“Exploring job demands and resources influencing mental health and work engagement among physical therapists: a cross-sectional survey of Norwegian physical therapists.”

ABSTRACT

Background

Physical therapists play a vital role in the Norwegian health care system, and their work environment may be a significant determinant for their wellbeing and job performance.

Objective

1) Assess differences in work environment, mental health problems, and work engagement between physical therapists working in specialist versus municipal health care services. 2) Assess the relationships between work environment factors and work engagement and mental health problems.

Methods

In this cross-sectional study, 273 physical therapists responded to the Survey for Workplace Health Promotion (response rate = 35%). Independent-sample t-tests, Pearson correlations, and multiple regression analyses were performed.

Results

This study did not find any significant differences between physical therapists working in Norwegian hospitals and therapists working in the municipal health care services. Analyses showed that general demands (β = 0.21), fragmented work tasks (0.18), predictability (−0.17) and social support (−0.34) were associated with mental health problems, while meaningful work (0.41), the opportunity to use one’s strengths and potential (0.14), and social support (0.25) were associated with higher work engagement.

Conclusion

This study highlights the role of poor job design and professional isolation as hindrances to work engagement among physical therapists, whereas work related meaningfulness and peer support promote their health and wellbeing.

KEYWORDS:

• Physiotherapist
• working environment
• sick leave
• health promotion
• work engagement

Introduction

Wellbeing at work is an important determinant of health (World Health Organization, 2008), and the work environment is a crucial factor (Burton, 2010). Physical therapists face high demands at work, which can lead to stress and ill health (Kim et al., 2020; Mertala et al., 2022; Niemi et al., 2018; Patel and Bartholomew, 2021). With their personal (typically one-on-one) engagement with patients and their problem-solving role (Starr et al., 2020), they face in particular high emotional demands (Pniak et al., 2021) and can be emotionally affected by their clients. Overall, this profession possesses a high degree of autonomy regarding their distinctive responsibility for assessing and treating patients (Strand, 2007), but patients who present especially complex needs or difficult situations may pose particular challenges for this group (Bruschini, Carli, and Burla, 2018; Niemi et al., 2018; Salles and d’Angelo, 2020). Research has shown that emotional demands increase risk of stress and health strain and lower levels of work engagement – especially if the work environment lacks compensating resources (Escudero-Escudero, Segura-Fragoso, and Cantero-Garlito, 2020; Patel and Bartholomew, 2021).

The Job Demand-Resources model [JD-R model] (Bakker and Demerouti, 2007) has become a standard approach for assessing how work environments affect employee motivation and health strain. The model focuses on the balance between job demands and the resources for meeting them available within the work environment. Demands are understood as the physical, psychological, social, or organizational aspects of work requiring skills and ongoing effort, and so carrying physical or mental costs. Resources refer to physical, psychological, social, or organizational aspects functional for achieving work goals, reducing job demands, or stimulating relevant personal learning, growth, and development (Bakker and Demerouti, 2007). The JD-R model has a focus on employee motivation through, for instance, work engagement. Being engaged at work – by feeling vigor, dedication, and absorption – is found to be of value both for the workplace and the worker because engaged employees perform well, experience wellbeing, and report job satisfaction (Bakker and Demerouti, 2017). Contrariwise, a mismatch of job demands with job resources is likely to reduce work engagement and impose stressors on workers that can manifest in poorer mental health (Bakker and Demerouti, 2017).

Physical therapists play a crucial role in Norwegian health care, both in hospitals and in the municipal primary health care services, and their work lives have been impacted by recent policy shifts. In 2012, public health care delivery in Norway was reorganized through the so-called “Coordination Reform” (Norwegian Directorate of Health, 2009), which aimed at setting health care on a more sustainable footing by attention to efficiency and economy. In particular, the reform focused on the relation between specialist care and primary health care delivery, by improving coordination between hospitals and municipal health services – emphasizing the latter as gatekeepers to specialist services – and stressing prevention ahead of rehabilitation (Norwegian Directorate of Health, 2009; The office of the Auditor General, 2016). For physical therapists, the Coordination Reform had implications for working conditions, in terms of changing workload, distribution of job tasks, job stress, and criteria of job performance (The office of the Auditor General, 2016). Therefore, it is of interest to see if there are differences in work conditions between physical therapists in the specialist health care system compared to colleagues in the primary health sector. One assumption might be that physical therapists in the latter faced heightened job burdens due to the reform’s emphasis on prevention and the transfer of responsibility for more complex patient care from hospitals to municipalities, thus confronting increased demands. Any difference in job burdens between physical therapists in primary versus specialist health care, especially in light of their differing institutional and organizational forms, could manifest in significant differences for work life and work-related health issues for this profession.

