macro level:Scientifically evaluating technical and labor value for improving physicians' income standards; optimizing medical practicing environment to reduce physicians' pressure of professional risk; improving professional management level of leaders in state-owned medical institution as well as leadership behavior; implementing the "strong grassroots" concept and reducing the workload of physicians in the third-grade hospitals.?Social mesosphere:Strengthening the popularization of medical knowledge and education of the public in the community; implementing professional censorship system in medical news and reports; enhancing the guidance and supervision of social media; strengthening the construction of medical social organizations and associations to protect physicians' speaking right.?Institutional micro-level:Emphasizing post matching and work autonomy and strengthening the cooperation mechanism between departments; perfecting the internal assessment and income distribution mechanism to promote equity; establishing the people-oriented concept and paying more attention to physicians' career design; making clear the development goals of hospital and core culture and increasing physicians' mental stimulation; actively carrying out physicians' psychological health education and training to help physicians release work pressure reasonably; paying particular attention to key population to keep medical core force stable.