JOB SATISFACTION, WORK-RELATED STRESS AND INTENTIONS TO QUIT OF SCOTTISH GPS
Steven Simoens, Anthony Scott,
Health
Economics Research Unit, University of Aberdeen, Foresterhill,
Aberdeen
AB25 2ZD
Bonnie Sibbald
National Primary Care Research and Development Centre, Williamson Building, University of Manchester, Oxford Road, Manchester M13 9PL
Email.
s.simoens@abdn.ac.uk
ABSTRACT
Background: Job satisfaction and work-related stress influence physician retention, turnover, and patient satisfaction.
Aims: This study purports to elicit the views of Scottish GPs on job satisfaction, stress, intentions to quit, and to examine any patterns by demographic, job, and practice characteristics.
Methods: A descriptive, cross-sectional study was undertaken by postal questionnaire on a random sample of 1,000 GP principals, 359 GP non-principals, and 62 PMS GPs.
Results: The response rate was 56%. GPs were most satisfied with their colleagues, variety in the job, and amount of responsibility given. The most frequently mentioned sources of job stress were increasing workloads, paperwork, insufficient time to do justice to the job, increased and inappropriate demands from patients. White, female, young (under 40 years) and old (55 years and over) GP non-principals and PMS GPs who work less than 50 hours per week as a GP were more likely to be satisfied with their job and reported lower levels of stress.
Conclusions: GP participation in the workforce could be promoted by introducing more flexible working patterns (e.g. part-time work), by expanding the scope of contractual arrangements, and by making patient expectations more realistic by clearly communicating what the role of a GP actually encompasses.
Keywords: job satisfaction, stress, intentions to quit, general practitioners.
Job
satisfaction and work-related stress are important determinants of physician
retention and turnover, and may affect the performance of the National Health
Service (NHS) Scotland.1,2 The
extent to which general practitioners (GPs) are satisfied with their job and
experience stress at work also influence patient satisfaction and compliance.3,4
A
first aim of the study is to describe job satisfaction, pressures at work, and
intentions to quit of Scottish GPs. A
second aim is to examine how GP job satisfaction, stress, and intentions to quit
vary with demographic, job, and practice characteristics. Information on GP job satisfaction and stress may assist
policy makers in devising incentives to encourage GP recruitment and retention.
Design of the study
Data were collected by means of a questionnaire sent to a sample of 1,421 Scottish GPs. The sample consisted of 1,000 GP principals drawn from the Information Statistics Division (ISD) database maintained by the Scottish Office. This database contained the names, addresses, contract status, and practice characteristics of all GPs in the NHS Scotland. Randomisation was achieved by a random numbers table. The sample also included all 359 GP non-principals and 62 personal medical service (PMS) GPs in Scotland, who were selected from the ISD database and from the database of the National Association for Non-Principals. The questionnaire enquired into job satisfaction, job stresses, and intentions to quit. A copy of the questionnaire is available from the authors on request.
The Warr-Cook-Wall scale was used to measure overall job satisfaction and satisfaction with nine aspects of work.5 Each item was rated on a seven-point Likert scale. Job stresses were measured by a 31-item scale6,7,8, with each item being scored on a five-point Likert scale. Both measures have been shown to have high validity and reliability5,6,7,8,9, and have been widely used to measure GP job satisfaction and job stresses.6,7,8,9,10 Intentions to quit were elicited on a five-point Likert scale.
GPs have recently experienced a number of far-reaching developments in the NHS Scotland, including the introduction of local health care co-operatives (LHCCs)11 and the implementation of clinical governance systems to enhance quality of care. LHCCs are networks of primary health care professionals, grouped around general practices. They are delivering a wide range of primary and community health care services, and are involved in cross-sectoral working with local authorities and the voluntary sector. Such developments can be stressful and may affect GP job satisfaction. Therefore, questions were included that assessed the attitude of GPs towards LHCCs and clinical governance and their impact, using a five-point Likert scale.
The questionnaire also elicited information about a number of demographic, job, and practice characteristics. The individual characteristics of GPs included gender, age, and ethnic background. Job characteristics were the number of hours worked per week as a GP (including surgeries, visits, and administration), type of GP (GP principal, GP non-principal, and PMS GP), and household income (total income from all sources for GP and spouse/partner, before taxes but after deducting practice expenses). The effect of LHCCs on clinical care, quality of care, and co-operation among general practices was quantified on a five-point Likert scale, with increasing values representing an improvement. Finally, practice characteristics related to the number of GPs in the practice, practice location, and level of deprivation of patient groups.
Statistical
analysis
To
identify patterns of job satisfaction and stress by demographic, job, and
practice characteristics, the two independent samples t-test was used for
normally distributed variables, the two independent samples Mann-Whitney test
was used for not normally distributed variables, and the Pearson chi-square test
was used for binary variables. The
results were analysed using simple descriptive statistics.