Overall, Norwegian physical therapists have been identified as facing high demands, low autonomy, and poor support from managers (NOA, 2020a, 2020b). Since being engaged at work is strongly linked to effective job performance and job satisfaction (Bakker and Leiter, 2010), the JD-R model applied to physical therapists can help map out the conditions that promote engagement and mitigate stressors. To our knowledge, job demands and job resources influencing physical therapists’ work engagement and mental wellbeing has never been assessed in Norway. Nationality aside, a recent literature review shows that research in this area has focused on other health professionals, such as nurses, paramedics, and physicians (Pniak et al., 2021). If important factors in the work environment of physical therapists are identified, this can focus efforts to create a sustainable environment promoting work engagement, wellbeing, and high job performance for this important profession. In the framework of the JD-R model, these factors would count as the resources crucial for not just getting the job done, but moderating job demands and stimulating employees’ learning processes and personal development.

The aim of this study was twofold: 1) assess differences in physical therapists’ experiences of the work environment, mental health problems, and work engagement between two work settings (specialist and municipal health care services), and 2) assess the relationships between job demands, job resources, mental health problems and work engagement in this profession.

Material and methods

Sample and procedure

We used a web-based (University of Oslo, 2021) cross-sectional questionnaire to collect single-source self-report data from occupational and physical therapists working in 22 hospitals and 17 municipalities. We invited all 1,260 therapists at these work sites to take part in the study between April 23 and May 8, 2020. After one reminder, we stopped collecting responses on June 3. To assure anonymity, researchers did not have the e-mail addresses of the therapists and had to depend on the department heads to distribute the questionnaires. Therefore, the exact number of therapists receiving the questionnaire is uncertain and we do not know the relative distribution between occupational and physical therapists. This study includes the physical therapists only. The results regarding the occupational therapists are published elsewhere (Torp and Bergheim, 2023).

In Norway, the COVID-19 pandemic began in February and March 2020, just before this study was conducted. Because of heavy restrictions implemented by the Norwegian government from March 12, 2020, work routines throughout the health care system changed. We therefore asked respondents to answer the survey with respect to their work situation in the weeks before the pandemic restrictions.

Measures

We used a modified version of the Norwegian Survey for Workplace Health Promotion (SHEFA) (Grimsmo and Torp, 2009; Midje, Nafstad, Syse, and Torp, 2014), and a total of 79 questions were included. The instrument includes various measures from other well-known and validated instruments and covers various characteristics of the work environment, work engagement, mental health problems, sick leave, and sickness presenteeism. The working environment and health measures are based on the Copenhagen Psychosocial Questionnaire (COPSOQ) (Kristensen, Hannerz, Høgh, and Borg, 2005) and the work engagement measure is collected from the nine-item version of Utrecht Work Engagement Scale (UWES) (Schaufeli, Bakker, and Salanova, 2006). After piloting the instrument with three therapists, certain measures (sexual harassment and collaboration) that were not very relevant to the test respondents were omitted to make the questionnaire shorter and easier to fill out. When we investigated the internal reliability of the indexes, a few questions were omitted from SHEFA’s original index because this increased the consistency of the index. [“Responsibility and varied work tasks” (five items – α = 0.46) was changed to “Fragmented work tasks” (two items – see Table 1)]. Further information about the overall SHEFA instrument is available on request. Table 1 presents all indexes and items included in this study.

Table 1. Questions, descriptive data, and internal consistency of indexes among 273 physical therapists in Norway.

