The family doctor system has been implemented in more than 50 countries, including the United States, the United Kingdom, Germany, Canada, and has been proven in practice to be the cost-effective and feasible way to protect and maintain public health [1]. Although operational mechanisms and service models of the family doctor system are varied among countries, there are some common features and practices that require residents and family doctors to sign service contracts. For example, residents in the Netherlands need to choose a single general practitioner to register [2], the general practitioners in Norway have to sign healthcare contracts with residents [3], and the UK has adopted a state-managed model requiring residents to sign contracts with family doctors [4].
In 2016, the Chinese government implemented the family doctor contract services system comprehensively, intending to improve the health status of the population and the ability of patients to rationally choose medical institutions. The family doctor contract services system in China takes the form of teams, usually consisting of family doctors, nurses, and public health doctors, and residents voluntarily sign a service contract with family doctor teams, with each contract being in principle for a one-year service period [5]. Family doctors in China, mainly registered general practitioners and competent village doctors, usually play the role of leaders in the team and provide basic medical services, public health services, and personalized services to contracted residents [6]. Basic medical services and public health services are provided free of charge, including treatment of common diseases and referral of difficult cases, as well as services such as health record establishment, disease prevention, and chronic disease management, and personalized services are fee-for-service to meet the individual needs of residents according to the content of the service contract [7]. The effective implementation of the family doctor contract services system is conducive to improving the quality of primary health care in China, accelerating the development of the graded diagnosis and treatment system, and ensuring targeted medical services to patients in the minimum amount of time [8]. Additionally, with over 900 million people living in rural China [9], and an average of only 1.3 licensed doctors per 1,000 people in rural areas [10], family doctors in rural China are responsible for more primary health care than those in urban areas and serve a vital role as health protectors for rural residents [11].
Turnover intention is possibly the most important and direct antecedent to the turnover decision, and the most immediate predictor of turnover [12], which affects the stability of the family doctor pool and the efficiency of services provided [13]. Most perspectives have placed turnover intention as the negative outcome of combined evaluation of job satisfaction and the utility of the current job, and taking steps to secure future employment, which can form the actual turnover [14]. In China, family doctors who are the main force of primary health care also suffer from continuous workforce shortages and high levels of turnover intention [15]. For example, Gan et al. (2019) [16] surveyed 3236 family doctors in China who were registered general practitioners in primary medical institutions and found that the percentage of those with moderate or high levels of turnover intention was 71.1%. Li et al. (2020) [17] revealed that younger family doctors reported higher levels of turnover intention, with 80% of family doctors under 35 years of age having the turnover intention. Family doctors with turnover intention result in lower morale, hidden absenteeism, and poor performance [18]. The prevalence of chronic diseases is higher and the accessibility of medical resources is lower in rural China [7, 10], if family doctors in rural areas have a widespread and continuous turnover intention, it could aggravate the shortage of human resources, undermine the stability and sustainability of the healthcare system, reduce the quality of primary health care, which are detrimental to improving the health status of rural residents.
Mobley et al. [19] identified job content characteristics as one of the significant factors influencing individuals’ turnover intention. Numerous studies [20-22] have also confirmed that the job characteristics of Chinese family doctors, such as heavy workload, variety of work, limited opportunities for career advancement, and the discrepancy between effort and income, can lead to the turnover intention. A further study [17] has found that 90% of Chinese family doctors feel constantly fatigued and emotional exhaustion, which is not only related to the mentioned job characteristics, but more importantly, to significant investment of energy and emotional resources. The accomplishment of family doctors’ work goals is closely related to the cooperation of residents, in this regard, family doctors keep optimizing their services to obtain residents’ support, which includes constantly improving their communication and attitudes to meet residents’ emotional needs, implying more emotional labor on the part of family doctors. Surface acting, as an emotional labor strategy with a disparity between inner feelings and emotional displays, increases family doctors’ emotional depletion and work stress, resulting in emotional exhaustion and mental fatigue, and thus the turnover intention. Additionally, occupational commitment, as a measure of individuals’ affective response to their occupation, can also play a role in turnover intention [23].
This study draws on the Conservation of Resources theory to examine the relationships between surface acting, emotional exhaustion, occupational commitment, and turnover intention among family doctors in rural China. It is beneficial to break through the limitations of existing studies, mostly exploring family doctors’ workload and work rewards, and rarely considering the amount of emotional labor undertaken by family doctors in their actual work, especially the insufficient awareness of the adverse effects of surface acting. In addition, the findings of this study may provide important practical guidance for health administrations and healthcare institutions as a basis for developing interventions to reduce family doctors’ turnover rates.
