Organizational commitment among general practitioners: A cross-sectional study of the role of psychosocial factors

Abstract

Objective. To examine whether general practitioners (GP) working in primary health care have lower organizational commitment compared with physicians working in other health sectors. The authors also tested whether psychosocial factors (job demands, job control, and colleague consultation) explain these differences in commitment between GPs and other physicians. Design. Cross-sectional postal questionnaire. Setting and participants. A postal questionnaire was sent to a random sample of physicians (n = 5000) drawn from the Finnish Association database in 2006. A total of 2841 physicians (response rate 57%) returned the questionnaire, of which 2657 (545 GPs and 2090 other physicians) fulfilled all the participant criteria. Main outcome measures. Organizational commitment was measured with two different indicators: intention to change jobs and low affective commitment. Results. GPs were less committed to their organizations than other physicians. Work-related psychosocial factors (high job demands, low job control, and poor colleague consultation) were all significant risk factors for low organizational commitment. Conclusions. The evidence collected suggests that policies that reduce psychological demands, such as job demands and low control, may contribute to better organizational commitment and, thus, alleviate the shortages of physicians in primary care. Furthermore, giving GPs a stronger say in decisions concerning their work and providing them with more variety in work tasks may even improve the quality of primary care. The strategies for workplace development should focus on redesigning jobs and identifying GPs at higher risk, such as those with especially high job strain.

Key Words::

• Family practice
• general practitioners
• job demand-control-support model
• organizational commitment
• primary healthcare
• psychosocial factors

An increasing shortage of general practitioners (GPs) threatens the effective functioning of primary healthcare.

• We showed that general practitioners had lower organizational commitment (higher levels of intention to change jobs and lower levels of affective commitment) than physicians working in other health sectors.

• Work-related psychosocial factors (high job demands, low job control, and poor colleague consultation) were found to be significant risk factors for low organizational commitment.

• psychological demands, such as job demands and low control, may contribute to better organizational commitment and, thus, lessen the shortage of physicians in primary care.

Low commitment to one's job influences various organizational outcomes such as high dropout rates, low job satisfaction, and low performance [1,2]. Among general practitioners (GP) organizational commitment is essential also for quality of care because GPs’ work is based on continuity of care and long-term doctor–patient relationship. However, the increasing shortage of physicians threatens the effective functioning of primary healthcare (PHC) in many countries [3,4]. Working as a GP has lost much of its attractiveness as a career option among Finnish physicians during the past 15 years [5]. Different actions have been taken to attempt to alleviate the chronic lack of GPs, for example by recruiting physicians through labour leasing companies [6]. Also the number of student places in faculties has been increased [6]. Nevertheless, the measures taken so far have not been successful in alleviating the shortage of GPs in Finland.

A considerable number of studies have investigated the link between organizational commitment and psychosocial factors at work. One of the most widely studied theoretical approaches to job stress is the “Job Demand-Control-Support” (JDCS) model [7,8], which suggests that employees working under high strain – defined as high demands and low job control – have a higher risk of health problems and reduced well-being than those with no such strain. The JDCS model was initially used to explain patterns of exhaustion and job dissatisfaction [9], but was later expanded to include cardiovascular disease [10], poor health functioning [11], and sickness absenteeism [12]. The model has also been shown to predict a wide variety of motivational outcomes, such as job commitment [13–16].

It has been suggested that job strain is one of the major mechanisms through which socioeconomic status affects employee well-being. According to the large body of evidence from the Whitehall II study, differences in health and well-being between civil servants of higher and lower rank are due primarily to working conditions defined by high demands and low control [17]. These results imply that high strain is more common among those working in lower than those working in higher rank occupations. Physicians are among the highest occupational groups in Finland and yet in particular those working as GPs seem to be dissatisfied with their job. It has also been suggested that of all physicians GPs have the lowest job control [18].

The aim of the present study was to examine whether GPs working in PHC have lower organizational commitment (intention to change jobs and low affective commitment) compared with physicians working in other health sectors. In addition, we tested whether psychosocial factors (high job demands, low job control, and poor colleague consultation) explain the potential differences between GPs and other physicians. We took into account the potential effects of various confounding factors, such as age, gender, graduation year, specialization, being on-call, and working hours [19,15–17,20].