	Variables	Cronbach’s α	Mean	Sd	Range	Questions included
Job demands (composite)		0.81	2.42	0.41	1.4–3.9
	General demands	0.72	3.13	0.52	1.5–4.8	How often do you have a lot to do at work? Is the workload unevenly distributed so that there are work peaks? Do you have duties that you consider professionally difficult? Does your job set high demands, so you have to constantly perform new duties? Does your job require you to have an overview and relate to many things at once? Do you make job decisions that you deem as complicated?
	Role conflict	0.80	2.07	0.60	1.0–5.0	Do you receive conflicting requests or demands from superiors and/or colleagues? Do you perform tasks that you think should have been done differently? Do you perform tasks that you think are unnecessary? Does your job include tasks that conflict with your personal values? Do you compromise your professional standards to get your work done?
	Conflicts	0.58	1.16	0.38	1.0–4.0	Have you been in conflict with one or more people at your workplace in the past 12 months? Have you been bullied or exposed to unwanted behavior in the past 12 months?
	Fragmented work tasks	0.74	2.36	0.80	1.0–5.0	Do you have many so many different tasks that it is difficult to achieve continuity during the working day? Does your work include work tasks that diverge in all directions?
	Job resources (composite)	0.92	3.75	0.48	2.0–4.8
	Meaningful work	0.89	4.21	0.71	1.5–5.0	Are your tasks meaningful? Do you get motivated by your tasks? Do you have tasks that provide work engagement?
	Job control	0.78	3.32	0.55	1.5–5.0	Do you have any influence on what specific activities or tasks in which you are involved? Can you choose which method or methods you will use in carrying out your job responsibilities? Can you influence the amount of work that you have? Do you have any influence on the deadlines and time allocated for your job responsibilities? Can you influence decisions regarding the people with whom you work? Can you influence decisions that are important for your work?
	Predictability	0.80	3.41	0.63	1.0–5.0	Do you get the information needed in time for important decisions, changes and plans? Are you given the opportunity to participate in organizational changes that affect your work? Are you capable of keeping up with the organizational changes at work? Do you get the information needed for executing work in a good way? Do you generally know what your tasks are 6 months ahead?
	Opportunity to use one’s strengths and potential	0.85	3.73	0.64	1.7–5.0	Does your job allow you to be creative and take initiatives? Does your job allow you to use your academic skills and competence? Does your job contribute to your academic development? Do you learn new things in your job? Is your job well aligned with your education and experience? Is there a reasonable relationship between your job development or career and the efforts you make in the job?
	Feedback from leader	0.89	3.40	0.90	1.0–5.0	Is your immediate superior willing to listen when you want to take something up? Do you get the help and support you need from your immediate superior? Does your immediate superior ask you how you feel? Does your immediate superior talk to you about the quality of your work?
	Social Support	0.88	3.85	0.61	1.9–5.0	Do you get the help and support you need from your colleagues? Do you get feedback from your colleagues on your job performance? Do you have a close colleague at work? Is there a good atmosphere between you and your colleagues? Are the colleagues collaborating well at your workplace? Do you feel you are part of a fellowship at your workplace?
	Work engagement	0.94	5.29	1.19	1.7–7.0	I am full of energy at work. I feel strong and energetic at work. I am enthusiastic about my job. I am inspired by my job. When I get up in the morning, I look forward to going to work. I feel happy when I am absorbed in my work. I am proud of the work I do. I am absorbed by my job. I am completely taken in by my job.
	Mental health problems	0.82	1.91	0.64	1.0–4.5	During the last 4 weeks: How often have you been emotionally exhausted? How often have you felt worn out? How often have you been irritable? How often have you been stressed?

SD = standard deviation.

Working environment

We included four job demands variables/indexes: general demands, role conflict, conflicts, and fragmented work tasks. General demands included six items with a response scale ranging from “very little” (1) to “very much” (5). Role conflict included five items with a response scale from “to a little degree” (1) to “a very high degree” (5). Conflicts at the workplace were measured with two items during the past 12 months on a scale from “no” (1) to “yes, daily” (5). Fragmented work tasks included two items with a response scale ranged from “no” (1) to “yes, to a very high degree” (5).

Job resources were measured by use of six variables/indexes

Meaningful work (six items), job control (six items), predictability (five items), the opportunity to use one’s strengths and potential (six items), feedback from leader (four items), and social support (six items). All questions had a five-point scale ranging from “no” or “to a very little degree” (1) to “to a very high degree” (5).

In addition to the ten single work environment indexes, two composite indexes called job demands and job resources were constructed by summing the scores of all included variables in the two main working environment categories.

Work engagement

The nine-item version of the UWES includes three subindexes: vigor (three items), dedication (three items), and absorption (three items), but we used the composite measure as this is recommended by the creators of the measure, Schaufeli and Bakker (2010). In SHEFA, the original four-point response scale in UWES has been changed to a seven-point scale ranging from “never during the past year” (1) to “daily” (7).

Mental health problems

To measure mental health problems in the past four weeks we used four items from COPSOQ (Kristensen, Hannerz, Høgh, and Borg, 2005), including questions on stress and mental exhaustion. The response scale ranged from “all the time” (1) to “not at any time” (5).

Sick leave

The respondents were asked to provide the number of days on sick leave because of health problems (disease, treatment, or clinical examination) for the past 12 months.

Sickness presenteeism

To measure presenteeism we asked the respondents to report how many days in the past 12 months they had gone to work despite their health being so poor that they should have stayed at home to recover.

Background data

We collected the following background data: gender, age (in whole years), seniority in current position (in whole years), and working hours. For working hours, the respondents were asked about the percentage of full-time employment. We dichotomized this into full time (37.5 hours per week) and part time (<37.5 hours per week).

Statistics

The item response scales were recoded so that high scores indicated high job demands, job resources, work engagement, mental health problems, sick leave, and presenteeism. The indexes were constructed by summing the scores and dividing the sum by the number of items included (Table 1). In population studies, the internal consistency of indexes, expressed by Cronbach’s alpha, is regarded as satisfactory if it exceeds 0.70 [7.80] (Field, 2013; Nunnally and Bernstein, 1994). In this study, all indexes exceeded 0.70 [0.72 (general demands) − 0.94 (work engagement)] except for the two-item variable conflicts with an α of 0.58.