Summary measures were based on the values reported by those who completed
the questionnaire. A p-value of 0.05 was used as the threshold for a
statistically significant result.
RESULTS
Response rates
The survey was conducted in August 2001. Non-respondents were mailed up to two more times at intervals of three weeks. After two months, 802 usable questionnaires had been completed and returned, yielding a response rate of 56% (see Table I).
A comparison of the characteristics of respondents and non-respondents is displayed in Table II. The absence of clear differences in measured characteristics between respondents and non-respondents indicated that each sample was broadly representative of the range of characteristics of its population, except for the sample of GP non-principals. Responding GP non-principals were older and worked in general practices with fewer GPs and fewer patients. Therefore, data were weighted to ensure that responding GP non-principals were representative of Scottish GP non-principals nationally in terms of doctors’ age, number of GPs in the general practice, and number of patients on the practice list.
GP job satisfaction
Table
III summarises overall job
satisfaction and satisfaction with nine aspects of work for GP principals, GP
non-principals, and PMS GPs. The
mean score for overall satisfaction indicated that GPs are more satisfied than
not with their job. GPs expressed
most satisfaction with colleagues and fellow workers, amount of variety in job,
and amount of responsibility given, but were least satisfied with remuneration
(except for PMS GPs) and hours of work.
The level of GP job satisfaction by demographic, job, and practice characteristics is displayed in Table IV. Female GP principals, white GP principals, female GP non-principals, and GP non-principals aged under 40 years or 55 years and over reported higher levels of job satisfaction than male GP principals, GP principals from another ethnic background, male GP non-principals, and GP principals aged between 40 and 54 years. Doctors who worked full-time as a GP, i.e. more than or equal to 50 hours per week, were less likely to be satisfied with their job than part-time doctors. GP non-principals who had a household income of £70,000 or less and worked in affluent areas reported higher levels of job satisfaction. GP job satisfaction was not influenced by the number of GPs in the general practice or the practice location (urban / rural).
GP job stress
The mean scores for stress at work suggested that GPs experience moderate pressures at work (see Table V). The highest sources of job stress related to increasing workloads, paperwork, insufficient time to do justice to the job, increased and inappropriate demands from patients.
Table VI presents the associations between levels of job stress and a number of demographic, job, and practice characteristics. Female GP non-principals were less likely to experience stress than male GP principals. White GP principals reported lower levels of stress than GP principals from another ethnic background. Doctors who worked 50 hours per week or more were more likely to experience stress than doctors who worked less than 50 hours per week. GP principals working in single-handed practices reported higher levels of stress than those working in group practices, although the opposite was true for GP non-principals. Finally, GP job stress was not influenced by age, household income, practice location (urban / rural), or the level of deprivation of patient groups.
GP intentions to quit
Intentions to quit of GP principals, GP non-principals, and PMS GPs are summarised in Table VII. Around one-third of GPs stated that it is likely that they will reduce their working hours within five years. The proportion of GPs who are likely to leave their current general practice within two years was 11% for GP principals, 38% for GP non-principals, and 14% for PMS GPs. A higher proportion of GP principals was likely to leave general practice medicine, leave direct patient care, or leave medical work entirely within five years than GP non-principals. PMS GPs were least likely to reduce work hours or intend to quit.
Intentions to leave direct patient care (primary or hospital) within five years was influenced by a number of demographic, job, and practice characteristics (see Table VIII). Male GP principals and non-principals were more likely to quit than female GP principals and non-principals. GP non-principals from another ethnic background reported a lower intention to quit than white GP non-principals. GP principals who worked 50 hours per week or more were more likely to quit than doctors who worked less than 50 hours per week. GP non-principals working in rural areas reported a higher intention to quit than GP non-principals working in urban areas. Intentions to leave direct patient care (primary or hospital) within five years were not influenced by age, household income, number of GPs in the general practice, or level of deprivation of patient groups.
Recent organisational changes in general practice
The way in which recent organisational changes in general practice have affected GPs is portrayed in Table IX. The majority of GPs reported that the development of LHCCs did not affect their workload, but that clinical governance had increased it. The attitude towards LHCCs and clinical governance was generally neutral or positive, with PMS GPs being more positive about these developments than GP non-principals and GP principals. The support offered by LHCCs in improving clinical care was found to be poor by 45% of GP principals, 37% of GP non-principals, and 21% of PMS GPs. The majority of GPs indicated that the LHCC had no impact on their quality of care. However, GPs thought that LHCCs had improved co-operation among general practices in clinical governance, quality improvement or service development activity.
DISCUSSION
The aim of this paper has been to describe the views of Scottish GPs on job satisfaction, stress, intentions to quit, and to examine any patterns by demographic, job, and practice characteristics. The main contributions have been to examine how job satisfaction, stress, and intentions to quit vary between GP principals, GP non-principals, and PMS GPs, and to examine the impact of recent organisational changes to the NHS Scotland.