Literature review and hypothesis development
Surface acting and turnover intention
The working of doctors is not only physical and mental efforts, but also the process of emotional labor [24]. Emotional labor, regulating the expression of feelings at work, was defined by Hochschild (1983) [25] as the management of feelings for creating a publicly observable display of the face and body to get paid. Emotional labor, a form of labor different from mental and physical labor, involves following specific emotional display rules that refer to the standards set by organizations as the appropriate expression of emotions, and requires employees to consciously control their emotions to achieve the tasks regardless of how they truly feel [26]. Deep acting and surface acting are two main strategies of emotional labor, but they differ in the efforts and intentions to regulate emotional expressions. When engaging in deep acting, individuals attempt to change inner feelings and show empathy to match the desired emotional displays [27]. While in surface acting, individuals display emotions by faking to cope with the work without shaping inner emotional states, which is assumed to be “faking in bad faith” [28].
Family doctors are in extensive contact with residents in their daily work. Given the low health literacy of rural residents [29], and poor trust of patients towards doctors [30], family doctors in rural areas are more frequently required to employ emotional strategies to improve communication and attitudes to obtain cooperation with rural residents in work [31]. It was revealed that deep acting is gradual over time and doctors rarely change their feelings immediately to truly understand their patients, but instead, surface acting is employed by doctors to help patients develop hope and change viewpoints [32]. Moreover, a positive relationship between harsh treatment from patients and surface acting by doctors was reported [31]. Gan et al. (2018) [13] found that Chinese family doctors are regularly exposed to workplace violence, with emotional abuse from patients being the most common type, so family doctors often employ surface acting in their work as well. Meanwhile, taking into account the demographics and health literacy of rural residents, family doctors in rural areas are more inclined to control their inner feelings and cater to the medical needs of the patients by surface acting to accomplish their work targets.
Compared to authentic, positive emotions elicited by deep acting, surface acting is generally related to more detrimental outcomes, such as developing emotional dissonance, and causing emotional exhaustion [33]. Grandey (2000) [34] found that individuals who have to engage in high levels of surface acting are more likely to be a turnover intention. Evidence of the link between surface acting and turnover intention can be provided from theoretical studies on emotional dissonance. Emotional dissonance, a state of being uncomfortable when individuals’ feelings and emotional displays are discrepant, often occurs as individuals engage in surface acting, and individuals are motivated to remove themselves from the surface acting that has caused the emotional dissonance, resulting in the turnover intention [35]. Also, the surface acting with high emotional display rules can lead to an uncomfortable state called emotional dissonance among rural family doctors, as a result of the discrepancy between inner feelings and emotional displays, and give rise to the turnover intention for the sake of getting rid of this state sooner. Studies in the medical field further indicated that professionals who regularly engage in surface acting have high levels of turnover intention [36, 37]. Summarizing the above theoretical arguments and empirical findings, we predict that:
Hypothesis 1: Rural family doctors’ surface acting is positively related to the turnover intention.
The mediating role of emotional exhaustion
Emotional exhaustion, an essential component of job burnout, is a chronic state where employees are depleted of emotional and physical resources due to excessively strict job requirements and continuous work stress [38]. The conservation of resources (COR) theory asserts that resources are available to help individuals cope with stressful experiences, but are also typically depleted by confronting stressful circumstances, and it further predicts that resource loss is a dominant component of the stressful process [39]. Resources refer to objects, personal characteristics, conditions, or energies that are valued by individuals or served as a means of attaining them, of which emotional resources also matter to individuals [40]. Emotional exhaustion occurs when individuals perceive they are no longer having sufficient emotional resources to cope with the stresses being faced, or perceive resources are threatened with loss and are not available after being invested [41].
Family doctors are regularly exposed to emotional happenstances and are expected to accept emotional management as part of their basic duties [42], and surface acting is a common strategy employed by them. In this circumstance, rural family doctors are constantly exposed to excessive mental stress as they fake their inner feelings in surface acting. According to COR theory, the stress posed by surface acting can lead to excessive depletion of resources, and emotional exhaustion occurs when rural family doctors’ emotional resources are difficult to overcome mental stress, and thus surface acting is positively associated with emotional exhaustion [43]. Numerous studies [44, 45] have also consistently revealed that surface acting serves as an antecedent to emotional exhaustion. A study of Chinese hospital nurses by Deng et al. (2020) [46] found that surface acting is positively associated with emotional exhaustion. Zhao et al. (2020) [47] also confirmed in a study of front-line service teams that surface acting positively predicts emotional exhaustion. With this theoretical and empirical evidence, we expect the following:
Hypothesis 2: Rural family doctors’ surface acting is positively related to emotional exhaustion.
