Objectives To assess the quality of working life (QWL) of medical doctors and associated risk factors.
Setting and participants A cross-sectional questionnaire survey of 2915 medical doctors from 48 hospitals was conducted in China.
Methods The QWL-7–32 scale was adopted to assess seven domains of QWL: physical health, mental health, job and career satisfaction, work passion and initiative, professional pride, professional competence, and balance between work and family.
Primary and secondary outcome measures Data were analysed using SPSS V.19.0. Analysis of variance tests and multivariate linear regression analyses were performed to identify the sociodemographic characteristics and job factors associated with overall QWL and its seven subdomain scores.
Results On average, the respondents reported an overall QWL score of 92.51 (SD=17.74) of a possible 160. Over 35% of respondents reported more than 60 hours of weekly working time; 59.9% experienced night sleep deprivation frequently; 16.6% encountered workplace violence frequently. The multivariate regression models revealed that the eastern region (β≤−2.887 for non-eastern regions, p<0.001), shorter working hours (β≤−2.638 for over 40 hours a week, p<0.01), less frequent night sleep deprivation (β≤−5.366 for sometimes or frequent, p<0.001), higher income (β≥2.795 for lower income, p<0.001) and less frequent encounters of workplace violence (β≤−9.267 for sometimes or frequent, p<0.001) were significant predictors of higher QWL. Night sleep deprivation and workplace violence were common predictors (p<0.05) for all seven domains of QWL.
Conclusion The low QWL of medical doctors working in public hospitals in China is evident, which is associated with high workloads, low rewards and workplace violence. There are also significant regional differences in the QWL of medical doctors, with the eastern developed region featuring better QWL. Public hospitals in China are facing serious challenges in occupational health and safety, which needs to be addressed through a systems approach.
- Human resource management
- Health & safety
- OCCUPATIONAL & INDUSTRIAL MEDICINE
Data availability statement
Data are available upon reasonable request. The data relevant to this manuscript are available from the corresponding authors on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
A large number (n=2915) of medical doctors from 48 public hospitals in China participated in the survey.
The overall quality of working life (QWL) and its seven domains (physical health, mental health, job and career satisfaction, work passion and initiative, professional pride, professional competence, and balance between work and family) were measured using the validated tool QWL-7–32.
Data were collected through field visits and face-to-face interviews, with a high response rate.
The study adopted a cross-sectional design and no causal relationships should be assumed.
Data were subject to recall and self-reporting bias.
Over the past few decades, quality of working life (QWL) has attracted increasing attention in the healthcare industry.1 2 QWL is a term that has been used to describe the broad job-related experience of an individual. High levels of QWL are important for healthcare organisations to attract and motivate employees that lead to good work performance.3–5 Low QWL is not only detrimental to the physical and mental health of employees,6 it may also be linked to poor work performance.2 7 In the health industry, there have been increasing concerns about the link between low QWL and the poor quality of patient care.8
However, our understanding about the QWL of medical doctors is quite limited. Most existing QWL studies in the health industry have been conducted in western countries and seem to have a focus on nurses.5 9 10 This is likely to be associated with the high prevalence of private practice of medical doctors in the study countries and their overemphasis on professional autonomy in medicine.11 In a publicly dominated system where medical doctors are hired as employees of hospitals, however, medical doctors are usually working under great pressure due to high compliance requirements from the professional body, the government, the organisation and the public. Unlike their private counterparts, medical doctors employed by public hospitals have limited entitlement to flexible working time. They are also required to work on the frontline in response to public health emergencies such as the COVID-19 pandemic.12 13 This study addresses the gap in the literature by assessing the QWL of medical doctors working in the public hospital system in China. Few QWL studies, if any, have been conducted on medical doctors in developing countries.
The Chinese health system is hospital dominant, with most hospital beds being owned by public hospitals. The rapid economic development in China over the past few decades has been accompanied with a rapid expansion and modernisation of hospitals, employing 56.93% of medical doctors and delivering about 78.64% of inpatient care and 43.81% of outpatient and emergency visits in 2018.14 Unfortunately, due to the relatively weak primary care system, the workloads of medical doctors in public hospitals have remained high.15 In China, patients enjoy the freedom to bypass primary care in seeking hospital services.16 The daily average outpatient visits to a public hospital physician reached 7.5 in 2018.14 There is evidence that the high stress level has started to result in serious damages to the health and well-being of medical doctors in public hospitals.17 18 In recent years, ‘Karoshi’ (overwork death) of young hospital doctors has attracted extensive reporting in China.17 19 Even more concerning is the deteriorating patient–doctor relationship. Workplace violence against medical doctors has been widely reported,20 21 jeopardising the professional pride and job satisfaction of health workers,22 23 as well as the QWL of medical doctors.24 This study aimed to assess the QWL of medical doctors in public hospitals in China and to identify the sociodemographic characteristics and job factors associated with QWL.
