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Job morale of physicians in low-income and middle-income countries: a systematic literature review of qualitative studies
  1. Alina Sabitova1,
  2. Sana Zehra Sajun1,
  3. Sandra Nicholson2,
  4. Franziska Mosler1,
  5. Stefan Priebe1
  1. 1 Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK
  2. 2 Institute of Health Sciences Education, Queen Mary University of London, London, UK
  1. Correspondence to Dr Alina Sabitova; a.sabitova{at}qmul.ac.uk

Abstract

Objectives To systematically review the available literature on physicians’ and dentists’ experiences influencing job motivation, job satisfaction, burnout, well-being and symptoms of depression as indicators of job morale in low-income and middle-income countries.

Design The review was reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for studies evaluating outcomes of interest using qualitative methods. The framework method was used to analyse and integrate review findings.

Data sources A primary search of electronic databases was performed by using a combination of search terms related to the following areas of interest: ‘morale’, ‘physicians and dentists’ and ‘low-income and middle-income countries’. A secondary search of the grey literature was conducted in addition to checking the reference list of included studies and review papers.

Results Ten papers representing 10 different studies and involving 581 participants across seven low-income and middle-income countries met the inclusion criteria for the review. However, none of the studies focused on dentists’ experiences was included. An analytical framework including four main categories was developed: work environment (physical and social), rewards (financial, non-financial and social respect), work content (workload, nature of work, job security/stability and safety), managerial context (staffing levels, protocols and guidelines consistency and political interference). The job morale of physicians working in low-income and middle-income countries was mainly influenced by negative experiences. Increasing salaries, offering opportunities for career and professional development, improving the physical and social working environment, implementing clear professional guidelines and protocols and tackling healthcare staff shortage may influence physicians’ job morale positively.

Conclusions There were a limited number of studies and a great degree of heterogeneity of evidence. Further research is recommended to assist in scrutinising context-specific issues and ways of addressing them to maximise their utility.

PROSPERO registration number CRD42017082579.

  • job morale
  • job motivation
  • job satisfaction
  • burnout
  • well-being and symptoms of depression
  • physicians
  • low- and middle-income countries

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

  • This study is novel in synthesising qualitative data from all available research on low-income and middle-income countries (LMICs) and provides conclusions based on findings from diverse countries, cultural backgrounds and clinical specialties.

  • This study can inform the design of potential interventions and workforce policies and interventions in LMICs; therefore, their clinical utility can be advanced.

  • Limited availability and heterogeneity of studies allowed drawing only tentative conclusions.

  • This study might be limited conceptually since a small number of studies were eligible.

Background

The crisis in human resources for health has been defined as one of the most severe global health problems1 and a major barrier to achieving universal health coverage and building a sustainable health system.2 This crisis is especially acute for low-income and middle-income countries (LMICs), many of which suffer from both a shortage and poor devotion of healthcare staff.3

Due to the far-reaching effect of job morale, interest in the issue among healthcare staff has increased considerably in recent decades.4 First, positive job morale is linked to a greater number of healthcare workers being recruited and retained5 which appears to be essential in solving the pressing issue of healthcare staff maldistribution in LMICs.2 Second, healthcare staff with positive job morale are more likely to provide higher quality care to patients.6 7 Furthermore, improving staff well-being could save healthcare spending by decreasing financial investments in medical education8 and lower spending on sickness absence and staff turnover.9

Despite its importance, there is no universally adopted definition for the concept of job morale nor an agreement on what it constitutes. This could partially explain why research studies aiming to measure job morale are somewhat sporadic.10 11 Although several authors have tried to investigate job morale as a single entity,5 12–16 they ended up measuring its outcomes or explanatory variables.4 Particularly, they referred to the significance of job motivation, job satisfaction, well-being, burnout and depressive symptoms. All these variables can be regarded as indicators of job morale.

Most studies on job morale in healthcare have focused on either nurses10 11 17–21 or healthcare staff in general,5 13 22–25 although job morale has been shown to vary by professional group22 and training status.26–28 A limitation of the current academic literature is that relatively little is known about physicians’ and dentists’ experience of job morale in LMICs.29–31 There is a lack of detailed description of contextual features and latent influences which could be provided by qualitative research.32 Identifying and dentists’ experiences that influence job morale may help to create an analytical framework for analysing workforce policies and interventions with clinical and economic benefits.

Against this background, this review aimed to answer for the following research question: Which experiences influence job motivation, job satisfaction, burnout, well-being and symptoms of depression as indicators of job morale among physicians and dentists in LMICs?

