Analysis on professional identity and related factors among Chinese general practitioners: a National Cross-sectional Study

General practitioners (GPs) are the main providers of community health service (CHS). They provide a wide range of healthcare services to residents [1]. Shortage of GPs and high turnover have been seen as frequently reported problems in both developed and developing countries. The GP workforce in the United Kingdom (UK) is insufficient to meet current demand [2]. In addition, there is a dramatic shortage of GPs in Germany, especially in rural areas [3], and more than half of physicians (57%) contemplated leaving general practice in New Zealand [4]. Among key steps aimed at addressing these shortages include increases in recruitment and retention of GPs and to greater user of other health professionals [5]. In spite of these strategies, it has been difficult to recruit doctors as GPs in adequate numbers in the UK [6, 7]. Other countries also have difficulties in recruiting enough GPs [8‐10]. The Finnish healthcare system is faced with similar challenges with GPs in addition to high turnover among primary care physician [11]. The quantity and quality of GPs workforce are related to the effectiveness and quality of health care delivery [12], thus, shortage of GPs in the CHS of China threatens the provision of quality health care.

Professional identity is often defined as career, occupational or even vocational identity [13]. It is a component of people overall identity and is augmented by the ‘position within society’, ‘interactions with others’ and their ‘interpretations of experiences’ [14]. The perception of professional identity varies among individuals, as experience and understanding are different among practitioners [15]. Professional identity has been identified as a key factor in GPs’ ability to provide high-quality care to improve patient outcomes [16].

GPs constitute an important part of China’s primary health care workforce, and their shortage has been identified as an urgent priority that should be addressed [17]. A positive and flexible professional identity is significant for GPs to enable them function at a high level since their performance benefits not only themselves, but also patients and other healthcare workers [18]. Professional identity is inextricably linked to, yet separated from overall self-concept [19] and can be measured and actively cultivated [20]. Previous studies have been conducted to examine professional identity and its associated factors (e.g., sex [21], age [22], education experience [18], job satisfaction [23], doctor-patient relationship [23], and turnover intention [17]) among nurses. Other studies have also been conducted to examine professional identity among specific healthcare workers such as township health inspectors [17], registered nurses [18, 24], physicians [23], midwives [25], nursing students [26], graduate nursing students [21], telephone GPs (GPs working on the helpline) [27], and prison health workers [28]. However, no study has been conducted to examine the status of professional identity and its determinants among GPs. Therefore, this study aimed to investigate professional identity and related factors among GPs in China.

The results from the professional identity scale across respondents and items are shown in Table 1. Among these 3236 GPs (response rate, 99.75%), 15 (0.5%), 33(1.0%), 3188 (98.5%) of them had a low level of professional identity, medium level of professional identity, and high level of professional identity, respectively. The average score for GPs’ professional identity was 51.23 (SD = 7.06).

Table 2 presents the main characteristics of respondents. A total of 3, 236 participants were involved in the study, and the ages ranged from 21 to 80 years (Mean = 37.42, SD = 7.92). Among these participants, 37.98, 30.01, and 32.01% were from Eastern China, Central China and Western China, respectively. More than half (63.84%) of them were females. The majority of GPs (85.63%) were married. More than 65 % (66.10%) of the study participants had a bachelor’s degree, and 67.52% had permanent work contracts. Less than a third of them (24.17%) had management responsibilities. Few respondents (5.62%) were not doing overtime duties on holidays or weekends. Overall, most of GPs (70.49%) were at moderate or lower-income level. More than half (58.56 and 51.55%) of GPs reported higher level of work stress and higher level of job satisfaction, respectively. Few participants (7.32%) had occupational development opportunities.

Table 2 demonstrates results comparing the differences in median scores of professional identity among various groups. There were significant differences in GPs’ professional identity across regions, sex, marital status, management responsibility, working overtime, income level, professional title, occupational development opportunities and job satisfaction (P < 0.05). There were no significant differences in professional identity among GPs with regard to education level, contract status, and work stress (P > 0.05).

Table 3 shows results from the multiple linear stepwise regression analysis to determine factors associated with GPs’ professional identity. Region, management responsibility, income level, working overtime, occupational development opportunities, age, and job satisfaction were significantly related to professional identity. GPs from central China, those who had management responsibility, who were at a moderate or higher income level, who often worked overtime, who had more occupational development opportunities, who had higher job satisfaction and were older had higher professional identity. There was no multicollinearity in this study since the variance inflation factors for these variables were below the value of 2.1.

The demand for primary healthcare services amongst the Chinese population is increasing and GPs constitute an essential part of the human resources need to provide these services. Training and retention of GPs are prudent strategies to improve quality care outcomes. Improvement in GPs’ professional identity is important for the provision of high-quality patient care. Identifying factors associated with professional identity would help Chinese government to implement effective plans to strengthen the GPs workforce.

This study investigated professional identity and related factors among GPs in China. It showed that Chinese GPs had a high level of professional identity. Further, our findings showed that significant factors associated with professional identity included age, region, management responsibility, income level, working overtime, occupational development opportunities, and job satisfaction.

