Village doctors play a fundamental role in the Chinese rural health care system, they are responsible for providing rural residents with life-cycle care involving prevention, treatment, health protection and rehabilitation, as well as two-way referral between village clinics and urban general hospitals, so that village doctors are the gatekeepers of health for the vast majority of rural residents in China[1]. With a rural population over 900 million, village doctors in China conduct a much broader scope of work compared to other countries. With the rapid development of China's economy in recent years, the overall quality of village doctors, their service conditions, and the fairness and accessibility of health services for rural residents have been continuously improved[2].
Yet village doctors are confronting serious challenges and pressures brought by some reformist policies concerning the medical and health system. The new national essential drugs system requires village doctors to use essential medicines and sell them to patients at zero-profit purchase price, which has shifted the income of village doctors from drug prices to local government compensation. The low level of government compensation and the delay in receiving such compensation have greatly reduced the income of village doctors. In 2014, the average monthly income of village doctors in Beijing, a more developed region in China, was only 1,293.07 yuan (166.637 euro) [3]. Meanwhile, many current situations in rural areas such as strong demand for health care, poor working conditions and environment, the aging of village medical team, and shortages of new doctors with professional knowledge and comprehensive quality[4] with incomes lower than urban doctors, and rural residents' distrust of their medical qualifications and medical technology, make the occupational environment of village doctors increasingly severe[5]. All these factors have been found to have an impact on burnout and subsequently village doctor turnover[3, 6].The detection rate of burnout among village doctors is as high as 68.60%, 45.3% of which had high turnover intention[7]. Recently, China's Henan province saw two serious cases of village doctors’ collective turnover, one involving 36 doctors and the other 28 doctors. As an important part of China's medical and health service team, when village doctors collectively leave their jobs then the rural medical institutions may face a "stall" and rural residents may fall into an incurable predicament, resulting in more serious social consequences[1, 8].
Turnover intention refers to an employee’s option to voluntarily vacate their work in a certain period of time[9]. Research on turnover can be traced to 1958 when March and Simon established the participant determination model[7, 10]. Subsequently, scholars have developed a series of theoretical models on turnover research; although the emphases of such models are different, they all state that turnover intention is the main cognitive precursor of turnover behaviour and has a strong explanatory power[11, 12]. Compared with turnover behaviour, turnover intention can better reflect the real management level of an organization. Based on this, this study finds that it is more meaningful to explore turnover intention than actual turnover behaviour. Hence the turnover intention of village doctors, rather than their actual behaviour, is the theme of this study.
Since the training of doctors requires a long period of education and practice[13], high turnover tendency may lead to huge transition costs and serious loss of patient confidence, which is a serious problem for the stability of hospitals and the medical system[14, 15]. Numerous studies have analysed the influencing factors of doctors’ turnover intention, including a country's medical system, occupational environment, doctor-patient relationship, level of employment and alternative job opportunities, and other external environmental factors[3, 16-18]. Internal individual factors include gender, age, marital status and work ability[4, 19, 20]. The most widely studied job-related factors including working hours, salary levels, social security, job stress and burnout, emotional commitment, job autonomy, fairness of remuneration[21, 22] were always incorporated into studies to explore the comprehensive impact on turnover intention. However, the influence of resilience on the turnover intention of village doctors has not been included in such studies. At the same time, existing studies have mostly used the t-test, ANOVA and chi-square test, multivariate linear regression analysis, and binary logistic regression analysis to analyse the influencing factors of turnover intention[3, 4, 16-22]. Structural Equation Modelling (SEM) can not only measure the correlation between observed variables, but also the correlation between latent variables, and even the causal relationship between measured variables. Therefore, this study adopts SEM to study the linear regression relationship between variables, which can compensate for current studies’ limitations.
Job satisfaction, defined as a personal positive subjective evaluation or attitude towards all aspects of a work environment, is affected by many factors such as the work itself, work challenge, salary system, interpersonal relationships, working conditions, work motivation, organizational environment, and so on, and has been typically considered to be the most representative antecedent variable that directly predicts turnover intention in health care providers[21, 23, 24]. Many empirical studies have found that job satisfaction is negatively correlated with turnover intention, and influence it through direct and indirect paths[8, 24, 25]. A meta-analysis demonstrated a strong negative correlation between job satisfaction and turnover intention among nurses[26]. For example, improving job satisfaction in terms of salary, promotion and job security is crucial to reduce the turnover intention of urban primary care physicians in rural South Africa[27]. Furthermore, job satisfaction is often the mediator between other factors and turnover intention, such as professional identity, and has an indirect negative effect on turnover intention through job satisfaction among township health inspectors in China[7]. The doctor-patient relationship and work engagement has also been found to play an indirect role in nursing staffs’ turnover through job satisfaction in southern Italy[28].