Methods

Search strategy

A systematic search of electronic databases and grey literature was performed according to the review protocol. The following six electronic databases were searched: Scopus, Pubmed, PsycINFO, Embase, Web of Science and The Cochrane Library up to May 2018. Search terms combined three overlapping areas with key words such as ‘morale’ OR ‘job motivation’ OR ‘job satisfaction’ OR ‘well-being’ OR ‘burnout’ OR ‘depression symptoms’ AND ‘physicians’ OR ‘dentists’ AND ‘LMICs’ (see online supplementary file 1). Publication bias was reduced by searching conference papers and unpublished literature; hand searches of key journals and reference lists were performed. This review was reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.33

Supplemental material

Selection criteria

Studies were eligible if they assessed any one of the job morale constructs such as job motivation, job satisfaction, well-being, burnout and depression symptoms by using qualitative methods; if at least 50% of the sample were qualified physicians and/or dentists employed in public healthcare settings or if data about qualified physicians and/or dentists employed in public healthcare settings were provided separately; if at least 50% of the sample were from the LMICs as defined by World Bank criteria34 or data from the country of interest was provided separately. Papers were excluded if more than 50% of the sample were not yet fully qualified physicians and (or) dentists who were undertaking training at the time of the study (medical students, residents, trainees, registrars or junior physicians), and if they were not written using Latin alphabet, Russian or Kazakh. There was no restriction on the date the studies were conducted. All included articles were inspected independently by a second researcher (SZS) to verify inclusion.

Considering the definitional imprecision of job morale and the different dimensions used to characterise it, we employed an inclusive approach adopting of five indicators of interest, including job motivation, job satisfaction, well-being, burnout and depression symptoms.

Review strategy

Titles and abstracts of identified articles were exported into EndNote V.X8 and were screened by the first reviewer (AS) in order to exclude irrelevant studies and duplicates. Full-text articles were inspected again for the relevance according to the inclusion criteria. A random sample of 20% of the articles was independently screened by the second reviewer (SZS) at each stage. Discrepancies were resolved by involving a third reviewer (SP). Mismatches at the full-text screening stage were added up and inter-rater reliability calculated. The level of agreement between AS and SZS was 80%, between AS and SP was 75%.

Data extraction and quality assessment

Data from each paper, including study details, participant demographics and key results were extracted (see online supplementary file 2). In the case of mixed methods studies, only qualitative findings were extracted. The second reviewer (SZS) ensured the accuracy at this stage by extracting data from 20% of the included papers. One article written in Portuguese was extracted by involving a native speaker. Methodological quality was assessed using the Critical Appraisal Skills Programme (CASP) for qualitative studies.35

Supplemental material

Data synthesis and risk of bias assessment

As part of the framework method,36 data from the results sections of included articles were coded in the reviewing software (EPPI-reviewer) and preliminary concepts describing physicians’ experiences were defined inductively. Similar concepts were grouped into categories and sub-categories independently by two reviewers (AS, SZS) and were discussed with other researchers (SP, FM, SN) to ensure the range and depth of the coding. The defined categories were then organised in the analytical framework. The framework matrix was used to provide a list of illustrative quotations. Additionally, vote counting37 was used as a descriptive tool to indicate patterns across the included studies. We calculated the frequency of defined categories to present how prevalent each category was within the included studies.

Based on CASP studies were appraised in accordance with 10 criteria, where the majority of studies were rated as appropriate with regard to aims, methodology and research findings (see online supplementary file 3).

Supplemental material

Patient and public involvement

The results of the analysis were solely based on the previously published literature, as this study did not involve patients or public.

Results

The original search yielded 11 347 articles through database searching and 30 through other sources. A total of 2021 articles were removed as duplicates, and 9297 articles were excluded for not meeting the inclusion criteria. The full texts of the remaining 59 papers were examined, 10 of which were included and represented 10 unique studies. None of the studies focused on dentists’ experiences met the inclusion criteria. The detailed selection process is presented in the PRISMA flow diagram (figure 1).

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

Overview of included studies

Included studies were published between 2010 and 2017, in English, with the exception of one. They were conducted across seven LMICs, including four upper-middle-income countries (South Africa, China, Brazil and Russia), two lower-income countries (Pakistan and Moldova) and one low-income country (Uganda). With regard to the study design, four were mixed methods and six were qualitative. The majority of studies were conducted in primary31 38–42 and secondary healthcare settings.43 44 The included studies’ characteristics are summarised in table 1.

Table 1

Characteristics of included studies

Physicians’ experiences influencing job morale

Identified concepts relevant to physicians’ experiences of job morale were grouped into four main framework categories: work environment (I), rewards (II), work content (III) and managerial context (IV). The respective sub-categories within each of these categories are presented in the following section. Illustrative quotations within each category are provided in table 2.

