Job satisfaction of certified primary care physicians in rural Shandong Province, China: a cross-sectional study

Job satisfaction is a measure of people’s contentedness with their job and an assessment of their work experience [16]. It can be measured using cognitive, affective, and behavioural components. Many researchers have provided definitions of job satisfaction. One of the most widely used is job satisfaciton defined as “a pleasurable or positive emotional state resulting from one’s work or work experiences” [17], while Motowidlo (1996) suggested that it is a perception of the “favourableness of the working environment” [18]. Attempting to combine both approaches, Brief (1998) defined job satisfaction as “an internal state that was expressed by affectively or cognitively evaluating an experienced job with some degree of favour or disfavour” [19]. Other researchers simply defined it as an individual’s satisfaction with one’s job, indicating whether or not he or she likes the job [16]. Numerous studies have revealed the importance of employee satisfaction. A study by Schneider and Bowen indicated that customer satisfaction was largely influenced by the attitudes and behaviours of service employees, while employee satisfaction was positively related to service quality [20]. Consequently, motivating and retaining qualified employees are crucial to the further success of service organizations [21]. To enhance customers’ perceptions of the quality of service, several studies have suggested that managers must increase employees’ self-efficacy and job satisfaction and reduce their role conflict and ambiguity [22, 23].

Several studies have examined the job satisfaction of physicians. A survey conducted by the American Physical Therapy Association in 1989 indicated that physicians were satisfied with their work [24]. The highest job satisfaction was the result of “autonomy,” whereas the lowest was the result of “reward”. This finding was consistent with the results of one study of doctors in Utah and another of doctors in Texas [25, 26]. Moreover, these two studies also revealed that the key factors contributing to physicians’ willingness to leave were heavy clinical workload, high patient expectations, and the clerical aspects of work. A study in New Zealand indicated that general practitioners had a rather high level of job satisfaction [27]. However, health care reforms, long working hours, too much bureaucracy and too many restrictions made them feel stressed and dissatisfied. Similar results were reported in a study of Pakistani public health professionals [28]. Working conditions, job description, and time pressures were the major reasons for dissatisfaction. Other factors influencing the level of job satisfaction were a low salary, lack of training opportunities, inadequate supervision, and insufficient financial incentives [28, 29].

According to an Australian study, lower job satisfaction was associated with poor health, training outside of Australia, fewer professional development opportunities, and longer working hours [10]. Meanwhile, lower job satisfaciton was also associated with a desire to reduce one’s working hours and an intention to leave medical profession. In contrast, a study in Lithuania found that doctors working in PHCFs had a relatively low level of overall job satisfaction [30]. The key factors influencing their dissatisfaction were compensation, social status, and workload.

The job satisfaction of physicians has garnered increasing attention among Chinese researchers. Numerous studies have discussed the factors infulencing job satisfaction and turnover intention. In Xinjiang and Anhui Provinces, Liu et al. (2010) conducted a quantitative study among township health centre (THC) employees in poor rural China. That study indicated that employees in THCs had a moderate level of job satisfaction. They were more satisfied with job significance, job competency, and teamwork than job rewards and working conditions [14]. In Hubei Province, more than a third (36.8%) of village doctors considered leaving their current positions voluntarily [31]. According to that study, income satisfaction, organizational policy implementation, wages and workload, career development opportunities, and working conditions were significant factors that contributed to the intention to quit among village doctors. This fingding was consistent with the results of a study of general practitioners in Hebei Province [32]. In Guangdong Province, the intention to quit among physicians was directly and negatively related to job satisfaction, and it was positively related to work stress and work–family conflict [33]. Thus, reducing working hours, increasing salaries, providing more opportunities for career development and training, and encouragement of senior managers may contribute to a reduction in their intention to quit. In Chongqing, a study found that 42.3% of primary care doctors intended to quit [34]. Findings suggested that the Government should increase its financial input to PHCFs, especially those in less-developed areas, and reform incentives to improve the job satisfaction among primary care physicians. A study in Liaoning indicated that Chinese community health workers enjoyed a moderate level of job satisfaction [35]. That study corroborated the evidence that stress and burnout are important predictors of intrinsic and extrinsic job satisfaction. Studies have examined the job satisfaction among rural village doctors, THC employees, community health workers, and physicians in urban state-owned medical facilities in other provinces of China [14, 36]. Their conclusions indicated that the respondents also enjoyed a moderate level of job satisfaction and that they were increasingly quitting or intending to quit because of job dissatisfaction.