Material and methods

Sample

A random sample of 5000 physicians was selected from the Finnish Association database. The sample covers 30% of the licensed physician population in Finland. Questionnaires were posted in autumn 2006, with up to two more reminders sent to non-responders. Questionnaires were returned by 2841 (57%) physicians, of which 116 were excluded because of a non-employed working status, with a further 90 excluded due to incomplete data. Thus, the final sample included 2635 physicians aged 25–65 years (mean = 46.3. SD = 9.7), which is representative of the eligible population in terms of age, gender, and employment sector [18]. Physicians were divided into two groups: (1) GPs working in PHC (n = 545) and (2) physicians working in other health sectors (n = 2090).

Measures

Organizational commitment was measured with two different indicators: intention to change jobs and low affective commitment. Intention to change jobs was established by the following question: “Would you like to change your present physician's job to some other physician's job? The response format was: “1 = No, 2 = Perhaps, and 3 = Yes”. In the analyses alternatives “perhaps” and “yes” were combined into one. Low affective commitment was assessed with an eight-item scale derived from Allen and Meyer's Affective Commitment scale [21]. The scale measures emotional attachments to, identification with, and involvement in a particular organization. The items were rated on a five-point Likert-scale ranging from 1 (totally agree) to 5 (totally disagree). (α= 0.80). The mean response score was calculated and for the purpose of the analyses it was divided into high and low groups through a median split.

Job demands were measured by a five-item scale derived from the Harris (1989) stress index, with questions such as “How often have you been distracted, worried or stressed about..?” with items like “not enough staff”. The items were rated on a five-point Likert-scale ranging from 1 (never) to 5 (very often) (α= 0.85). The mean response score was median split into low and high groups.

Job control was measured by decision authority with nine items derived from Karasek's Job Content Questionnaire (JCQ) [22]. Decision authority measures the freedom to make independent decisions and possibilities to choose how to perform work. The items were rated on a five-point Likert-scale ranging from 1 (totally disagree) to 5 (totally agree) (α = 0.77). The mean response score was divided into high and low groups through a median split.

Colleague consultation was measured with two questions: “How often you have been distracted, worried or stressed about (1) ‘not having anyone to consult with’ and (2) ‘working alone’” with 5-point Likert-scale ranging from 1 (never) to 5 (very often) (α= 0.62). The mean response score was divided into good and poor groups through a median split.

Potential confounders

Potential confounders included age, gender, graduation year (0 = < 1980, 1 = 1981–2006), specialization status (1 = specialized, 2 = ongoing specialization, and 3 = not specialized), full-time working hours per week, and on-call (0 = no on-call duties and 1 = yes, work includes on-call duties).

Statistical analyses

Logistic regression analyses were performed to test the associations of physician's employment sector (PHC vs. other health sectors) with the intention to change jobs and with low affective commitment. Analyses were conducted in three steps: (1) for demographic factors (age and gender), (2) for work-related factors (graduation year, specialization status, full-time working hours, and on-call duty), and (3) for work-related psychosocial factors (job demands, job control, and colleague consultation). All analyses were performed using the software program SPSS version 17.0.

Results

More than half of GPs were female and the mean age was 46.2 year (range 25–65 years and SD = 9.8). Among other physicians, some two-thirds of respondents were female and the mean age was 46.3 years (range 25–65 years and SD = 9.7). Of the participants, 32% had graduated before 1980. More than half and nearly 90% of the other physicians were specialized or were undergoing specialization. GPs had fewer on-call duties, more job demands, less job control, and poorer consultation with colleagues than other physicians (Table I).

Table I. Descriptive statistics of the study population.

	Primary health care		Other health sector
Characteristics	%	n	%	N	p-value for*
All	21	545	79	2090**
Gender					<0.001
Female	67	360	56	1152
Male	33	178	44	905
On-call duty					<0.001
Yes	64	346	47	982
No	36	196	53	1098
Graduation year					<0.432
<1980	21	174	79	652
1981–2006	21	366	79	1403
Specialization status					<0.001
Specialized	51	275	70	1434
Ongoing specialization	17	89	21	426
Not specialized	32	174	9	182
Job demands					<0.001
Low	30	152	51	1057
High	69	390	49	1011
Job control					<0.001
Low	55	300	47	976
High	45	243	53	1100
Colleague consultation					<0.001
Good	28	165	42	858
Poor	72	375	58	1198

Notes: *Based on chi-squared test. **Due to incomplete data, numbers vary in totals.