We performed descriptive analysis (Tables 1 and 2) to give an overview of the participants and the relevant data. Independent-sample t-tests and Chi² (Tables 2 and 3) were used to investigate differences between physical therapists in specialist health care and municipal health care regarding demographics and scores on the working environment, health, and work engagement measures. Bivariate Pearson correlations (Tables 4–6) and multivariable ordinary least square (OLS) regression analysis (Tables 5 and 6) were used to investigate correlations between the independent (background and working environment) and dependent variables (mental health problems and work engagement). Because questions could not be omitted when filling out the electronic questionnaire, no data were missing. The software package IBM SPSS Statistics (version 28) was used for the analyses. The significance level was set at 0.05 (two-tailed).

Table 2. Overview of demographic variables among physical therapists.

Demographic variables	All physical therapists (n = 273)	Physical therapists in specialist health care (n = 147)	Physical therapists in municipal health care (n = 126)	P
Age, mean (range/SD)	41.4 (22–65/10.4)	43.2 (22–65/11.2)	39.3 (22–64/9.0)	0.001^a
Sex, n (%)				0.65^b
Women	220 (80.6)	117 (79.6)	103 (81.7)
Men	53 (19.4)	30 (20.4)	23 (18.3)
Sector, n (%)
Specialist health care	147 (53.8)	Na	Na
Municipal health care	126 (46.2)	Na	Na
Seniority, mean (range/SD)	8.9 (0–34/7.6)	9.9 (0–34/8.3)	7.7 (0–24/6.4)	0.017^a
Working hours, n (%)				0.021^b
Full hour	220 (80.6)	126 (85.7)	94 (74.6)
Part time	53 (19.4)	21 (14.3)	32 (25.4)

^aIndependent samples t-test; 2 Chi^b.

Range: minimum and maximum years; SD: standard deviation; NA: not applicable.

Table 3. Differences between physical therapists working in specialist and municipal health care services.^a

	All physical therapists (SD) (n = 273)	Specialist health care (SD) (n = 147)	Municipal health care (SD) (n = 126)	Mean Difference	95% CI for difference	P
Job demands	2.42 (0.41)	2.41 (0.42)	2.43 (0.40)	−0.02	−0.12–0.08	0.69
Job resources	3.75 (0.48)	3.71 (0.47)	3.79 (0.49)	−0.08	−0.19–0.04	0.20
Work engagement	5.29 (1.20)	5.30 (1.22)	5.27 (1.17)	0.03	−0.26–0.32	0.83
Mental health problems	1.92 (0.64)	1.93 (0.66)	1.90 (0.62)	0.03	−0.12–0.19	0.67
Sick leave (days/year)	7.72 (19.14)	7.87 (20.63)	7.54 (17.32)	0.33	−4.25–4.92	0.89
Sickness presenteeism (days/year)	2.90 (6.37)	3.31 (7.53)	2.43 (4.65)	0.88	−0.64–2.40	0.26

^aIndependent samples t-test. SD: standard deviation; CI: confidence interval.

Table 4. Bivariate correlations (Pearson r) for all variables among physical therapists (n = 273).

	1	2	3	4	5	6	7	8	9
Background variables
1. Sex (1=women; 2=men)	1
2. Age	−0.12*	1
3. Seniority	−0.06	0.67***	1
4. Working hours	−0.15*	0.10	0.00	1
5. Sector (1=specialist; 2=municipality)	−0.03	−0.19**	−0.14*	0.14*	1
Job demands
6. General demands	−0.04	−0.07	0.01	0.00	−0.03	1
7. Role conflict	0.11	−0.02	0.02	0.08	0.04	0.23**	1
8. Conflicts	−0.04	−0.00	0.02	0.01	0.03	0.05	0.27***	1
9. Fragmented work tasks	0.02	−0.03	0.01	0.04	0.06	0.51***	0.51***	0.27***	1
Job resources
10. Meaningful work	−0.15*	0.09	0.15*	−0.13*	−0.07	0.14*	−0.32***	−0.16**	−0.18**
11. Job control	0.02	−0.12*	−0.10	0.06	0.32***	−0.01	−0.26***	0.09	−0.17**
12. Predictability	−0.05	−0.00	0.02	0.04	0.15*	−0.00	−0.44***	−0.10	−0.20**
13. Use strengths & potential	−0.04	−0.06*	−0.01	−0.08	−0.16**	0.22**	−0.39***	−0.22***	−0.18**
14. Feedback leader	0.00	−0.13*	−0.13*	−0.03	0.02	−0.00	−0.44***	−0.20**	−0.22***
15. Social Support	0.02	−0.19**	−0.13*	−0.09	0.08	0.06	−0.44***	−0.24***	−0.27***
Health
16. Work engagement	−0.10	0.03	0.12	−0.13*	−0.01	0.07	−0.26***	−0.12	−0.21***
17. Mental health problems	−0.07	−0.04	−0.01	0.13*	−0.03	0.30***	0.38***	0.13*	0.42***
18. Sick leave	−0.05	0.07	0.04	0.03	−0.01	0.01	0.02	−0.06	0.01
19. Presenteeism	0.07	0.08	0.11	0.03	−0.07	0.04	0.17**	0.13*	0.13*
	10	11	12	13	14	15	16	17	18
	1
	0.27***	1
	0.44***	0.48***	1
	0.60***	0.34***	0.46***	1
	0.32*	0.38***	0.49***	0.46***	1
	0.47***	0.38***	0.44***	0.57***	0.76***	1
	0.62***	0.30***	0.37***	0.51***	0.33***	0.48***	1
	−0.21***	−0.22***	−0.33***	−0.26***	−0.28***	−0.38***	−0.33***	1
	0.01	−0.16**	−0.11	0.01	−0.11	−0.10	−0.04	0.22***	1
	−0.03	−0.12*	−0.10	−0.09	−0.16**	−0.19**	−0.08	0.24***	0.32***