A cross-sectional survey of medical doctors in public hospitals was conducted.
Participants and sampling
A multistage stratified sampling strategy was adopted to select study participants. Six provinces were purposely identified considering a balance of geographical location and economic development: Shandong and Hebei from the east (most developed), Hubei and Hunan from the central (less developed), Guizhou and Qinghai from the west (least developed). In each selected province, four tertiary hospitals in metropolitan areas and four county hospitals in rural areas were conveniently selected. In total, 48 hospitals participated in this study: 24 urban tertiary and 24 rural county hospitals. All of these were government-owned public hospitals. All medical doctors employed by the participating hospitals were eligible for this study.
Patient and public involvement
Data were collected from medical doctors in public hospitals in China. There was no direct patient involvement.
The questionnaire, which contains two sections, was designed by the research team in the Chinese language. The first section collected the sociodemographic characteristics and work experience data of the study participants. The second section measured QWL.
Quality of working life
Complex interactions exist between working and personal lives.25 Several scales have been developed to disentangle working life from personal life.25–28 They tend to measure working life from the perspectives of employee engagement, control at work, home–work interface, general well-being, job and career satisfaction, working conditions and stress at work. Arguably, QWL is a highly contextualised concept.29 This study adopted the QWL-7–32 scale, a scale that was developed in reference to the existing scales but was adapted to the specific context of China.30 31 It defines quality of working life as ‘the physical and mental effects of occupation on workers and their feelings on occupation’. The QWL-7–32 contains 32 items measuring seven domains of QWL, namely physical health (eight items), mental health (five items), job and career satisfaction (eight items), work passion and initiative (four items), professional pride (three items), professional competence (two items), and balance between work and family (two items). Each item was rated on a 5-point Likert scale, with a higher score indicating higher QWL. A summed score was calculated for the entire QWL scale and its seven domains, respectively. The reliability of the scale was tested in 248 medical doctors conveniently selected from two urban tertiary hospitals and two county hospitals. The Cronbach’s alpha coefficients indicate acceptable internal consistency for the scale and its seven domains (table 1).
Sociodemographic characteristics and work experience
The selection of the variables measuring sociodemographic characteristics and work experience was guided by the existing literature. QWL is associated with both intrinsic and extrinsic factors.29 32 33 In this study, the sociodemographic characteristics of the study participants (including gender, age and marital status) reflected the intrinsic factors associated with QWL. Work-related extrinsic factors measured in this study included salary, professional title, workload, night sleep deprivation and experience of violence against health workers. Empirical evidence shows that low income is associated with low employee satisfaction.34 A high workload is usually blamed for driving the deterioration of QWL.2 31 Professional title is deemed as a proxy indicator of career success. Workplace violence against health workers has become a serious issue of concern in the hospital sector over the past few years in China,20 21 which has a profound impact on the QWL of health workers. We also considered regional variations and urban–rural differences in QWL, a common theme studied in health services research.35
Data were collected from January to November 2018. Trained investigators visited each participating hospital, inviting the medical doctors who were working at the time to self-complete a paper questionnaire. Participation in the survey was anonymous and voluntary. Respondents provided their implied informed consent prior to commencement of the survey. They were allowed to skip questions with which they felt uncomfortable.
A sample size of 2500 would enable us to detect an effect size of less than 0.01 for a multivariate linear regression analysis containing 20 predictors, with an alpha error being set at 0.05 and a statistical power being set at 0.80.36 Considering that missing data commonly occur in questionnaire surveys, we collected at least 80 questionnaires in each urban tertiary hospital and 60 in each county hospital. A total of 3360 questionnaires were dispatched and 3170 (94.35%) were returned. This resulted in a final sample of 2915 (86.76%) containing no missing data for data analyses. The pilot sample was not included in the final data analysis.
Data were entered into EpiData V.3.0 and analysed using SPSS V.19.0. In all of the analyses, a two-sided p value of less than 0.05 was deemed statistically significant.
Frequency distributions in different categories of the sociodemographic characteristics and work experience of the study participants were described and compared between urban and rural and across regions using Χ2 tests.
Means and SDs of the QWL (including its seven domains) scores were calculated. Differences in the QWL scores among the study participants with different characteristics were tested through analysis of variance tests. Multivariate linear regression models were established with an Enter approach involving all of the independent variables with a statistical significance in the univariate analyses to identify the sociodemographic and work-related predictors of QWL after adjustment for variations in other variables.
