Exploration of how primary care models influence job satisfaction among primary care providers during the COVID-19 pandemic in New Brunswick: a descriptive and comparative study

The main finding of our study was that a substantial proportion (77%) of participants declared being satisfied at work by expressing a moderate to high level of job satisfaction. The reported job satisfaction levels did not appear to be influenced by the primary care model. As such, primary care providers reported similar job satisfaction levels regardless of the primary care model or whether they worked in collaborative or solo practice. The findings suggest that irrespective of the model of care, what is important to providers is having the professional autonomy to choose the care model that best suits their individual preferences. Weber (2015) agrees with this finding, stating the decision-making autonomy of physicians is a determining factor in their professional satisfaction [24]. Most physicians agree on the importance of autonomy, and add that having control over their daily practice is an important predictor of job satisfaction [25, 26]. This also means having autonomy over their schedule, and the choice to increase their patient load, which is associated with a higher level of satisfaction than if this load is imposed [25]. However, sometimes to control outcomes or performance, some decision-makers or government officials may set new policies that can reduce their autonomy. Consequently, such initiatives may reduce their job satisfaction [27]. In addition, administrative overload, evaluation standards, and time pressures also tend to lower their level of satisfaction (Bovier & Perneger, 2003; Epstein, 2000; Weber, 2015). It is important to reflect on the risk-benefit analysis of imposing specific standards on physicians (on patient load, for example) as it may influence autonomy, and then may impact job satisfaction. Generally, a heavy-handed or authoritarian approach may backfire, and it is crucial to include primary care professionals on topics that will influence their practice. For example, imposing a minimum number of patients in their roster or that a certain number of patients are seen per day, requiring that primary care providers work in collaboration, or imposing a specific pay structure, are all situations that could limit their autonomy. Although the benefits of measuring outcomes or performance are also important, they should be done in a way that promotes the empowerment and autonomy of primary care providers.

The potential changes to job satisfaction levels with the COVID-19 pandemic must also be considered. According to the results of our study, 55.2% of the care providers in the sample expressed a decline in their level of satisfaction since the pandemic. In contrast, only 5% indicated an improvement. Some researchers confirm that physicians are vulnerable to dissatisfaction and burnout symptoms, as was established by a group of physicians in a paper on the subject published during the COVID-19 pandemic [28]. The findings of our study suggest that the reported deterioration in job satisfaction was associated with factors other than models of care since there was no significant difference in changes to job satisfaction between providers who work alone and or as part of a team. This suggests that other factors, such as decreased direct contact with patients during the COVID-19 pandemic, may explain the reported deterioration in satisfaction [24]. In a study out of New Brunswick on the use of telehealth during the COVID-19 pandemic, many physicians reported seeing the benefit of incorporating telehealth into their practice [29]. Still, they also said telehealth was overused during the pandemic [29]. The perceived overuse of telehealth was a source of anxiety for them since they worried about the health and well-being of their patients. In addition, the changes to their practice brought on by the COVID-19 pandemic left them little time to get organized. The urgency of the changes brought to their practice also impacted their level of job satisfaction [29]. At this time, it is difficult to determine whether the deterioration observed in the results is indeed linked to personal stressors, which generally affected the population during the COVID-19 pandemic, or to factors directly related to work. Further studies will undoubtedly provide clarity on this critical topic in the future.

More than half (53.3%) of primary care providers surveyed revealed that they had experienced one or more symptoms related to burnout. The proportion found in our study is similar to results from the United States, where roughly 50% of physicians reported signs of burnout before the COVID-19 pandemic [30]. Furthermore, participants reported no significant difference in burnout symptoms based on their models of care, once again illustrating that working alone or in a team does not appear to be a determinant in predicting burnout symptoms. This indicator should be carefully considered, as burnout can have severe consequences for the personal well-being of the person experiencing it, as well as a deterioration in job satisfaction, the care provided and employee retention [30, 31]. Healthcare provider burnout is often linked to excessive workloads, inefficient work processes, administrative burdens, work-home conflicts and lack of contribution or control [31]. Although mostly anecdotal at this time, there have been multiple media reports on how the COVID-19 pandemic has added strain on healthcare providers, which has increased the risk of developing burnout symptoms, often leading to an increase in turnover rates and worsening staff shortages [3, 32]. Ultimately, this creates a vicious cycle, where healthcare providers end up working with fewer resources (or “short staffed”); this increases workload, which increases symptoms of burnout and leads to people leaving their jobs, and once again leads to more staff shortages [30]. Through primarily anecdotal reports, it is reasonable to think that the COVID-19 pandemic has contributed to an increase in burnout symptoms. It may explain why many healthcare providers leave their jobs or professions [33]. Given the exogenous shocks brought on by the COVID-19 pandemic that impacted an already fragile workforce, strategies to retain and recruit healthcare providers in New Brunswick have become a priority for leaders and government officials.