Table 2

Illustrative quotations

Work environment

Categories such as physical31 38 40–46 and social31 38 40–46 work environment appeared in all included studies.

Physical

Participants expressed that job morale was influenced considerably by working conditions, as a crucial source of job motivation45 and satisfaction.38 40 Few of them were ‘satisfied with physical environment’,31 but the majority of physicians felt ‘very disgusted’46 and ‘very ashamed’44 of the hospital infrastructure and constraints of resources, including lack of medicines and equipment deficiency.31 38 40 44 46 Additionally, physicians noted that poor physical environment in the hospitals ‘annoyed patients’31 and showed awareness that poor hygienic conditions were making patients ‘more sick’.46 The category addressing ‘physical work environment’ included residential living conditions for physicians who were based in more rural health settings.31 40 They described their residences as ‘inhabitable’ houses with poor ‘water and electricity connections’,31 that are ‘falling apart’.40 The limited options for schooling for their children31 46 and underdeveloped road access31 were frustrating and demotivating.

Social

Physicians described a sense of ‘collegiality’ and ‘regular interactions’ among staff in the healthcare facilities as a motivator44 and perceived ‘poor interpersonal relations’ as generally as demotivating.45 Four main sub-categories contributed to defining the ‘social environment’ category: relationships with nurses and auxiliary,31 40 41 44 45 relationships with other physicians40 44; relationships with patients31 38 42–44 and relationships with managers/ supervisors.31 40 43 44 46

Participants questioned the professional ‘competency’44 and ‘power’41 of nurses and noticed that auxiliary staff were ‘unsupportive and apprehensive’ and worked ‘often without a license to practice’.31

Relationships with other fellow physicians were found to be ‘very stimulating’44 not only within a hospital, but this view also emerged in case of ‘visiting consultants’ in rural settings.40

There was inconsistency in experiences relating to physician-patient relationships. Some participants ‘seemed fairly happy’44 and ‘expressed satisfaction with their current relationships’.38 However, others expressed the view that physicians ‘often had to see angry patients’,31 who ‘could not understand the physicians’ work’38 and tend to ‘bring all their problems [beyond health-related]’.42 It was emphasised that “difficult” patients are a significant cause of physicians’ burnout.

Physicians indicated that relationships with managers/supervisors mainly depended on the provision of ‘adequate supervision’46 with enough respect,40 44 support,44 46 recognition31 44 and autonomy.43 46 ‘Poor supervision’45 demotivated physicians and ‘total control’ by managers/supervisors contributed to their burnout.43

Rewards

Almost all papers discussed the importance of financial31 38–40 43–46 and non-financial31 38–40 44–46 rewards in medical practice.

Financial

The majority of physicians felt that their financial compensation was ‘not acceptable’,46 ‘low’43 and ‘failed to reflect the job’s value’,38 especially in rural areas39 40 and considered their low salaries as a significant ‘demotivator’.45 However, some participants noted that medical practice has advantageous financial incentives, such as state pension, paid holidays and sabbatical leaves.44

Non-financial

Despite the importance of financial incentives, physicians highlighted that ‘money is not the most important factor for any clinician’.40 Career development appeared to be significant in determining physicians’ job morale.31 40 44–46 However, they showed the general sense of dissatisfaction ‘with overall process of promotions and transfers in the public health sector’.31 Conceptually, career development closely connected with the availability of learning, teaching and research opportunities31 40 41 44 45 which were ‘necessary for the professional growth of physicians’.31 Moreover, social respect was also considered a non-financial incentive31 38 39 42 which varied in terms of the professional reputation, gained by years of practice39 and admiration of public servants, as a part of the community culture31 and across different physicians’ specialties.42

Work content

The overarching category of ‘work content’ sub-categories, such as workload, nature of work,31 39 42 44 job security31 44 45 and physical and legal safety, was observed in almost all included papers as experiences influencing job morale.