*p < .05, **p < .01, ***p < .001.

Table 5. Linear multivariable regression analysis measuring how working environment factors affect mental health problems among physical therapists (n = 273).

	Model 0^a	Model 1^b	Model 2^b	Model 3^b
Background variables
Sex (women = 1, men = 2)	−0.07	−0.10	−0.08	−0.08
Age	−0.04	−0.03	−0.12*	−0.09
Job demands
General demands	0.30***	0.11		0.21**
Role conflict	0.38***	0.24***		0.07
Conflicts	0.13*	0.00		−0.03
Fragmented work tasks	0.42***	0.24***		0.18*
Job resources
Meaningful work	−0.21***		0.06	0.05
Job control	−0.22***		−0.03	−0.01
Predictability	−0.33***		−0.22**	−0.17*
Opportunity to use one’s strengths and potential	−0.26*		−0.03	−0.08
Feedback from leader	−0.28***		0.12	0.14
Social Support	−0.38***		−0.40***	−0.34***
Adjusted R^2		0.22	0.18	0.30

*p < .05, **p < .01, ***p < .001.

^aBivariate (Pearson r).

^bMultivariable (standardized β), adjusted for the effects of the other variables included in the regression model.

Table 6. Linear multiple regression analysis measuring how work-related factors affect work engagement among physical therapists (n = 273).

	Model 0^a	Model 1^b	Model 2^b	Model 3^b
Background variables
Sex (women = 1, men = 2)	−0.10	−0.06	−0.04	−0.05
Age	0.03	0.03	0.04	0.04
Job demands
General demands	0.07	0.24***		0.00
Role conflict	−0.26***	−0.18**		0.08
Conflicts	−0.12	−0.01		0.04
Fragmented work tasks	−0.21***	−0.24**		−0.09
Job resources
Meaningful work	0.62***		0.41***	0.41***
Job control	0.30**		0.08	0.07
Predictability	0.37***		0.03	0.04
Opportunity to use one’s strengths and potential	0.51***		0.13*	0.14*
Feedback from leader	0.33***		−0.09	−0.08
Social Support	0.48***		0.25**	0.25**
Adjusted R^2		0.10	0.43	0.43

*p < .05, **p < .01, ***p < .001.

^aBivariate (Pearson r).

^bMultivariable (standardized β), adjusted for the effects of the other variables included in the regression model.

Compliance with ethical standards

The Norwegian Social Sciences Data Service approved this study (reference 926830, April 6, 2020). All participants received written information about the study, gave informed consent to participate and answered the questionnaire anonymously.

Results

Of the 1,260 questionnaires distributed, 443 were returned, and 273 of these were from physical therapists (approximate response rate = 35%). Table 2 shows that mean age of the physical therapists was about 41 years, with 9 years as a therapist in the current position; 81% were women; 54% worked in specialist health care services; and 81% worked full-time. The physical therapists working in the specialist health care were significantly older, had worked longer in their current position, and were more likely to work full-time compared to those therapists working at the municipal level.

Despite the differences in age, seniority, and full-time work (Table 2) the two groups of physical therapists working in the specialist and the municipal health care services reported no significant differences in job demands, job resources, work engagement, mental health problems, sick leave, or presenteeism (Table 3).

Few background variables correlated significantly with the work environment and health measures (Table 4). Still, the older physical therapists reported less opportunity to use their strengths and potential, and experienced poorer social support and feedback from managers compared to their younger counterparts. Compared to the physical therapists in the specialist health care services, the therapists working in the municipality scored higher on job control and predictability but lower on opportunity to use their strengths and potential. In addition, physical therapists working part-time reported lower work engagement and more mental health problems than therapists working full-time.

