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Abstract
Objective The well-being of primary care physicians (PCPs) has become an object of concern for governments due to staff shortages and high staff turnover. The objective of this study was to carry out a systematic review of individualised interventions aimed at improving the well-being of PCPs, which allowed us to determine (1) the type of interventions being carried out; (2) the well-being indicators being used and the instruments used to assess them; (3) the theories proposed to support the interventions and the mechanisms of action (MoA) put forward to explain the results obtained and (4) the role that individual motivation plays in the interventions to improve well-being among PCPs.
Design Systematic review.
Eligibility criteria Clinical trials on interventions aimed at improving the well-being of PCPs.
Information sources: a search of studies published between 2000 and 2022 was carried out in MEDLINE/PubMed, SCOPUS and Web of Science (WOS).
Results From the search, 250 articles were retrieved. The two authors each reviewed the articles independently, duplicate articles and those that did not meet the inclusion criteria were discarded. A total of 14 studies that met the criteria were included: 6 randomised clinical trials, 4 controlled clinical trials and 4 unique cohorts, with a before-and-after assessment of the intervention, involving a total of 655 individuals participating in the interventions. A meta-analysis was not possible due to the heterogeneity of the studies.
Conclusions The information evaluated is insufficient to accurately assess which outcomes are the best indicators of PCPs well-being or what role plays in the individual motivation in the results of the interventions. More studies need to be carried out on the subject to determine the MoA of the different interventions on the results and the motivation of the participating PCPs.
- Occupational Stress
- Primary Health Care
- Physicians
- Systematic Review
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
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
The information about interventions for improving well-being among primary care physicians and the motivational mechanisms of action that support them seems scattered.
Most of the studies reviewed had a strong design, however, the samples were small, which diminishes the external validity of the results.
The study examines the role of individual motivation and agency in intervention to improve primary care physicians occupational well-being.
The existence of multiple motivational constructs was a limitation to a comprehensive search strategy.
The systematic review protocol was not registered in PROSPERO.
Introduction
Primary care physicians (PCPs) play a key role within the health system. They are often the first point of contact with the patient; in many cases, they know them personally and are aware of their social and family environment. PCPs, thus, become a vital link in the chain of hospital treatment and social healthcare, providing patients with follow-up and support.1
However, in recent years, it has become a challenge to cover all the PCPs posts required for an adequate patient/doctor ratio1 and to reduce staff turnover. PCPs shortages are a considerable problem, with impacts on public health around the world. One reason put forward to explain the problem is the high percentage of primary care personnel at risk of burn-out.2 In a study carried out by the European General Practice Research Network on PCPs throughout Europe, it was shown that 43% of professionals suffered emotional exhaustion due to work and that 12% obtained high scores in the three components of burn-out (emotional exhaustion, depersonalisation and personal accomplishment).3
Various studies have been carried out to assess whether these elevated levels of burn-out among PCPs influences the medical care offered to the patient.4 A systematic review carried out in 2019 found that exhaustion among healthcare professionals increases the possibility of medical errors and that this can affect patient safety.5 It was also shown that burn-out impinges on the workers’ quality of life, leading to increases in absenteeism from exhaustion and more staff leaving the healthcare profession. This poses considerable difficulties for patient care—the central pillar of primary care. An earlier systematic review on burn-out in PCPs, carried out in 2018, recommended broadening approaches aimed at improving health systems so as to include, as an objective, improving the lives of health professionals and their experience at work.6 This approach coincides with a paradigm shift in occupational health studies, which has led to focusing attention not only on the prevention of burn-out and the risks derived from work, but also on fostering the health and well-being of workers. Expanding the focus of occupational health towards a perspective centred on the well-being of the worker has been influenced by, among others, United Nations recognition of health and well-being as a sustainable development goal; the WHO’s model for action7; the policy guidelines published by the UK’s National Institute for Health and Care Excellence aimed at improving workers’ health and well-being8; and the promotion of healthy organisations based on the contributions of positive psychology.9 With this new approach, improving the health and well-being of workers constitutes an end in itself; it is not subordinated solely to the productive demands of the organisation, but oriented towards a relationship of ‘mutual gains’ for all stakeholders.10
In this context, it no longer makes sense to make a distinction between person-centred interventions and contextualised interventions acting on organisational and environmental determining factors: the two strategies—aimed at improving well-being—are complementary. Individual interventions are still necessary to foster motivation and facilitate measures that are committed to the goals of personal, organisational and social well-being.