Workload

The workload was mentioned broadly across all included studies.31 39 41–46 Specifically, physicians complained about ‘too many working hours’43 and the necessity to be ‘on the end of the phone’.44 Emergency duties and long working hours were especially discouraging for married female physicians and single mothers44 because they worried that ‘their other responsibilities remain unattended’.31 Additional frustration was related to a large number of patients in-charge39 and ‘fixed times for appointments’.42

Nature of work

Despite the excessive workload, physicians have emphasised that the ‘serving’ nature of medical profession31 38 39 42 44 and the diversity42 44 of work was extremely satisfying38 and motivating.45 Participants felt ‘a sense of achievement’38 when they ‘get results and see patients feeling better’.42 They also expressed a ‘passion to serve their own communities’.31

Job security/stability

Furthermore, some physicians reported that regardless of ‘whether you do it well or whether you don’t do it so well’44 working in public healthcare facilities ‘ensured job security for the rest of their careers’31 and provided them with the ‘ability to support’ their families.45

Physical and legal safety

The motivation experienced as a result of job security and stability was contrasted with the demotivation felt due to low levels of ‘personal safety’,45 especially for rural female physicians31 and growing responsibility for patients, ‘in [a] legal sense’.44 However, it has been noted that medico-legal risk for physicians could be mitigated by interns, residents and registrars, who ‘shield’ physicians from assuming complete medicolegal responsibility for all patients.44

Managerial context

Experiences within the managerial aspect of medical practice were broadly discussed in terms of the staffing levels,31 38 40 42–44 46 protocols and guidelines consistency,31 41 44 46 and political interference.31 46

Staffing levels

Low staffing levels of physicians, medical assistants and managers appeared to be a substantial cause of dissatisfaction38 44 and contributed towards absenteeism31 46 and retention problems.44 Excessive workload caused by the deficit of physicians46 and medical assistants42 resulted in physicians being frequently ‘absent’ from their duties31 and ‘encourage[d] others to leave’44 as well. Moreover, it seemed quite difficult to attract people to work in healthcare facilities, ‘despite the district posting the growing vacancies for multiple years, no applications had been received’.46 At the same time, physicians raised a concern that vacant posts may not be advertised properly.40 The additional burden of paperwork42 43 fell on physicians as a result of administrative staff deficiency44 which could be alleviated by implementing electronic medical systems.42

Protocols and guidelines consistency

Physicians stated that job description, protocols and guidelines regulating the drug prescriptions41 and performance appraisal31 processes ‘needed to be revised to include the solutions to the current work place problems’.31 Nonetheless, the ‘growing requirements’43 as a consequence of the increasing number of ‘regulations and rules’44 were highlighted as a source of frustration44 and burnout.43

Political interference

Certain physicians felt that managerial work context was possibly disrupted by ‘politically powerful persons’31 interfering ‘in the decision making [process] at health facilities’46 and their attempts to get a prioritised treatment for relatives.31 Some participants believed that it was difficult to be promoted or transferred to a desired position ‘without links with any influential person’31 and mentioned cases of ‘intimidation of health workers by local politicians’.46

Discussion

Main findings

The aim of our systematic review was to synthesise qualitative studies exploring physicians’ experiences influencing job motivation, job satisfaction, burnout, well-being and symptoms of depression as indicators of job morale in LMICs.

The analytical framework that comprised four main categories of the work environment (I), rewards (II), work content (III) and managerial context (IV), was developed based on concepts that emerged from included studies. According to the vote counting results, workloads, working conditions and financial rewards were most frequently mentioned as influencing job morale and have been described in almost all studies. The majority of studies mentioned important experiences regarding staffing levels, career and professional development, relationships with nurses/auxiliary staff and managers/supervisors. Physicians from almost half of the included studies focused their attention on the nature of work, relationships with patients, protocols and guidelines consistency.

Physicians were quite consistent in defining whether their experiences were positive or negative. Experiences of excessive workload, low salaries, poor working and living conditions, fewer opportunities for career and professional development, staff shortage, tense physician–nurse and physician–manager/supervisor relationships, inconsistent professional guidelines and political interference were described as negative. Although physicians reported more negative experiences, positive experiences were also underlined in terms of the serving nature of work, being given social respect, job stability and collegial relationships with other physicians.

Strengths and limitations

To our knowledge, this is the first systematic review of qualitative studies exploring physicians’ experiences influencing job morale in LMICs. A further strength is that the review searched through papers from all LMICs and was not limited by physicians’ specialty or to English language publications. This allowed for the inclusion of data from diverse countries, cultural backgrounds and clinical specialties. However, this approach presented some limitations. First, although it was possible to extract general concepts in physicians’ experiences, there is not enough evidence to assess whether these apply to all medical specialties and to other countries. There may be regional and clinical nuances that have not been identified in this review. Second, the prevalence of negative experiences over positive ones could be caused by a biased focus of studies on exploring difficulties. Third, heterogeneity of studies due to imprecise definitions of the concept of ‘job morale’, made it challenging to provide firm conclusions. Although dentists were included in the literature search, none of the studies on dentists met the inclusion criteria; therefore, the results cannot be generalised to them.