The results of the logistic regression analyses showed that GPs working in PHC more often intended to change jobs, and this association remained after adjustments for age, gender, and work-related factors (Table II). Being younger, graduating after 1980, undergoing specialization, and working long hours were all associated with intention to change jobs. Adjusting the model for psychosocial factors attenuated somewhat the association between working in PHC and intention to change jobs. Physicians who had high levels of job demands, low levels of job control, or poor consultation with colleagues were more likely than others to express an intention to change jobs. The final model explains 16% of the variation in the physicians’ intention to change jobs.

Table II. Physicians' intention to change jobs: results of the logistic regression analysis.

	Model 1			Model 2			Model 3			Model 4
	OR	(95% CI)	P	OR	(95% CI)	P	OR	(95% CI)	P	OR	(95% CI)	P
Health sector
Other health sector	1.00			1.00			1.00			1.00
Primary healthcare	1.97	(1.63–2.38) R^2 = 0.03	0.000	2.05	1.68–2.50	0.000	1.91	1.54–2.37	0.000	1.63	1.30–2.03	0.000
Age				0.96	0.95–0.97	0.000	0.97	0.96–0.98	0.000	0.97	0.95–0.98	0.000
Gender
Male				1.00			1.00			1.00
Female				0.98	0.83–1.17 R^2 = 0.08	0.842	0.97	0.81–1.16	0.742	0.87	0.72–1.05	0.149
Graduation year							1.00			1.00
<1980
1981–2006							1.34	1.02–1.77	0.036	1.35	1.04–1.80	0.040
Specialization status
Specialized							1.00			1.00
Ongoing specialization							1.08	0.83–1.40	0.579	1.00	0.76–1.30	0.975
Not specialized							1.31	1.01–1.70	0.045	1.24	0.95–1.63	0.118
Working hours (total)							1.00	0.99–1.01	0.834	1.00	0.99–1.01	0.955
On-call duty
No							1.00			1.00
Yes							1.08	0.90–1.30 R^2 = 0.08	0.418	0.94	0.78–1.14	0.547
Job demands
Low										1.00
High										1.88	1.56–2.28	0.000
Job control
Low										1.00
High										0.52	0.44–0.63	0.000
Colleague consultation
Good										1.00
Poor										1.63	1.34–1.97 R^2 = 0.16	0.000

The results of the logistic regression analyses regarding affective commitment are given in Table III. GPs working in PHC were less committed to their jobs than other physicians. This association was robust following adjustments for age, gender, and work-related factors such as graduation year, specialization, full-time working hours, and working on-call. Being younger, male, graduating after 1980, non-specialized, and undergoing specialization were each associated with low commitment to one's job. After adjusting the model for psychosocial factors the association between working in PHC and low commitment was no longer statistically significant. Physicians who had high job demands, low levels of job control, or poor colleague consultation were more likely than others to have low commitment to their job. The final model explains 19% of the variation in the physicians’ organizational commitment.

Table III. Physician's low commitment to his/her job: results of the logistic regression analysis.