Individual well-being is defined ‘as an integrative concept that characterises quality of life with respect to an individual’s health and work-related environmental, organisational and psychosocial factors. Well-being is the experience of positive perceptions and the presence of constructive conditions at work, and beyond, that enables workers to thrive and achieve their full potential’.11 This definition includes the two theoretical traditions that have dealt with the study of well-being: hedonic well-being (HWB) and eudaimonic well-being.12 HWB is usually linked to the concept of subjective well-being and includes the components of pleasant affect, unpleasant affect and life satisfaction.13 On the other hand, from an eudaimonic perspective, well-being is considered as the individual ideal that provides purpose and direction to one’s life, through personal growth and self-realisation.14
Although notable progress has been made in recent years both in research and in the definition and operationalisation of occupational well-being as a construct,11 less attention has been devoted to the role of motivation and individual agency in research on interventions aimed at improving it. The objective of this study is to carry out a systematic review to evaluate the current research available on individualised interventions aimed at improving the well-being of PCPs based on the following questions: (1) What type of interventions are being carried out to improve the well-being of PCPs? (2) Which well-being indicators are used to assess outcomes, and which instruments are used to assess them? (3) What theories support such interventions, and what mechanisms of action (MoA) are proposed to explain the results obtained? And (4) What role does individual motivation play in interventions to improve well-being among PCPs?
Methods
Data sources, search strategy and study selection
A systematic review protocol was designed in line with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.15 We consulted a specialist librarian in thematic documentation in Psychology from (omitted for blind peer review) in order to define the search descriptors. The search was carried out in the MEDLINE/PubMed, Scopus and WOS databases, in October 2022.
Terms were selected following the PICO strategy (Population, Intervention, Comparison, Outcome). Population was defined as currently active, primary care physician, for which the Medical Subject Headings (MeSH) terms used were “primary care physician” OR “general practitioner” OR “GP” OR “family physician” OR “family practitioner” OR “family doctor”. The MeSH term “intervention” was used for the search. The main outcomes indicators referred to motivation and well-being at work, for which various MeSH terms appearing in titles, abstracts or keywords were used: “job well-being” OR “work engagement” OR “workplace commitment” OR “job satisfaction” OR “workplace enjoyment” OR “workplace motivation” and other synonyms. The search strategy is shown in online supplemental figure 1.
Supplemental material
The search was carried out using MeSH terms in the MEDLINE/PubMed database, the search in SCOPUS and WOS was made using natural language indexing as they do not employ controlled vocabulary or thesaurus; afterwards, a manual search was carried out and we also reviewed the references of similar systematic reviews for further relevant references. It was limited to quantitative experimental and quasi-experimental articles published between 2000 and 2022, available in Spanish, English and French. We included clinical trials, controlled trials and single cohorts (CBA: control before and after). Only articles in which the target population were PCPs were included and, of those where other members of the primary care team participated, only the data corresponding to PCPs were taken into account.
Articles where interventions were carried out to improve the well-being of doctors in training were discarded. Also excluded were articles in which the intervention was carried out at the organisational level or in the health system, or those in which the primary outcome was not PCPs well-being. Figure 1 shows the process of identification, screening and selection of the articles.
Flow diagram of article selection process (PRISMA guidelines 2020).15
After the preliminary search, each author first read the titles independently, and then the information was pooled. 250 articles were found that met the criteria of population target, publication date, study design and language. They were manually reviewed to exclude duplicates, leaving 228 abstracts. After a closer inspection through the abstracts 205 were discarded because they did not meet the inclusion criteria. The full texts of the 23 selected articles were retrieved and then read in depth, and 9 of these were discarded for not meeting the inclusion criteria.
For example, studies such as the one by Rees et al16 were not included because they involved mixed designs in which the qualitative component was used to evaluate the outcome; in total, there were five articles discarded for this reason. Four other articles were discarded because they focused on a different primary outcome, for example the objective of Dunn et al17 was to improve the well-being of the organisation and the quality of patient care.