Job satisfaction was not uniform across Scottish GPs, but was concentrated in particular subsets of the workforce. The most satisfied doctors were white, female, young (under 40 years) and old (55 years and over) GP non-principals and PMS GPs who work less than 50 hours per week. These GPs also reported the lowest levels of stress.
Implications for GPs and policy makers
PMS GPs enjoyed a greater job satisfaction and had a lower propensity to quit their job than GP principals and GP non-principals. PMS contracts offer benefits to both the GP and the NHS. GPs profit from less administrative responsibilities, more flexible working hours, and ease in moving practice.12 The NHS benefits from reduced financial risk and less professional autonomy. However, it should be noted that PMS status is a choice variable and GPs choosing a PMS contract may have already been more satisfied and less likely to quit their job.
Women reported higher levels of job satisfaction and lower levels of stress than men. The data indicated that this was because women were more likely to work part-time. Moreover, the longer hours worked by men caused stress in their family life. Men reported significantly higher levels of stress than women in relation to disturbance of home/family life by GP work and dividing time between work and spouse/family. Finally, given that the proportion of women entering general practice is increasing13, job satisfaction in the GP workforce in Scotland is likely to rise in the future.
These findings imply that GP recruitment and retention could be promoted by introducing more flexible working arrangements (e.g. part-time work, job share, temporary work, career break). It would encourage women to enter general practice and would reduce concerns about dividing time between work and family. Such policies could also improve retention by reducing work-related stress and by encouraging older doctors to phase their retirement through part-time working.
There was GP dissatisfaction with recognition for good work and increased stress associated with increased demands from patients, unrealistically high expectation of role by others, and worrying about patient complaints / litigation. This mirrors changes in the normative environment surrounding the health care sector, with increased consumerism by patients challenging the status and role of GPs. Patient expectations could be made more realistic by clearly communicating what the role of a GP actually encompasses.
GPs were dissatisfied with their remuneration and experienced stress associated with insufficient resources within the practice and worrying about finances. However, GPs with higher incomes had similar levels of job satisfaction and stress than those with lower incomes. Moreover, household income was not associated with intentions to quit. This supports the view that, although a lack of financial resources may be a source of job stress, increasing the income of GPs may only have a limited potential to offset dissatisfaction with other aspects of work.
GPs reported high levels of stress related to changes imposed by the Health Board (HB) or LHCC and the pace of change within the general practice. This is consistent with other research, which shows that GPs experience a feeling of fatigue with continuous organisational change in the NHS14 and uncertainty about future government policy.15 It should be noted that change, whether positive or negative, is stressful in its own right and affects job satisfaction. However, such stress can be offset by the benefits which reform can bring to GPs’ working lives.
Limitations of the study
The following limitations of the study should be noted. Job satisfaction was measured by Warr-Cook questionnaire. Items on the questionnaire were developed to be used in many occupations, and have not been specifically designed for GPs. The results are self-reported and, therefore, may not correspond to what GPs actually experience. Response bias may also be a concern. Responding GPs may have been more likely to be satisfied with their job and experience less stress. However, the absence of many clear differences in measured characteristics between respondents and non-respondents indicated that the sample was broadly representative of the range of characteristics of all Scottish GPs. Finally, the small sample size of 35 PMS GPs was disappointing. However, this still represented a response rate of 56%.
Comparison with previous studies
A recent survey by the Scottish General Practitioners Committee suggested that a high proportion of GPs were pessimistic about the introduction of LHCCs, did not feel involved with recent organisational changes, and were experiencing low morale.16 However, the value of this survey was limited by the use of non-standard measures of job satisfaction which do not permit comparison with other workforce groups, and by the failure to investigate sources of job dissatisfaction and their relationship to GPs’ characteristics.
Avenues of future research
More work is required to identify and assess the relative impact of demographic traits, job attributes, recent organisational changes to the NHS Scotland, and practice characteristics on GP job satisfaction, stress, and intentions to quit. There is also a need to examine longitudinal changes in job satisfaction and intentions to quit of Scottish GPs as NHS reforms continue. Other areas of future work are to investigate how job satisfaction affects performance in the NHS Scotland and to predict recruitment and retention patterns for particular groups of GPs. Additional research is required on how new employment arrangements such as PMS contracted or PMS salaried GPs influence GP job satisfaction and intentions to quit.
CONCLUSIONS
Although a majority of GPs were satisfied with their job, they were experiencing a number of pressures at work. Moreover, demographic, job, and practice characteristics influenced job satisfaction and stress of Scottish GPs. GP participation in the workforce could be promoted by introducing more flexible working patterns (e.g. part-time work), by expanding the scope of contractual arrangements, and by making patient expectations more realistic by clearly communicating what the role of a GP actually encompasses.
ACKNOWLEDGEMENTS
This study was funded by the Scottish Executive Health Department. The Health Economics Research Unit is funded by the Chief Scientist Office of the Scottish Executive Health Deparment. The views expressed in this paper are those of the authors and not the Chief Scientist Office.
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