Satisfaction with clinical pathway implementation versus job performance of clinicians: empirical evidence on the mediating role of work engagement from public hospitals in Sichuan, China

Job performance is an important concept in human resource management, which is the output of an organization’s activities to obtain the desired quantity, quality and efficiency of product or service [1]. The job performance of clinicians is their performance in the management of therapeutic treatment modalities and services offered by the hospital unit, which is an important manifestation of the capability and level of hospital service and is essential for the quality of medical services [2, 3]. Currently, job performance is widely used to evaluate the competence of individual members of medical staff to make clinical diagnosis, administer treatment, and to assess their achievements and adherence to healthcare quality standards [4]. Research on the factors influencing the job performance of medical staff was done by both international and domestic scholars. While international studies highlight factors such as organizational support [5, 6], teamwork [7, 8], job satisfaction [9], work engagement, and role awareness [5, 10], domestic research tends to emphasize psychological capital and work ability, as well as organizational commitment [11‐13]. While existing research has made significant strides, much of the relevant literature predominantly examines healthcare systems in developed countries, with a particular emphasis on nurses. Studies addressing healthcare in developing countries, especially concerning doctors, are comparatively underrepresented in the literature [14]. Therefore, this study centers on clinicians in China and aims to provide academics with empirical evidence pertaining to the experiences of doctors in developing countries.

A clinical pathway is an interdisciplinary and integrated management model for clinical diagnosis and treatment, which is a standardized service plan for patients developed in a hospital by a group of multidisciplinary professionals for a particular disease. Its aim is to standardize procedures performed by medical staff, improve the quality and efficacy of medical services, and provide patients with better treatment [15, 16]. Clinical pathways are now widely used in the global healthcare industry [17]. More than 80% of hospitals in the United States implemented them as early as in 2003, and most European countries are using them now [18]. By 2021, 91.3% of Chinese public hospitals at the secondary level and above had implemented clinical pathways [19]. Given that clinicians play a critical role in the implementation of clinical pathways, their satisfaction with this process has a significant impact on the application of clinical pathways and the effectiveness of medical quality management to a certain extent in Chinese public hospitals. Satisfaction among clinicians with the implementation of clinical pathways refers to their perceptions of organizational structure, assurance mechanisms, process operations, and outcome evaluations within the clinical pathway process. This satisfaction generally includes three dimensions: organizational support, process identification, and effect perception [20]. Li et al.‘s study demonstrated that the satisfaction of medical staff with clinical pathway implementation had a significant positive effect on the quality of healthcare services [21]. However, in reality, public hospital administrators pay more attention to patients’ attitudes and evaluation of the effects of implementing clinical pathways [22, 23], while the attitudes and evaluations of doctors in this regard are usually overlooked. Hence, to enhance the quality of clinical pathway management in public hospitals, it is especially necessary to investigate doctors’ satisfaction with the implementation of clinical pathways and its impact on their work performance.

At present, there have been few studies exploring clinicians’ satisfaction with clinical pathway implementation [24], and even fewer examining the potential correlation between satisfaction and job performance. Recognizing the importance of this issue, the present study was designed and carried out to explore the relationship between satisfaction with clinical pathway implementation and job performance among Chinese clinicians.