The job demands variables correlated positively with each other, and so did the job resources variables. The correlations were mostly negative between job demands and resources, but physical therapists experiencing high general demands reported that they had more meaningful work and better opportunity to use their strengths and potential than those facing lower level of demands.

Physical therapists having much sick leave reported more mental health problems and presenteeism. Sick leave correlated weakly with the working environment factors whereas presenteeism was negatively related to some job demands, such as role conflict, and positively related to resources such as social support from leaders and colleagues.

Table 5 shows relationships between mental health problems among the physical therapists and background variables, working environment, and work engagement. Gender and age did not have any substantial effect on mental health problems in the models. Variables measuring job demands correlated positively and significantly with mental health problems, and all the job resources variables and work engagement correlated negatively and significantly (β = −0.21–0.42) (Model 0). When the demands variables were entered simultaneously into the regression model, the coefficients were reduced for all the variables (Model 1). Role conflict and fragmented work tasks remained significant (β = 0.24 for both variables). Likewise, the correlations for the job resources variables were reduced when entered simultaneously, and only predictability and social support remained significant (β = −0.22 and −0.40, respectively) (Model 2).

When all job demands and resources variables were entered simultaneously (Model 3), role conflict was reduced to non-significance, fragmented work tasks retained its significance, and general demands’ positive effect was increased to significance (β = 0.21). The negative effects of predictability and social support on mental health problems retained their significant relationships. The working environment explained 30% of the variance in mental health problems of the physical therapists (Model 3).

Table 6 shows the results of a bivariate correlation analysis (Model 0) and multiple regression analyses (Models 1–3) investigating how job demands and resources affect work engagement. Overall, gender and age did not contribute much to the variance in work engagement in any of the models. In Model 0, role conflict, and fragmented work tasks correlated negatively and significantly with engagement (r = −0.26 and −0.21 respectively), whereas all the resource variables correlated positively (r = 0.30–0.62) with work engagement.

When the demands variables were entered simultaneously into the regression model (Model 1), the relationship between general demands and engagement changed to a significant positive relationship (β = 0.24), whereas the negative coefficients were slightly altered for the other demands variables.

When the job resources variables were entered simultaneously (Model 2), the strength of all relationships was reduced, and only meaningful work, opportunity to use one’s strengths and potential, and social support remained significant (β = 0.41, 0.13 and, 0.25, respectively).

All job demands and resources variables were entered simultaneously in Model 3. The relationships between the demands variables and work engagement were then reduced to non-significance whereas the positive relationships for the resource variables were the same as in Model 2. The included variables explained a total of 43% of the variance in work engagement, and it was solely the resources that contributed to this rather high explained variance.

Discussion

In this study, we wanted to explore the work-related health and wellbeing of Norwegian physical therapists, and the relationships between factors at work influencing their mental health problems and work engagement. Overall, this study did not find any noteworthy differences between physical therapists working in the Norwegian specialist health care system compared to those working in primary health care in relation to work environment, mental health problems, and work engagement. Further, this study identified that mental health problems among physical therapists were related to job demands such as general demands at work and fragmented working tasks, but mental health problems were also related to the lack of resources such as predictability and social support. Work engagement for physical therapists was related to job resources such as meaningful work, social support from colleagues, and the opportunity to use one’s strength and potential.

The physical therapists – a strong and uniform profession, no matter the setting

Our results show that physical therapists working in hospitals and therapists working in municipal health care services are essentially alike with respect to mental health problems, work engagement, sick leave, and sickness presenteeism (Table 3). At first glance, this might be a surprising result because one could assume that working in a hospital, in contrast to working in the municipal health, would differ with respect to work environment, organizational conditions, organizational culture, and types of patients. Given the reorganization of Norwegian health care system (The office of the Auditor General, 2016) under the 2012 Coordination Reform (Norwegian Directorate of Health, 2009), one might expect that physical therapists in the municipal sector would experience more work pressure and higher workload compared to their colleagues in hospitals. This could potentially affect their health and wellbeing. How can we interpret the result contradicting this expectation?

One explanation could be that the practice of physical therapy is significantly invariant with respect to work setting. Physical therapists are highly autonomous in performing their work; to a great degree they can choose the methods, approaches, and treatment duration by themselves when providing care to patients (Higgs, Refshauge, and Ellis, 2001; Starr et al., 2020; Strand, 2007). This internal professional autonomy may foster a sense of uniformity and cohesion within the profession (Strand, 2007) – contributing to similar work-related health outcomes among physical therapists in hospitals and municipalities. Our findings are in line with another study, investigating empathy levels and disengagement among physical therapists (Starr et al., 2020). In that study as well, the hypothesis was that physical therapists in different working settings would vary on these dimensions, but the results disconfirmed that idea, with the authors concluding that this profession in general is characterized by having strong relationships with patients, regardless of working settings (Starr et al., 2020). On the other hand, studies have suggested status differences among different subspecialties of physical therapists in terms of health and wellbeing, in particular symptoms of burnout (Pniak et al., 2021) and degree of job satisfaction (Alkassabi et al., 2018). Further, self-employed therapists have been found to be more satisfied than salaried employees (Salles and d’Angelo, 2020), and those working in the private sector face burnout to a lesser degree (Patel and Bartholomew, 2021). In our study, we did not divide our sample by subspecialty, neither in the specialist nor the primary health sectors – but if we had, we may have found differences in mental health problems and engagement that remain undetected in this dataset.