Data extraction and risk of bias
The search was carried out independently by each author, AF and EV-H, the information was pooled and registered in a summary table. Subsequently, and again independently, we used the Effective Public Health Practice Project (EPHPP)18 to assess the quality of the selected studies; the discrepancies in the items were discussed and agreed on. We chose the EPHPP tool as a quality assessment measure because it is designed to comprehend a wider range of study designs and takes into account the validity and reliability of data collection methods, which fits with our object of study. Table 1 shows the evaluation of the quality of the studies using the EPHPP tool.
Quality analysis based on the tool EPHPP
The EPHPP scale was applied to assess the quality of the studies in the articles. In the general classification, 42% of the studies were classified as weak, this is due to the fact that 85% of the studies were classified as weak in category A (which assesses bias in the selection of the participants) because they participate voluntarily. In only 14% of the articles, the participants were selected in a systematic way. Of the 14 studies, 77% had a strong study design—42% were randomised clinical trials and 35% were clinical controlled trials—the remaining 23% were single cohort studies (CBA). All of the studies scored strongly in category E that correspond to data collection methods. In the category D—blinding, 57% of the articles scored weakly because the participants knew the objective of the intervention as they chose to participate in them.
After evaluating the quality of the studies, they were organised into tables in order to register the main findings. Including the type of intervention, the number of participants, the well-being indicators and the test used to evaluate them. Subsequently, an analysis of the theoretical models and MoA proposed for the reviewed interventions was carried out.
Afterwards a thematic analysis was carried out to evaluate the role of motivation in the interventions. The atlas.ti V.23 software was used to perform a text search and to automatically encode mentions that included the following terms (and their inflections): ‘motivation’, ‘engagement’, ‘commitment’, ‘empowerment’, ‘involvement’, ‘intention’, ‘agency’ and ‘participation’. The text segments in each code were analysed inductively to generate recurring patterns of meaning across the motivational constructs used in the interventions and thematic categories were developed in relation to the research question.
Patient and public involvement
This research was done without patient or public involvement.
Findings
What type of interventions are being carried out to improve the well-being of PCPs?
Taking as a reference the design strategy of each intervention and its objective, the studies were classified according to the type of interventions carried out. Mindfulness was used in 50% of the studies, while the other 50% used various strategies such as coaching, discussion groups, gratitude journals and cognitive–behavioural training. Table 2 shows the interventions used in the studies, along with the authors, the date of the study, the study design and the sample size.
Type of intervention and study design
Although half of the articles employ mindfulness programmes in their intervention strategy, it should be noted that, in most cases, a multicomponent programme is employed which includes various other elements such as psychoeducation, discussion groups, narrative and appreciative inquiry exercises on communication skills. This makes it difficult to determine the impact of each of the different elements of the programme on the results.
Which well-being indicators are used to assess outcomes, and which instruments are used to assess them?
The main well-being indicators used in the articles to assess the outcomes of the interventions were identified, and the instruments used to assess them were recorded. These indicators may measure positive aspects (eg, resilience) or negative aspects (eg, burn-out). Only indicators assessed in at least two studies were recorded in the summary table. Table 3 indicates how commonly these indicators were used in the selected articles, and the instruments used to assess them.
Well-being indicators, the number of studies that used them and the instruments used to assess them
There were 16 indicators used to assess well-being among PCPs. Two of these, social support and fatigue, are not listed in table 3 since they were only assessed in a single study but were included in the analysis. Distress and burn-out, as indicators of lack of well-being: 71% evaluated distress and 64% burn-out, whereas only one of the studies did not evaluate either aspect. The Maslach Burnout Inventory19 was applied in 57% of the studies evaluated and the Perceived Stress Scale20 in 35%.
Some of the indicators used in the studies referred to positive health aspects were: mindfulness, job satisfaction, meaning at work, resilience, compassion, empowerment, engagement, empathy, self reflection and psychological capital. A number of different scales were employed to measure these parameters before and after the intervention. To evaluate the interventions, 21% of the studies opted for their own assessment tools that were not validated.
What theories support such interventions, and what MoA are proposed to explain the results obtained?
Table 4 lists the theoretical foundations supporting the interventions carried out in the studies in this review. Mindfulness programmes are based mostly on the programme designed by Kabat-Zinn (Mindfulness-Based Stress Reduction).21 Regarding the rest, all the proposed interventions take a cognitive–behavioural approach.
Theoretical models and mechanisms of action (MoAs) proposed for the reviewed interventions
What role does individual motivation play in interventions to improve well-being among PCPs?