Prior studies [41, 48] have linked emotional exhaustion to numerous adverse work outcomes, such as increasing the turnover intention. A study [49] with general practitioners in Chain confirmed a positive association between emotional exhaustion and turnover intention. A meta-analysis by Kim et al. (2021) [50] on predicting factors of turnover intention for Korean hospital nurses also identified emotional exhaustion as a significant factor contributing to turnover intention. Shah et al. (2022) [51] conducted a study in the context of nurses’ job stress during COVID-19 to support the positive effect of emotional exhaustion on turnover intention. The relationship of emotional exhaustion to turnover intention can also be explained by COR theory. The basic concept of COR theory states that individuals strive to acquire, retain, and protect what they value, and minimize the threat of any resource loss, with the absence of resources leading to defensive attempts to protect the remaining resources [52] This theory can be taken to explain that when faced with emotional exhaustion, individuals choose to leave their jobs to protect the remaining emotional resources from continuing depletion and minimize the loss of their emotional resources [26].
Compared to urban areas, rural areas are relatively lagging in terms of healthcare facilities construction and physician teams building [53]. Family doctors in rural areas have heavy workloads with workforce shortages, and more frequent emotional labor [13], resulting in a state of emotional exhaustion where they are often depleted of resources and difficult to preserve. As explained by COR theory [26], individuals’ self-protective defensive mechanisms are triggered in the state of emotional exhaustion, and leaving can protect their remaining emotional resources from further depletion. Therefore, rural family doctors in this situation may develop turnover intention, by leaving the present job to keep individuals from the threat of excessive resource depletion. Thus, the following hypothesis is proposed:
Hypothesis 3: Rural family doctors’ emotional exhaustion is positively related to turnover intention.
COR theory suggests that individuals’ initial loss of resources will cause further loss with adverse behaviors and effects in the future, resulting in what is called a “downward spiral of loss” [54]. The COR theory and its “loss spiral” account for the fact that rural family doctors’ continuous surface acting accelerates the loss of emotional resources, leading to emotional exhaustion and further adverse behavioral or attitudinal inclinations toward avoiding or leaving the current situation. Thus, emotional exhaustion is a mediating role of surface acting and turnover intention, as confirmed in relevant studies [55, 56]. Therefore, it is proposed the following:
Hypothesis 4: Emotional exhaustion mediates the relationship between rural family doctors’ surface acting and turnover intention.
The moderating role of occupational commitment
Occupational commitment is defined in one dimension as affective commitment, expressing individuals’ positive feelings about their occupation, and in multiple dimensions such as continuance commitment and normative commitment [57, 58]. Yin et al. (2014) [59] described Chinese physicians’ occupational commitment from the one-dimensional perspective as positive feelings toward the occupation, expressing enjoyment, affirmation, and identification. Occupational commitment is perceived as a personal inner motivation for the occupation [60]. Individuals with strong occupational commitment are more adept at motivating their inner resources to properly solve problems at work, which can play an important role in the intention to stay [61]. Consistent with the resource replenishment principle in COR theory [62], which states individuals rely on additional resources to replenish lost resources and minimize the adverse impact of resource loss, occupational commitment allows individuals to reinforce personal characteristic resources including resilience, in order to enhance their mental strength in dealing with work stress and resource depletion, and strengthen their ability to adapt to challenging environments, thereby reducing the impact of adverse events[52, 63]. A study of Chinese village doctors [9] has shown that improving resilience can reduce turnover intention.
Emotional exhaustion is a state of excessive depletion of individuals’ emotional resources and an undesirable work situation that requires individuals to proactively respond to [64]. When occupational commitment is relatively high, it provides a strong mental resource for individuals to reduce the effect of emotional exhaustion on turnover intention. While occupational commitment is relatively low, individuals cannot develop solutions or personal resources, thus making the effect of emotional exhaustion on the turnover intention more severe. This logic is supported by studies indicating that occupational commitment can reduce the effect of emotional exhaustion on turnover intention. For example, it has been confirmed that higher levels of occupational commitment are less likely to involve emotional exhaustion, which can also reduce the adverse effect of emotional exhaustion, such as turnover intention[65, 66]. Also, occupational commitment is a predictor of turnover intention, with higher levels of occupational commitment contributing to lower turnover intention[12, 57]. Combining the above analysis, and considering the existing rural health system situation, we assume that rural family doctors with higher levels of occupational commitment are less likely to have turnover intention after exposure to emotional exhaustion. Therefore, the following hypothesis is formulated:
Hypothesis 5: Occupational commitment moderates the positive relationship between rural family doctors’ emotional exhaustion and turnover intention, such that the relationship is weaker for those with a higher level of occupational commitment than with a lower level of occupational commitment.
The above hypotheses demonstrate an indirect effect of rural family doctors’ surface acting on their turnover intention mediated by emotional exhaustion, while occupational commitment moderates the effect of emotional exhaustion on turnover intention. It is reasonable to integrate these hypotheses into a moderated mediation model, as we hypothesized that:
Hypothesis 6: Occupational commitment moderates the indirect effect of rural family doctors’ surface acting on the turnover intention via emotional exhaustion, such that the indirect effect is weaker for those with a higher level of occupational commitment than with a lower level of occupational commitment.