Sociodemographic characteristics and work experience
The majority of respondents were male (53.2%) and aged between 30 and 45 years (61.0%). Most (76.7%) were married at the time of the survey. Only 17.9% had been awarded a senior professional title, while 46.9% had a junior title or below. About 48% of respondents had a monthly basic salary of less than ¥5000 (US$785), compared with 40.9% earning ¥5000–¥8000 (US$785–US$1255) and 11.2% earning more than ¥8000 (US$1255).
The vast majority (88.9%) of respondents reported working more than 40 hours a week. The weekly workload of 35.3% of respondents exceeded 60 hours. Night sleep deprivation was frequent in 59.9% of respondents. Over 68% of respondents reported sometimes while 16.6% reported frequent experience of workplace violence from patients and/or their family members (table 2).
There were significant regional and urban–rural differences in the sociodemographic characteristics and work experience of the study participants. The eastern participants were more likely to be female and married, while the central participants were more likely to report higher than 60-hour weekly workload and more frequent night sleep deprivation, and the western participants were more likely to be younger, had a junior professional title, earned a basic salary in the middle range (¥5000–¥8000) and reported experience of workplace violence more frequently. Compared with their urban counterparts, the rural participants were more likely to be married, held a lower professional title, reported workplace violence more frequently, and earned lower salary despite reporting a higher workload and more frequent night sleep deprivation (table 2).
Quality of working life
On average, the respondents reported a QWL score of 92.51 (SD=17.74) of a highest possible 160: 22.68±4.56 for physical health; 13.71±4.09 for mental health; 22.30±6.16 for job and career satisfaction; 13.10±2.74 for work passion and initiative; 9.24±2.32 for professional pride; 6.66±1.42 for professional competence; and 4.82±1.65 for balance between work and family, respectively (table 3).
Overall, the respondents from rural hospitals in the central region and those who were aged between 30 and 45 years and married, held a middle professional title, earned a lower income, worked longer hours, experienced more frequent night sleep deprivation and encountered more frequent workplace violence reported lower QWL than others (p<0.05): although urban–rural location was not associated with professional pride (p=0.090) and professional competence (p=0.345); marital status was not associated with work passion and initiative (p=0.388) and professional pride (p=0.473); professional title was not associated with job and career satisfaction (p=0.139) and work passion and initiative (p=0.661); and salary was not associated with work passion and initiative (p=0.878). The male respondents had lower job and career satisfaction (p=0.005) and work passion and initiative (p<0.001), despite reporting higher professional competence (p<0.001) than their female counterparts (table 3).
The multivariate regression models confirmed that eastern region, less frequent night sleep deprivation and less frequent encounters of workplace violence were significant predictors of higher QWL across all of the seven domains after adjustment for variations of other variables. Urban location remained a significant predictor of lower work passion and initiative. Male gender was a significant predictor of higher physical health and professional competence, but lower work passion and initiative. A younger age was associated with higher physical health and mental health, and higher professional pride, but lower professional competence. Those who were married had lower physical health but higher professional competency than those who were unmarried. A junior professional title was associated with higher job and career satisfaction, but lower professional competency. Lower income was associated with lower QWL, but the effects were not statistically significant for work passion and initiative, and professional competency. Less working hours was associated with higher QWL, but the effects were not statistically significant for work passion and initiative, professional pride and professional competence (table 4).
The study participants reported an overall QWL score of 92.51 (SD=17.74) of a highest possible 160. This level of QWL is low in comparison with the findings of studies conducted in some non-health industries such as primary and secondary schoolteachers37 and oil-drilling workers.31 38 Although medical practice requires high levels of work commitment, it is usually considered a respectful and highly rewarding job.11 However, medical practice also involves high levels of patient safety risk, especially in under-resourced facilities.39 Patients often hold very high expectations due to the high expense of medical services. The respectful doctor–patient relationship can be jeopardised when things do not go as well as anticipated.40
We found that long working hours, frequent night sleep deprivation, frequent encounters of medical violence and low salary are major predictors of low QWL. The respondents from the eastern region also reported higher QWL than their central and western counterparts. These results are consistent with the findings of previous studies.41–49 Our study showed that exceedingly long working hours were particularly detrimental to the physical health, mental health, job satisfaction and work–life balance of the study participants. Indeed, long working hours are not uncommon in medical services given the global shortage of a medical workforce, which has been shown to impair the health of medical workers,41–43 leading to depressive symptoms,44 low job satisfaction45 and the increased risk of job stress.46 In addition to long working hours, empirical evidence also shows that night sleep deprivation can cause sleep disturbances and fatigue, and increase the risk of serious illness47 including depression.48 Frequent night sleep deprivation can even negatively influence the performance of medical doctors as indicated in this study and others.49 Unfortunately, insufficient sleep is one of the most frequently reported concerns of medical doctors in China.50 The problems resulting from high workloads and disruptions to daily routine can be further exacerbated by low financial rewards. Compared with medical practitioners in many other countries, doctors in China earn a much lower level of income.