Despite these limitations, the current review is a valuable collation of studies and specifies which experiences influence the job morale of physicians.

Comparison with literature from high-income countries

The present review supports qualitative findings from previous studies that have been conducted in high-income countries (HICs). It is particularly consistent with findings that serving and helping patients,13 47 48 working on diverse medical cases13 22 48 49 and healthy relationships with other medical staff13 14 48 50 51 constitute positive experiences and enhances workers’ job morale. It supports evidence that excessive workload,16 22 49 50 52 insufficient staffing levels,13 16 51 administrative burden16 22 50 and poor relationships and understanding between medical staff and managers13 16 50 influence job morale negatively. In general, the tendency that professionals are more satisfied with the job content than with its structure and management can be observed not only among physicians. It applies also to employees of different occupations.

Contrary to our findings, healthcare staff employed in high-income countries indicated positive experiences regarding the consistency of existing protocols and guidelines,13 48 relationships with patients47 50 51 and opportunities for continuing education.22 The review also demonstrated some evidence regarding poor physical environment within healthcare facilities and constraints of resources, as has been recorded previously.13 16 50 However, these findings should be interpreted with caution due to their context-dependency.53 The context often includes increasing poverty,54 inequality55 and collapsing healthcare systems.56 57 The structural adjustment programmes promoted by international financial institutions and widely implemented across LMICs may influence the context.58–61 In particular, the freezing of vacant posts and mandated ceilings on wages can be substantial barriers to recruiting and retaining healthcare staff.55 62 63

Quantitative findings from research on healthcare staff working in HICs helped to corroborate the results of this review. Single studies and reviews conducted in HICs also report associations between job morale and factors such as financial rewards,64–68 workload,4 64–66 68 recognition,13 23 support,16 23 autonomy,23 65 67 staffing levels,69 learning/teaching/research opportunities,64 69 workload,4 64–66 68 diversity of work,64 68 relationships with colleagues,23 64 65 67 69 job security and protocols and guidelines consistency.16 67 This is consistent with what this review found in LMICs. Despite this consistency, it is not clear as to whether evidence from HICs can be simply transferred to LMICs and the other way around.

Implications for research and practice

By considering physicians’ experiences across seven LMICs, the current review findings suggest that in order to advance current clinical practices by enhancing job morale, interventions and workforce policies should aim at increasing salaries, improving working and living conditions, tackling healthcare staff shortage and excessive workload and providing more opportunities for career and professional development. However, it is very difficult to achieve in resource-scarce settings. Finding the right balance between growing demands and limited resources is a key challenge. A critical approach to healthcare policy with a specific reference to ethics and a range of disciplines in social science are likely to be required to achieve and maintain that balance.70 71 Also, findings suggest that professional guidelines, such as job descriptions, performance appraisal and protocols regulating drug prescriptions should be revised and effectively implemented. This may have a potential positive influence on physician-nurse relationships by maximising role clarity.

There are at least four implications for future research. First, in order to generate clear directives for improvements, future research studies should investigate whether job morale is perceived and valued differently by different medical specialties, and the research gap around dentists’ experiences should be addressed. Second, the structural and social determinants of job morale of physicians in LMICs should be studied more systematically which requires funding for such research. Third, contextual features should be considered as they might limit the applicability of findings from one healthcare setting and region to another. Fourth, existing interventions and strategies should be assessed rigorously to define implementation requirements, cost-effectiveness and long-term changes.

Conclusions

The current review has identified that perceived threats to positive job morale of physicians in LMICs outweigh perceived incentives. It has highlighted several areas in which strategies aiming to improve physicians’ job morale in in LMICs may be targeted. However, generalised conclusions are tentative because of the heterogeneity, limited number and inconsistent quality of the existing studies. Future research into physicians’ experiences influencing job morale in LMICs should robustly examine context-specific issues and appropriate ways of addressing them, to ensure that the results can be translated into practical programmes for improving healthcare practice.

Acknowledgments

We are deeply grateful to all members of the Unit for Social and Community Psychiatry for their assistance in data analysis. We wish to thank Dr Mariana Pinto da Costa for translating the article in Portuguese.

References

Footnotes

  • Contributors AS and SP designed the study with input from SN. AS conducted the systematic searches of the literature, selected the studies, performed data analysis and drafted the manuscript. SZS ensured the consistency of study selection, data extraction and analysis. FM contributed to the analysis and edited the manuscript. All authors approved the final version of the manuscript.

  • Funding This study was sponsored by the Kazakhstan Ministry of Education and Science Center forInternational Programs as part of a PhD studentship.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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