Work engagement is defined as a positive, affective-motivational state of work-related well-being, with the characteristics of vigour, dedication and absorption[7, 29]. In countries or regions with limited medical resources, the work engagement of medical staff, in contrast to job burnout and high turnover intention, is recognized as an irreplaceable and much-desired organizational asset[30]. Personal characteristics such as psychological status, job identity and personality affect work engagement. Meanwhile, available work resources, organizational support and fairness, and other work characteristics are also highly positively correlated with work engagement[31, 32]. Accordingly, the outcome variables of work engagement include organizational variables such as organizational efficiency and performance, and personal variables such as job burnout and turnover intention[33, 34]. The total score of work engagement, vigour, dedication and absorption were negatively correlated with turnover intention. Some studies have explored the mediating role of work engagement in turnover intention[28, 35, 36]. Silvia De Simone et al found that patient satisfaction had a negative effect on nurses’ turnover intention through the mediating effect of work engagement in southern Italy[35]. A cross-sectional and correlational study in a Portuguese hospital revealed the mediating effect of job engagement between social support, job satisfaction and turnover intention[37].
Yet even in the same working environment, facing the same pressure and adversity, not every village doctor will have job burnout or turnover intention. This can be explained by the concept of individual resilience, which refers to a person's ability to recover from a traumatic or painful event and to achieve good adjustment and higher development[20]. Research shows that individuals become stronger, more confident and more productive by experiencing stressful events and overcoming them through resilience[38]. In addition, resilience may not alleviate the stress experienced by village doctors, but it can enhance their ability to overcome stress, thus improving overall job satisfaction and work engagement, and reducing job burnout and turnover tendency[39]. A national survey of nurses' turnover intentions in South Korea found that resilience had a positive direct effect on work engagement, which had a negative direct effect on turnover intention. Resilience and work engagement mediated the effect of work satisfaction and burnout on turnover intention[40].
Based on the above-mentioned theoretical analysis and empirical demonstration, we attempted to link the relationships among job satisfaction, resilience, work engagement and turnover intention, and a double mediator model is presented in Table 1 and Figure 1. We assumed that job satisfaction, resilience and work engagement directly affect turnover intention. Meanwhile, through resilience and work engagement, job satisfaction has an indirect effect on turnover intention, and work engagement mediated the effect of resilience on turnover intention. So this study aims to verify the direct impact of job satisfaction, resilience and work engagement on turnover intention, and to analyse and quantify the mediating role of resilience and work engagement between job satisfaction and turnover intention among village doctors in China. This study is the first to consider the influence of job satisfaction, resilience, and work engagement on village doctors’ turnover intention in China.
Jining in southwest Shandong province lags behind the province’s eastern part in terms of economic development. According to 2018 statistics, the total population of Jining is 8.375 million, of which the rural population is 3.5916 million. Jining has 6,489 villages with 5,307 village clinics. There were 11,715 village doctors, 870 fewer than in 2017, averaging 2.99 per village. The number of consultations in village clinics was 21,262,000, with an average annual consultation volume of 4006.41 per clinic [41]. As village doctors have a heavy workload, Jining city is taken as the research site to ascertain the turnover intention of village doctors and the influencing factors.
Table 1. The Theoretical Hypotheses
Hypotheses
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1. Job satisfaction has a direct negative effect on turnover intention
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2. Job satisfaction has a positive effect on resilience
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3. Job satisfaction has a positive effect on work engagement
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4. Job satisfaction has an indirect negative effect on turnover intention through the mediating effect of resilience
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5. Job satisfaction has an indirect negative effect on turnover intention through the mediating effect of work engagement
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6. Job satisfaction has an indirect positive effect on work engagement through the mediating effect of resilience
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7. Resilience has a negative effect on turnover intention
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8. Resilience has a positive effect on work engagement
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9. Resilience has an indirect negative effect on turnover intention through the mediating effect of work engagement
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10. Work engagement has a negative effect on turnover intention
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