The risk of poorly designed jobs for doing the work tasks

This study revealed that both demands and lack of resources were associated with mental health problems for physical therapists (Table 5). Specifically, general demands and fragmented tasks (for instance, having too much do, being exposed to uneven work task distribution, getting too many diverging tasks) were related to mental health problems. Other studies investigating health strain – for instance, manifesting in burnout – found a causal connection to high demands and high degree of stress (Castro et al., 2020; Lindsay, Hanson, Taylor, and McBurney, 2008; Pniak et al., 2021). In accordance with our study showing that lack of social support and lack of work task predictability may lead to mental health problems, another study recognized that low support from coworkers, lack of control, and lack of congruence were related to burnout (Castro et al., 2020).

Physical therapists are called upon to show high communication and problem-solving skills, and they are tasked with high physical and emotional demands from having to tackle patients’ complex problems (Escudero-Escudero, Segura-Fragoso, and Cantero-Garlito, 2020; Starr et al., 2020). It is well-known in the literature that demands may exhaust employees’ mental and physical reserves if they are ongoing at an excessive level (Bakker and Demerouti, 2007; Bakker and Leiter, 2010). In accordance with our findings, a recent review confirmed the assumptions that job demands and lack of resources are related to health strain (Galanakis and Tsitouri, 2022), but the review distinguished between hinderance and challenging demands – respectively, demands that tend to thwart workers’ control and effective performance versus demands tending to stimulate and help spur professional development. In line with our results (Table 5), poorly designed jobs – characterized by hindrance demands such as uneven work task distribution, excessive caseloads and diverging tasks – may contribute to health strain and mental health problems among physical therapists. While challenging demands – stimulating to professional growth despite emotional burdens – may be hard to erase or conquer due to this professions’ patient group, hindrance demands may be modified through work environment initiatives. Particularly when these problems arise from structural issues, they can be handled by redesigning the structure of the work environment, and this initiative may impact the issue of mental health problems for this profession.

The power of meaningfulness and social support

Several studies have confirmed the well-known core claims of the JD-R model: that resources are the key drivers for work engagement (Bakker and Demerouti, 2007; Hakanen, Bakker, and Turunen, 2021). This study adds to the evidence base by showing that job resources – and not job demands – were related to work engagement for physical therapists (Table 6). Along with social support and the opportunity to use one’s strengths and potential, we found meaningfulness to be a significant resource for this group (Table 6). Physical therapists are involved emotionally, physically, and intellectually with their patients as they work to help them heal from injury or medical interventions, manage pain, reduce symptoms, or prevent (or reduce the rate of) debilitation to improve their quality of life (Higgs, Refshauge, and Ellis, 2021; Starr et al., 2020). This dimension of meaning captures the complexity of this picture: not only the engagement with patients, but the striving to master the knowledge and skills on which such help depends. Earlier research has found that physical therapy’s scientific basis and professional status are related to practitioners’ perceived impact on their patients, ability to apply their skills, and the respect they receive (Alkassabi et al., 2018; Eker, Tüzün, Daskapan, and Sürenkök, 2004; Patel and Bartholomew, 2021; Starr et al., 2020), results that are in line with our findings.

Overall, this study has recognized that social support is an important work resource for the physical therapist, both for being engaged and also reducing risk of mental health problems (Tables 5 and 6). Social support serves coping, self-esteem, the confidence to act autonomously, and a feeling of belonging and inspiration (House, 1981). The variables physical therapists face routinely are multitudinous. Every patient meeting is unique, and individual patients’ needs will differ even when presenting with similar problems. The challenges thus posed may encourage interaction and mutual support among therapists. With physical therapists working so autonomously, there is often need for confirmation about a case or sharing feelings and reflections around the patient or related to organizational matters and management. Peer and lateral support might be of more value than the hierarchical support from an administrative superior, especially if outside the profession. A recent review found that team empowerment – therapists being part of a team that is supportive and efficacious – is a driver for engagement (Hakanen, Bakker, and Turunen, 2021), and another study showed that clinical supervision is a very strong coping strategy for therapists, important for achieving high job performance (Preece, 2020). Both studies resonate with our findings. Other studies have also identified social support to be of significance for this group (Eker, Tüzün, Daskapan, and Sürenkök, 2004; Patel and Bartholomew, 2021), somewhat in contrast to occupational therapists, for whom social support was not a notable correlate of work engagement (Torp and Bergheim, 2023). As well, our findings suggest that for physical therapists, lack of belongingness and fellowship may represent drivers for mental health problems (Table 5).