	Model 1			Model 2			Model 3			Model 4
	OR	(95% CI)	P	OR	(95% CI)	P	OR	(95% CI)	P	OR	(95% CI)	P
Health sector
Other health sector	1.00			1.00			1.00			1.00
Primary health care	1.45	(1.20–1.76) R^2 = 0.00	0.000	1.50	1.23–1.83	0.000	1.42	1.14–1.76	0.001	1.17	0.93–1.47	0.177
Age				0.96	0.95–1.00	0.000	0.97	0.96–0.99	0.001	0.97	0.96–1.00	0.001
Gender
Male				1.00			1.00			1.00
Female				0.80	0.68–0.94 R^2 = 0.05	0.007	0.76	0.63–0.89	0.001	0.66	0.55–0.80	0.000
Graduation year
<1980							1.00			1.00
1981–2006								0.97–1.66	0.080	1.33	1.01–1.76	0.046
Specialization
Specialized							1.00			1.00
Ongoing specialization							1.24	0.95–1.61	0.109	1.13	0.86–1.49	0.389
Not specialized							1.41	1.09–1.83	0.009	1.37	1.04–1.80	0.028
Working hours (total)							0.97	0.96-.98	0.000	0.97	0.96–0.98	0.000
On-call duty
No							1.00			1.00
Yes							1.25	1.05–1.49 R^2 = 0.08	0.014	1.03	0.85–1.25	0.740
Job demands
Low										1.00
High										1.70	1.42–2.06	0.000
Job control
Low										1.00
High										0.36	0.30–0.43	0.000
Colleague consultation
Good										1.00
Poor										1.49	1.24–1.79 R^2 = 0.19	0.000

Discussion

Our results showed that GPs working in PHC are less committed to their organization than other physicians. The lower commitment and higher probability to change one's job among those in PHC was mediated by psychosocial work characteristics – such as high job demands, low job control, or poor colleague consultation – rather than by demographic and structural factors like work hours or having to work on-call. The above-mentioned psychosocial factors correspond to the dimensions underlying the JDCS Model, meaning our results are probably consistent with previous studies conducted in other occupations [15,19–23]. Low job control and high job demand, that is high job strain, have previously been shown to be associated with low job satisfaction also among physicians [22–24]. In most occupational cohorts, job strain is more common among lower employment grades [25] and high job strain has been suggested as one of the factors explaining the social gradient in health. Our results suggest that GPs seem to have a low-grade psychosocial work profile, which may affect their low organizational commitment.

The effects of job strain on various outcomes have been found to be stronger in younger age groups [17]. Our results are consistent with this finding by showing that physicians who had graduated in the 1980s or earlier were more committed to their job than those who graduated later. Kankaanranta et al. reported that younger GPs more often expressed an intention to change sector from PHC to the private sector [5]. One reason for this may be better possibilities to influence their working schedules in the private sector, thus increasing job control.

This study's findings need to be interpreted in the context of developmental trends in medical school, in PHC, and changes in the work of GPs. A medical education given within a high-tech framework in university hospitals has been shown to lessen medical students’ gravitation towards PHC [26]. Moreover to improve access, continuity of care, and cost-saving, the “personal doctor” system was introduced in Finland in the 1980s [6]. In that system, a person is allocated to one health centre G P. During the same time frame (1980–2008) the average treatment periods in specialized care have become shorter and a larger share of the provision of long-term care has been transferred to PHC centres in Finland and in other countries e.g. the UK and the Netherlands [27]. It has been suggested that changes have increased job demands and decreased job control for GPs [27].

The demand, control, and support theory can be used to structure a dialogue between managers and employees and it may offer a valuable framework for designing a better work environment for GPs. There are, however, other issues that need to be addressed, including increasing community-oriented medical education, better staffing in PHC, forming larger PHC units and promoting better teamwork [e.g. 28,29].

This study made use of a large representative sample of Finnish physicians covering a broad age range. However, the fact that the study was conducted in one country means the results are anchored to the Finnish context. Moreover, the cross-sectional design prevents us from making causal interpretations, while the use of self-report data means results may be over-inflated. To minimize problems with self-reports, we have used well-known validated measures that have shown good reliability. Even though we controlled for many variables, we can never rule out residual confounding in observational studies.

Longitudinal studies are necessary in the future to explore possible causal relationships and to investigate more deeply the different work-related psycho-social factors and their relation to physicians’ work. Due to the increased number of foreign physicians, it would also be important to develop culturally sensitive measurements for investigating work-related psychosocial factors and the integration of physicians from different cultural backgrounds into the health system.

Conclusion

Policies that reduce job demands and increase job control will probably lead to increased organizational commitment among GPs. Giving GPs a stronger say in decisions about their work and providing them with more varied work tasks could also improve the quality of PHC.

Acknowledgements

This study was supported by the Finnish Work Environment Fund (project number 107154) and the Academy of Finland (project number 128002).

Competing interests

The authors declare that they have no competing interests.