Few investigations have been conducted to ascertain the job satisfaction of certified physicians in PHCFs in Shandong province following China’s recent health system reforms. Accordingly, the current study has been conducted in order to help policymakers to improve strategies designed to enhance physicians’ job satisfaction.

This study was designed to analyse current working conditions and to measure the job satisfaction of certified physicians working in PHCFs in rural Shandong in order to ascertain the factors influencing job satisfaction.

Shandong Province, one of China’s typical densely populated and economically developed regions, governs 17 prefectural-level cities. It has a good medical personnel foundation. By the end of 2016, there were 643,000 health care technicians in Shandong Province, of whom 245,000 were certified physicians, including 126,000 physicians working in rural areas. There is uneven economic development and an imbalance in medical resources among the eastern, middle, and western parts of Shandong Province. Therefore, a thorough survey of the job satisfaction of certified physicians in Shandong would provide general and representative data. Stratified random sampling was used in this study. It is a fact that the economy of Shandong is more developed in the east and less towards the west. First, two prefectural-level cities were randomly selected from the economically developed areas in the east, the developing areas in the middle, and the less-developed areas in the west, for a total of 6 prefectural-level cities. Second, two counties in each city were randomly selected, for a total of 12 counties. Finally, 12 CHs and 30 THs were randomly selected in those counties. In total, 540 copies of a questionnaire were distributed to certified physicians at the selected PHCFs. Trained research assistants distributed and collected the questionnaire. The survey was conducted from June to August 2016. Valid responses were received from 495 physicians (valid response rate: 91.6%). The questionnaire was anonymous and all participants provided informed consent prior to the study.

A review of the literature indicated that many instruments have been used to investigate the job satisfaction of different groups of people, such as village doctors, THC employees, and community health workers [31, 36‐41]. However, those tools were not conductive to the aim of the current study. The features of questonnaires were adapted and revised, and a new one (see Additional file 1 for the questionnaire) was developed [42‐44]. This questionnaire, consisting of 48 items in two parts, was used to evaluate the job satisfaction of certified primary care physicians. The first part includes socio-demographic information, such as gender, age, marital status, educational background, technical title, monthly salary, form of employment, years of service, hospital category and hospital grade. The second part consists of 38 items to assess job satisfaction, covering organizational management, the internal environment, the external environment, working conditions, competency behaviours, job rewards, and job description. These aspects are measured on a 5-point scale ranging from 1 to 5, where “1” represents extremely dissatisfied, “2” represents dissatisfied, “3” represents neither satisfied nor dissatisfied, “4” represents satisfied, and “5” represents extremely satisfied. Reliability statistics indicated a weak correlation among these items, and a regression analysis revealed no multicollinearity. The reliability coefficient (Cronbach’s alpha) was 0.945.

In total, 495 certified physicians in rural Shandong Province participated in this study, including 310 (62.6%) males and 185 (37.4%) females. Among the respondents, 291 physicians (58.8%) worked in township hospitals (THs), and 204 (41.2%) worked in county hospitals (CHs). The average age of the participants was 37.78 years. Most respondents (61.8%) were university graduates, 31.7% were junior college or technical school graduates, and a small proportion (6.5%) were recipients of a master’s degree. Of the respondents, 86.7% were permanent full-time employees. In addition, 87.3% of participants had a junior technical title while only 12.7% of physicians had a senior technical title. Most (88.6%) of the physicians surveyed had a monthly salary between 2000 and 5000 CNY. However, 4% earned less than 2000 CNY a month and 8% earned more than 5000 CNY. Further details on the participants are shown in Table 1.

An EFA was conducted using a correlation matrix with varimax rotation. There were 7 factors with eigenvalues greater than 1.0. Eigenvalues measure how much the factors explian the observed components. The initial eigenvalues indicated that the factors explained from 2.841 to 38.379% of the variance. As a result, these 7 factors were selected, with a cumulative initial eigenvalue of 65.804% and a Kaiser-Meyer-Olkin (KMO) value of 0.944 (Table 2).