Recruitment and retention success depends on proximity to family and friends, work-family balance and professional autonomy according to the results of our study. They were reported as predominant at the time of career establishment (recruitment) and at the time of survey (retention). Multiple studies support the importance of community factors (like proximity to family and friends) as an important determinant for recruitment and retention [34‐36]. In addition to proximity to family and friends (ranked first, 35% of respondents reported it as important during recruitment and 43% for retention), reconciling work and family life was also a priority, ranking second in the rate of responses obtained with 33% of respondents reporting it as important during recruitment, and 43% of them stating it was important for retention. Johnson & Ravitsky (2015) studied how work-family balance was challenging for physicians (especially women) with children. Consequently, the lack of balance can harm physician satisfaction (especially for physicians 35 to 54 years old) [37]. In multiple studies, work-life or work-family balance strongly predicts physicians’ job satisfaction [26, 38‐40]. In partnership with Family Medicine New Brunswick, the province of New Brunswick has considered this by promoting the development of family medicine units that offer the advantage of work-family balance [41]. Remarkably, the top four most frequently chosen factors during recruitment (proximity to family and friends, work-family balance, professional autonomy and living conditions) were the same factors chosen as important during retention. However, most studies on recruitment and retention tend to highlight the differences between the two strategies [34]. Based on the findings of our study, the same factors seem to be important throughout primary care providers’ careers, which could make recruitment and retention strategies easier in the province, since the factors may remain the same. Overall, there was little variation between factors important during recruitment or retention for family physicians and nurse practitioners. The discrepancies between recruitment and retention for different groups of professionals should be examined in more depth in future studies to understand how to utilize them more efficiently.

As with determining patient load and job satisfaction, professional autonomy emerges as a crucial element for recruitment for family physicians and nurse practitioners. Approximately 30% of participants consider it important when establishing their practice and staying in their job. In addition to being a springboard for satisfaction, professional autonomy is important for the doctor who wants to practice freely without too many constraints (Koebisch et al., 2020). The autonomy to choose the type of primary care model may explain many of our study’s findings since almost half of the participants reported choosing their current primary care model based on preference. In addition, this phenomenon was supported by the minimal variations observed between primary care providers working alone or as part of a team. Many participants shared in the survey’s written comments section (data not shown) that they sought a practice that suited them when establishing their careers. They shared that having the autonomy to choose the location, the type of primary care model and the size of their practice was especially important to them. However, a few participants reported not feeling very empowered at the beginning of their careers. Those participants stated that they took over an established practice in a desirable geographical location and kept it running in a similar fashion. Many participants did not feel compelled to modernize the practice they took over. At the same time, others described taking over an established practice, then changing it to match their preferences.

It was surprising to note that financial incentives are not considered an important recruiting factor and constitute an attractive factor for retention for only a few participants (8%). Although many studies on recruitment and retention report financial incentives as not being a strong predictor [34, 39, 42, 43], it remains a popular government strategy (signing bonuses and loan repayments, for example) [13, 44]. According to some of these same authors, it would be preferable to use financial incentives strategically. For instance, if they were granted in the form of a support program for partners’ relocation or integration into the community [34]. That way, the financial incentive would encompass other factors that could help the primary care provider (and their family) integrate into the community, which is more important for predicting retention [45]. Focused and strategically placed financial incentives may help recruit and retain primary care providers more effectively.

Finally, nurse practitioners were recruited as primary care providers for our study because they are often targeted as part of the solution to improve access to primary care in Canada [46]. The findings in Tables 10 and 11 illustrated how little variations were observed between nurse practitioners and family physicians for key satisfaction indicators during our study. However, it is difficult to compare with other studies on job satisfaction and retention of nurse practitioners in primary care because of the lack of data on the subject. Further studies are needed to better understand the differences between nurse practitioners and physicians in primary care. Currently, nurse practitioners cannot open a solo practice to offer medical services covered by public insurance because they are required to work with a physician in New Brunswick. However, nurse practitioners reported having many options when choosing where to work, in other words there are various fields where they can practice [47]. In our study, nurse practitioners reported that having many options to choose from when deciding where to work was important to them. But, once a nurse practitioner chooses a work place, it is not as crucial to them to have the opportunity to work in multiple environments. Our results highlighted the importance for nurse practitioners in primary to have professional autonomy, this is a topic that needs a more in-depth investigation.