This study did not identify any directly relationship between feedback or support from leaders and work engagement (Table 6), although other studies suggest that quality of leadership has a significant relationship with physical therapist’s satisfaction at work (Alkassabi et al., 2018; Eker, Tüzün, Daskapan, and Sürenkök, 2004). Our results might relate to this profession’s high degree of autonomy in carrying out work with patients and concomitant expectation of personal professional responsibility for choices of treatment and methods (Higgs, Refshauge, and Ellis, 2001). This underscores how perhaps peer and lateral support are more functional and valuable for this group in contrast to support from management. Nevertheless, the results from our bivariate correlation analyses (Table 6, Model 0) showed a positive association between support from leaders and work engagement, and this might indicate that social support from managers has an indirect effect on work engagement by influencing other job resources of significance. On the other hand, a study investigating organizational citizenship among physical therapists found that focus on getting attention from superiors was counter-productive, leading to a work environment characterized by less solidarity and more disconnection (Hou et al., 2021). Another study found that physical therapists had difficulties feeling confidence in managers outside their profession, especially if they were embedded in nursing or were unfamiliar with, or not inclined to give credence to, rehabilitation principles (Niemi et al., 2018). Hakanen, Bakker, and Turunen (2021) highlight that engagement refers to the relationship between employees and their work, and thus the closer the job resources are to the employee, the greater the influence. Most likely, the physical therapists studied here found the most relevant resources close to them was support from their colleagues. Therefore, organizations and leaders may prioritize fostering a supportive work culture where colleagues can provide mutual support, which seems to be crucial for physical therapists’ wellbeing and performance.

Study limitations

First, because of the use of cross-sectional data, we cannot claim that we have established causality between the included variables. Nevertheless, cross-sectional designs are suitable for investigating fields that are poorly examined (Theorell and Hasselhorn, 2005), which is the case regarding Norwegian physical therapists’ work environment and its associations with mental health problems and work engagement. Second, this study is based on self-reported data, which may affect the validity of the results. The documented correlations might have been overestimated due to common method variance (Conway, 2002). On the other hand, the homogeneity of respondents in this study may have led to restricted variance, thus potentially underestimating the correlations. Third, this study origins from a questionnaire distributed to both occupational and physical therapists. We do not know exactly how many therapists received the questionnaire, nor the relative distribution of occupational and physical therapists, and thus, not the exact response rate. The relatively low response rate (approximately 35%) may have had consequences for the validity of the study. But a response rate of 30–40% is rather common for such studies (Johannessen, Christoffersen, and Tufte, 2010). A large public health study from Norway documented few and modest differences regarding prevalence estimates and sociodemographic distribution between respondents and nonrespondents, and the two groups did not differ in any significant way in the correlations between antecedents and outcomes. Fourth, this study was conducted after the outbreak of the COVID-19 pandemic, and we asked the respondents about the work environment and work-related health were before the outbreak. This may be a limitation, but we do believe that the results are representative for physical therapists in Norway, and relevant for physical therapists working elsewhere in similar health care systems such as in the other Nordic countries.

Conclusion

This study has investigated the health and wellbeing of Norwegian physical therapists in relation to their work environment. Overall, we did not find any differences in work-related health among therapists working in the specialist versus the primary health care system. The relevant job demands we identified impacting mental health were work task fragmentation, excessive workload, and unevenly distributed demands – pointing to the importance for this profession of well-designed jobs, adequate staffing, and managerial skills in allocating. More importantly, we found that professional peer social support at work was the most significant resource in the work environment, associated both with reduced mental problems and higher work engagement. In addition, meaningfulness, and the opportunity to use one’s strength were also identified as significant resources for work engagement.

Our findings point to physical therapy – typically provided one-on-one to patients with high situational-specificity in choice of most appropriate methods – as demanding high autonomy and resourcefulness among practitioners. Despite the independence and occasional isolation experienced in their daily work, this study suggests that therapists compensate for this through a strong professional self-identity characterized by shared values, methodological orientation, and a desire for mutual support in problem-solving. Opportunities for this mutual support are shown here to be important for creating engagement, job satisfaction, and good performance.

This study contributes to the knowledge base about the working context of physical therapists, and it highlights the importance of organizational design and provision of resources to workers in the health sector. Overall, this study supports the assumption of the dual-process focus – on strain and motivation – of the JD-R model. Further research should focus on how to design work environments that improve these processes and balance job demands and job resources for this important professional group.

Acknowledgments

We are grateful to the people who enabled the questionnaires to be distributed and to all the physical therapists that returned the completed survey.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The study did not have any funding.