The Chinese version of the 13-item professional identity assessment scale has been used among Chinese healthcare workers, which was different from the versions commonly used in western countries [33‐36]. For example, Cowin et al. [35] in 2013 showed that professional identity results from the internalization of professional knowledge, skills, attitudes, values and standards of ethics, and then the integration of these characteristics into one’s personal identity and behaviors within practice. Another study conducted by Deppoliti [36] reported that professional identity is the person’s perception of himself/herself as the member of the profession, which has a core meaning of occupational integration. By contrast, our professional identity has more focused on the commitment and importance of the profession itself. This scale has paid more attention to the health care workers’ views and attitudes towards social value of profession, and which was more suitable within Chinese culture and health system.

This study showed that there was a statistically significant relationship between professional identity and age (β = 0.5). Previous studies have found that there was a slightly positive correlation between age and professional identity [37‐40]. Again, in terms of age, two earlier studies [22, 41] concluded that with increasing age whilst working, GPs acquire more experience in dealing with doctor-patient relationships and communications, patient outcomes and the environment resulting in the acquisition of more professional and technical skills compared to younger colleagues, thereby helping them to improve their professional identity.

GPs from Central China recorded the highest professional identity compared to those from eastern (β = − 1.18) and western regions of China (β = − 0.67). It is known that, Eastern China developed more rapidly than Central and Western China because of the geographical advantage. After the eastern priority development strategy, the Chinese government formulated a balanced development strategy. With the policy of raising Central China, the local government invested massively in education, economy, healthcare, etc. Compared with GPs practicing in Western China, Central China GPs had more advantages with respect to income and occupational development opportunities, which led to improvement in their professional identity levels at work.

According to our results, professional identity of respondents at moderate or higher income level were higher than those at moderate or lower income level (β = 1.64), which indicated that income level was significantly related to professional identity. This finding was comparable to an observation conducted in Taiwan, where nurses’ wages were positively correlated with professional commitment [24]. Increasing income levels could be an effective way to improve the professional identity of GPs. In Sweden, the UK, and the United States, GPs’ income was 2 ~ 4 times higher than their social average income [42, 43]. However, in China, the income of GPs was less than average income and far less than specialists’ income, especially among those working in primary heath institutions.

The more overtime work GPs do, the higher their professional identity level. The professional identity level of GPs with frequent overtime works was higher than those with no overtime work (β = 1.12). One possible reason is that there is a positive relationship between working overtime and a feeling of pride and personal achievement, because healthcare professionals belong to a noble profession. Traditional Chinese culture considers doctors as saviors. GPs interviewed described their professional identity using the traditional Chinese idiom: reviving the dying and curing the wounded [23], which is consistent with traditional Chinese culture [44]. On the contrary, GPs, who have a higher level of professional identity, maybe have a frequent overtime work in their practices. When some aspects of an individual’s identity are consistent with his occupation, individuals would keep a high level of work engagement even in unfavorable work environments [45]; thus, they may have a frequent overtime work in their career.

The results of our research also showed that higher job satisfaction may lead to higher professional identity (β = 0.33). Studies conducted in Taiwan [24] and Turkey [33] revealed that there was a positive correlation between job satisfaction and professional identity among nurses. Thus, improvement in job satisfaction can be an important tool to increase professional identity among GPs. In addition, previous studies [17, 33, 46] showed that the professional identity was an important predictor of job satisfaction. When individuals have a positive identity with their careers, they will devote more energy and enthusiasm to their work, and the dissatisfaction resulted from working environment would be eliminated to a certain extent [47].

The results of our study indicated that participants with occupational development opportunities had a higher level of professional identity than those without occupational development opportunities (β = 1.35). The occupational development opportunity was designed to clearly spell out the roles and responsibilities of GPs in an organization, which helped to establish their professional identity. Previous studies have shown that continuous professional development may influence the perceptions on professional identity [48, 49]. Fewer occupational development opportunities seemed to drive GPs away from primary health care. However, more occupational development opportunities can help attract more GPs. A previous study supported our finding showed that lack of or inadequate occupational development opportunities on a job may reduce efficiency, cut or reduce enthusiasm or even lead to staff resignation [50].

Notably, values of professional identity might be biased by social desirability, which was very common in psychology and the social sciences [51, 52]. Some of the methodological remedies that can be employed to reduce bias include question randomization, anonymity and confidentiality, double-blind protocols, and grouped answer method [51]. In the present study, we have used the anonymous and web-based survey administration to collect data. Compared with in-person or phone-based administration, this method has been shown to elicit higher reporting of items with social desirability bias [53].

In summary, Chinese GPs have higher levels of professional identity. Age, region, management responsibility, income level, working overtime, occupational development opportunities, and job satisfaction are significantly associated with professional identity. The results of our study suggest that policymakers need to better understand the predictors of professional identity among GPs, and the Chinese government should take some measures to boost GPs’ professional identity to sustain the stability of GPs group.