Having first eliminated mentions that appeared in the references section of the papers, a thematic analysis of the 105 citations selected was carried out. Four defined thematic categories were developed with the objective of evaluating the role of motivation in the interventions applied, as shown in table 5.
Role of motivation in the interventions reviewed
Discussion
Although in recent years there has been an upward trend in the number of studies that seek to improve and evaluate well-being among PCPs, much remains to be investigated. Many of the interventions analysed attempt to answer what Shapiro et al22 call the first-order question, ‘Are interventions effective?’, but do not empirically answer the second-order question, ‘How do the interventions actually work?’.
The studies analysed have methodological limitations. In 85% of the studies, the participants voluntarily decided to take part in them, this implies a selection bias as PCPs who sign up to participate are likely to be more motivated to improve their well-being, while those who may need the intervention the most do not take part.23 24 The intention to participate and individual motivation can play a role in the outcomes.
The interventions used in the studies are proposed to improve individuals well-being; however, the needs of the potential participants are not first evaluated in order to select the adequate intervention, which raises the question whether the intervention used was appropriate to improve well-being in PCPs.
Although participation in most studies was self-acceded, follow-up and continuity in the adherence to treatment was an obstacle. The study samples are small and not representative, threatening the external validity of interventions.
The lack of well-being at work is assessed in most studies, with distress and degree of burn-out being used as indicators. Positive outcomes, such as those referring to level of mindfulness, empowerment, commitment and resilience, are also assessed, but less frequently. This raises the question of which is more effective for evaluating well-being: the absence of negative outcomes or the presence of positive outcomes. As Karademas25 states that it is more reasonable to think of well-being as a parallel construct of negative and positive outcomes rather than as a continuum.
With regard to the MoA that are proposed to explain the results of interventions, many of the studies use multicomponent programmes without adequate controls that would allow researchers to determine which MoA are actually working. The clearest case of this relates to the methods used to apply the interventions, which mostly involve group work. In many studies, the participants share experiences and problems, discuss work issues, seek solutions together and, ultimately, give each other support. However, variables such as socialisation of beliefs, norms and values, as well as bonding and social support are not explicitly controlled and assessed as part of the intervention.
Although most of the works include some specific theoretical background about the interventions, the focus of them is mainly pragmatic and is not aimed at verification or theoretical construction which makes the reproducibility of the intervention and the assessment of its effectiveness difficult. The results reveal a certain bias in how individual motivation is treated in the interventions. Mostly, the impact on work-related results is evaluated and, to a lesser extent, on other dimensions such as relationships with others or orientation towards patients. But there is also a need to investigate personal reasons for participating in the interventions, since different motivations may lead to differential results of the treatments applied.26
It was observed that some studies did not use validated scales in their entirety, probably due to their excessive length. New tools may be necessary to measure well-being, or lack of it, as well as briefer and easier-to-apply designs that improve levels of adherence to treatment. Most of the interventions focused on strategies aimed at reducing stress, and produced results that imply an improvement after the intervention. However, the sample sizes and selection criteria do not allow the results to be extrapolated.
More studies on the subject are needed to provide more precise definitions of the determinants of well-being at work; the interventions aimed at improving it and their MoA; the appropriate indicators and scales to measure them; and the motivations PCPs workers have to participate.
Limitations
We have excluded studies carried out before 2000, because the literature on well-being at work in medicine is a more current research trend and, moreover, medical practice has changed substantially in the last two decades. Voluntary participation and self-reported measurements may cause bias, considering that different health systems and cultural differences among participants make comparisons difficult.
Conclusion
Despite the growing interest in improving well-being among PCPs at work, the available clinical evidence on the interventions carried out does still not allow us to provide an accurate assessment of which are the outcomes that are the best indicators of well-being or what role plays in the individual motivation in the results of the interventions. More research, and more controlled studies, are needed to determine the specific MoA of the different interventions, as well as the motivations of the participants.
Supplemental material
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors AF and EV-H conceptualised and designed the review. AF and EV-H reviewed titles, abstracts and full-text papers for eligibility. Authors resolved disagreement by discussion. AF was responsible for extracting data and all data extraction was verified by EV-H. AF and EV-H independently assessed the methodological quality of each study. AF and EV-H prepared, reviewed and edited the manuscript. AF guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.