Unsurprisingly, frequent encounters of workplace violence emerged as a significant predictor of low QWL of medical doctors across all of the seven domains in this study. Over the past few years, China has witnessed increasing reports of incidence of violence against health workers, raising serious questions about the patient–provider relationship.51–54 The deteriorating practice environment has led to the increased intention of health workers to leave the industry.55 In this study, 16.6% of respondents reported frequent encounters with medical violence, compared with 68.7% reporting sometimes and 14.6% never. In China, most county hospitals are classified as secondary hospitals. They have suffered the most in patient–provider conflicts compared with their tertiary and primary care counterparts.53 56 However, rural medical workers seem to have maintained a relatively higher work passion and initiative than their urban counterparts according to the findings of our study. It is likely that both health workers and patients may hold a relatively lower expectation of the medical services delivered in rural settings than those delivered in urban settings.57 In recent years, the urban–rural disparities in medical resources58 and healthcare services59 in China have started to narrow.
The regional differences of QWL revealed in this study are perhaps a reflection of the widespread issue of regional disparity in China. The relatively more developed eastern region has more financial resources and invests more in health than the less developed central and western regions.60–62 As a result, medical doctors in the eastern region experience a better working environment, thus reporting higher QWL.
China is facing serious challenges in maintaining a healthy and sustainable health workforce. Healthcare demands have increased dramatically with the rapid economic growth and ageing population over the past few decades.63–65 This has imposed a great burden on the healthcare delivery system, further exacerbating the challenge of the health workforce shortage. The long working hours (35.3% reporting >60 hours per week), coupled with frequent night sleep deprivation (60%) and low salary (less than 12% earning >US$1255 per month), present a significant risk for occupational health and safety as indicated by the findings of this study. Low QWL not only affects the health and well-being of medical workers,66 it can also affect their competency and work performance.5 This can become a serious risk of patient safety and quality of care.67
It is unlikely that the aforementioned occupational health and safety risks can be addressed without taking a systems approach. China has recently launched a series of health system reforms, aiming at improving healthcare accessibility and affordability by containing hospital costs and encouraging patients to seek medical care in primary care.16 68 The central government has increased its investment in rural health development, in particular in the least developed western region. Strengthening law enforcement was also proposed to deal with workplace violence. These measures, though necessary, may not be enough to address the low QWL issue experienced by medical doctors. Although the cost containment measures may be welcomed by patients, they may hinder the potential salary growth of health workers. Increasing policy attention needs to be paid to sustainable workload, proper financial and professional rewards, and the work–life balance of medical workers. While growing the health workforce is fundamental for a long-term solution, urgent efforts should be made to foster a safe working environment where health workers and patients can work in partnership.
Strengths and limitations
The sample size of this study is large. Data were collected through field visits, which ensured a high response rate. However, such an approach cannot catch those who were not working at the time of the survey. The data were also subject to recall and self-reporting bias. The study adopted a cross-sectional design and no causal relationships should be assumed.
The low QWL of medical doctors working in public hospitals in China is evident, which is associated with long working hours, frequent night sleep deprivations, frequent encounters of workplace violence and low salary. There are also significant regional differences in the QWL of medical doctors, with the eastern developed region featuring better QWL. Adequate resource support and a safe working environment are critical for ensuring a sustainable healthy medical workforce, which requires a systems approach.
Data availability statement
Data are available upon reasonable request. The data relevant to this manuscript are available from the corresponding authors on reasonable request.
Patient consent for publication
This study involves human participants and ethics approval was granted by the Research Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (no: IORG0003571). Participants gave informed consent to participate in the study before taking part.
We would like to thank our colleagues who facilitated the field visits and data collection and all of the participating hospitals and study participants.
Contributors CT, CG and CL performed the literature review, designed the project and drafted the article. CT and CG participated in the data collection and data analyses. CT is responsible for the overall content as the guarantor. All authors have read and approved the final article.
Funding This study was funded by the National Natural Science Foundation of China (no. 71603077).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.