The results of the correlation analysis showed a significant correlation between satisfaction with clinical pathway implementation and job performance among clinicians in public hospitals, and that satisfaction with clinical pathway implementation had a positive effect on job performance, indicating that Hypothesis 1 has been confirmed. These results are consistent with findings from numerous studies examining the interrelation between job satisfaction and job performance. Specifically, Ekingen’s study on nurses [9], Hou et al.’s study on residents [54], and Liu et al.’s study on primary healthcare workers [55] provide concrete evidence of this relationship. While other studies focusing on the relationship between satisfaction with clinical pathway implementation and job performance have not been retrieved, the results of this study can be corroborated with the findings of Askari et al. Their research showed that clinical pathway software improved healthcare workers’ satisfaction and job performance [56]. According to Li et al., clinicians perceived their own satisfaction with clinical pathway implementation in three dimensions: satisfaction with organizational support, process identity, and perceived effectiveness during clinical pathway implementation [20]. Related studies have shown that a high level of organizational support leads to the perception of reciprocity [57, 58]. When clinicians feel that the organization is willing and able to support them practically over the course of the implementation process, they, in return, will consciously engage in the behaviors expected by the hospital authorities, displaying more positive work attitudes and behaviors, thereby improving their job performance. As a standardized diagnosis and treatment mode, the standardized diagnosis and treatment implemented by a given clinical pathway are based on the guidelines developed by clinicians. As a result, effective cooperation within the department, also between the medical and nursing staff has a crucial role in implementing this clinical pathway. If clinicians show a low level of satisfaction with the programs and operating mechanisms during the implementation of a clinical pathway, it indicates that the implementation is challenging for them. Such a perception will inevitably reduce the efficiency of their work and negatively affect job performance. According to the social exchange theory and the principle of reciprocity [59], when an individual perceives that their effort is not proportional to the reward, this individual’s motivation to work will decrease, thereby reducing their job performance. A clinical pathway, as an important means to standardize clinicians’ responsibilities regarding giving diagnosis and administering treatment and to reduce patients’ medical costs, decreases, to a certain extent, the clinicians’ autonomy. Benefits from a clinical pathway for clinicians may include comparatively greater work efficiency, economic returns, quality of medical services or doctor-patient relationship after the implementation. If the clinicians’ perception of the benefits of the clinical pathway does not outweigh the effort required to implement it, their motivation and enthusiasm will decrease, and thereby their job performance. As a result when the clinicians’ perception of the clinicians’ a high level of satisfaction with clinical pathway implementation has, therefore, a positive effect on the job performance of clinicians in public hospitals.

Our findings show that work engagement has a partial mediating effect on the relationship between clinicians’ satisfaction with clinical pathway implementation and job performance in public hospitals. Namely, clinicians’ satisfaction with clinical pathway implementation not only directly, but also indirectly affects the job performance through the engagement in work, indicating that Hypothesis 2 and Hypothesis 3 have been confirmed. These hypotheses are backed by evidence from multiple studies. For instance, González-Gancedo et al. found a significant positive correlation between job satisfaction and work engagement among nurses [60]. Additionally, Bernales-Turpo et al. [61] and Zhang et al. [62] demonstrated in their research on medical staff that work engagement can function as a mediating variable for job performance and its predictors. Job satisfaction influences work engagement, which in turn is associated with higher job performance [63]. According to the job-demand resource theory, the factors affecting work engagement include both work demand and work resources, and if an individual’s work resources are continuously depleted and not replenished in a timely manner, their motivation for work and work engagement will be reduced [34, 64, 65]. Clinicians’ satisfaction with clinical pathway implementation is essentially their perception of organizational support, operating mechanisms, teamwork, and work effects during the clinical pathway implementation, which is an important component of clinicians’ work resources [66]. Such as when clinicians are unsatisfied with the implementation of clinical pathway, which means that benefits from the implementation of clinical pathway are smaller than the continuous input, their work motivation will decrease, which in turn will reduce their work engagement (i.e. they will devote less energy, focus and dedication to their work) [67]. Eventually, this will result in a reduction of in clinicians’ effectiveness and job performance. Taking into consideration the above, high levels of satisfaction of clinicians can help them engage more in work during implementing clinical pathways, which in turn will increase their job performance and ensure high standards of medical care.

To the best of our knowledge, this is the first study to offer empirical evidence on the impact of satisfaction of clinicians in public hospitals with clinical pathway implementation on their job performance. We confirmed that clinicians’ satisfaction with clinical pathway implementation in public hospitals has a direct positive effect on job performance, and also indirectly affects job performance through the mediating role of work engagement. Our findings provide evidence from a Chinese province for future research into relevant topics. The study suggests that the satisfaction among clinicians derived from effective clinical pathway implementation considerably improves their job performance. Therefore, public hospital administrators should take appropriate measures to improve the level of clinicians’ satisfaction with clinical pathway implementation in order to improve the work performance of this group as well as the quality of medical care.