Table 3 shows the categories of survey questions and their associated factor loadings. Six questions were not closely associated (greater than 0.5) with any factors (Q32: Competence improved, Q46: Recognition by the patient, Q16: Pay equivalent to ability, Q15: Interest in the job, Q34: Attention of leadership, and Q33: Business training). The remaining 32 items had large factor loadings ranging from 0.508 to 0.845. These 32 items can be categorized into 7 common factors using PCA with Kaiser Normalization Varimax rotation. Cronbach’s alpha indicated that the items included in six common factors had good internal consistency, except for the job description factor. The first factor related to organizational management included 11 items. The second factor related to the internal environment included 4 items. The third factor related to the external environment included 5 items. The fourth factor related to working conditions included 4 items. The fifth factor related to competency behaviours included 3 items. The sixth factor relating to job rewards included 2 items. The seventh factor related to job description included 3 items.

Statistical results for job satisfaction are shown in Table 4. In general, the mean score of job satisfaction was 3.41 (SD 0.68), which confirmed that certified physicians employed in PHCFs in rural Shandong Province were partially satisfied with their jobs. Respondents were most satisfied with the internal environment (median 4.50, QR 1.00) and their job description (median 4.33, QR 1.00). They were partially satisfied with competency behaviours (median 3.67, QR 1.33) and organizational management (mean 3.24, SD 0.95). However, respondents had a neutral attitude towards working conditions (median 3.00, QR 1.25) and job rewards (median 3.00, QR 2.00). In contrast, physicians were slightly dissatisfied with the external environment (median 2.80, QR 1.40).

As shown in Table 5, the descriptive variables of age, educational background, technical title, monthly salary, form of employment, and years of service were found to be significantly associated with job satisfaction (P < 0.05), whereas the other four variables, including gender, marital status, hospital category, and hospital grade, were not significant. Additionally, Table 5 indicates that older physicians were significantly less satisfied with their jobs compared to younger ones (P < 0.01). Physicians over 46 years old had the lowest level of job satisfaction. Physicians with a higher level of education or senior technical title were significantly less satisfied with their jobs than those with a lower level of education or junior technical title (P < 0.01). Physicians with the title of chief physician or a master’s degree had the lowest satisfaction. Thus, retaining talented personnel is one of the greatest challenges for PHCFs and can easily lead to a serious “brain drain.” Moreover, three-quarters of physicians’ monthly salaries were between 2000 and 4000 CNY (P < 0.01). Only 4% of physicians earned more than 5000 CNY a month. Physicians who were temporary/casual employees were more satisfied with their jobs than those who were permanent full-time employees (P < 0.05). Moreover, physicians with numerous years of service were significantly less satisfied with their jobs (P < 0.05). There was no significant difference in job satisfaction for physicians at CHs and THs, and the same was true for the hospital grade.

The results of multivariate linear regression analysis of overall job satisfaction are shown in Table 6. The 7 multi-item scales were entered as regressors in a multivariate linear regression model estimated using ordinary least squares (OLS). During analysis, the 7 factors were found to be significantly associated with job satisfaction (P < 0.05). From the highest to the lowest regression coefficient, those factors were organizational management, the external environment, the internal environment, working conditions, job rewards, competency behaviours, and job description. Organizational management and the external environment were closely realted to job satisfaction. Organizational management was the most important factor for job satisfaction. This means that better hospital management can imporve physicians’ job satisfaction. The second important factor was the external environment. This finding is enlightening since job satisfaction among physicians could be improved through intensifying reforms in the medical system, strengthening supervision of care, improving the physician-patient relationship, promoting media reporting, resolving medical disputes, and other efforts to create a favourable external environment.

This study had several limitations. First, during this cross-sectional study investigation, the respondents may be reluctant to give correct answers to some sensitive questions, which may result in report bias. At the same time, there may be bias in the random selection control of objects. Second, this study only examined the job satisfaction of physicians and there are no historical data for comparison. With the intensifying of China’s medical reform, it is of great value to enrich and verify the current results through in depth interviews with administrators and physicians in PHCFs, and further investigation can be carried out to establish time series data for comparison in the future. Further conclusions may be drawn if the study encompassed all medical staff, including administrators and technicians. Third, this scale has rather unsatisfactory internal consistency reliability. Lastly, the instrument developed in this study was not adequately validated and the structural validity of the questionnaire was not assessed. Its reliability and validity need to be assessed further in the future.