Threats or violence from patients was associated with turnover intention among foreign-born GPs - a comparison of four workplace factors associated with attitudes of wanting to quit one's job as a GP.

OBJECTIVE: General practitioners (GPs) are crucial in medical healthcare, but there is currently a shortage of GPs in Sweden and elsewhere. Recruitment of GPs from abroad is essential, but foreign-born physicians face difficulties at work that may be related to turnover intention, i.e. wanting to quit one's job. The study aims to explore the reasons to why foreign-born GPs may intend to quit their job.
DESIGN: Survey data were used to compare four work-related factors that can be associated with turnover intentions; patient-related stress, threats or violence from patients, control of work pace, and empowering leadership, among native-born and foreign-born GPs. These work-related factors were subsequently examined in relation to turnover intention among the foreign-born GPs by means of linear hierarchical regression analyses. The questionnaire consisted of items from the QPS Nordic and items constructed by the authors.
SETTING: A primary care setting in a central area of Sweden.
SUBJECTS: Native-born (n = 208) and foreign-born GPs (n = 73).
RESULTS: Turnover intention was more common among foreign-born GPs (19.2% compared with 14.9%), as was the experience of threats or violence from patients (22% compared with 3% of the native-born GPs). Threats or violence was also associated with increased turnover intention. Control of work pace and an empowering leadership was associated with reduced turnover intention. PRACTICE IMPLICATIONS: The organisations need to recognise that foreign-born GPs may face increased rates of threats and/or violence from patients, which may ultimately cause job turnover and be harmful to the exposed individual.

Introduction

General practitioners (GPs) are essential for public health [1,2] but the number of graduates entering primary care has levelled off in several Western countries [3-5]. One way to maintain the quality and quantity of health care is to recruit GPs from abroad. The number of primary care residents with foreign medical school degrees has increased in Sweden and elsewhere, and about one-quarter of Swedish GPs were born or educated abroad [3,6]. However, several studies have shown that the turnover intention [7], which can be described as an attitude of wanting to quit one’s job, or plans to do this, is greater among foreign-born physicians than among native-born [8,9]. This is alarming since turnover intention has a direct connection with actual turnover [8,10] and is regarded as the principal predictor of actual quitting [11,12].

Previous research has investigated factors important for turnover intentions. Dealing with uncooperative patients increases work stress and burnout [13] and is associated with greater intention to quit [11]. In a Norwegian study, it was found that 39% of physicians at OOH primary care centres had been subjected to threats, and 12% had been physically abused [14]. Threats against GPs have also been found to be common in the UK and Australia [15,16]. There are limited Swedish data describing this, but Swedish nursing personnel and physicians in psychiatric care have been found to be at considerable risk of workplace violence in the course of their careers [17].

Physician satisfaction and retention may on the contrary be enhanced by clinical autonomy and perceived control over the work environment [9,18,19] as well as by an empowering leadership [18,20-22]. Opportunity for job control has a buffering effect on turnover intention among physicians who have experienced workplace violence [19].

Aim of the study

The aim of the study was to explore how four work factors: patient-related stress, threats or violence from patients, control of work pace and empowering leadership related to turnover intentions among foreign-born GPs in Sweden.

Material and methods

This study was conducted in a public health care region in central Sweden and is part of a longitudinal research program. GPs permanently employed and actively working (n = 698; women = 61%) were invited to participate. From the total sample, 283 general practitioners, including residents, participated (women = 63%, response rate = 41%). A survey containing in total 126 questions was sent out as an electronic version that could be downloaded via an email link, and the data collection took place from December 2012 to January 2013. Oral presentations about the survey were given and physicians also received written information about it. Confidentiality was stressed as participants were assured that it would not be possible for answers to be traced back to individuals and that data would be computed and analysed on an organizational level. The response rate was higher among women (43%) than men (38%), but was similar among age groups.

Approximately a quarter of the participants were foreign-born (26%). The ages of the respondents were categorized into three groups: 44 years or younger (40.6%), between 45–54 (27.2%) and 55 or older (32.2%). Background questions about age, position, gender, civil status, number of children and place of birth were included.

The Swedish regional ethics board examined and approved the project (reference no. 2012/1500-32).

Dependent variable

The dependent variable turnover intention was measured with a scale consisting of three items constructed by the authors after adaptation from Sjöberg and Sverke (2000) [23] (Cronbach’s α = .86): ‘Nowadays, I often consider quitting’, ‘Right now, I feel like staying in this organization as long as possible’, ‘I would quit today if it was possible’. The response alternatives ranged from 1 to 5 (‘I completely disagree, I do not agree at all’, ‘I disagree’, ‘I partly agree’, ‘I agree’ and ‘I completely agree’).

Independent variables

Patient-related stress was measured with a scale consisting of three items constructed by the authors (Cronbach’s α = .69): ‘Contact with patients is often stimulating’, ‘Contact with patients is very demanding’ and ‘The contact with patients motivates me in my work’, Responses were given on a five-point scale from ‘1 = I do not agree at all’ to 5 = ‘I completely agree’.

Threats or violence from patients was measured with a single item constructed by the authors: ‘Does it occur that you are subjected to threats or violence from patients?’ The response alternatives were ‘‘1 = Very seldom or never’, ‘2 = Somewhat seldom’, ‘3 = Sometimes’, ‘4 = Somewhat often’ and ‘5 = Very often or always’.

Control over work pace was acquired from the General Nordic Questionnaire for psychological and social factors at work (QPS Nordic) [24] (Cronbach’s α = .77). The scale consisted of five items: ‘Can you control the amount of work assigned to you?’, ‘Can you control your own work pace?’, ‘Can you decide when to take a break?’, ‘Can you decide for how long your break is?’ and ‘Can you set your own work hours? (flexitime)’. Responses were given on a five-point scale from ‘‘1 = Very seldom or never’ to ‘5 = Very often or always’.

Empowering leadership (QPS Nordic) [24] (Cronbach’s α = .87) was measured with three items. ‘At your organization, are you rewarded for a job well done?’, ‘Are employees well taken care of in your organization?’ and ‘To what extent does the management take an interest in the health and well-being of the personnel?’. Responses were given on a five-point scale from ‘1 = Very seldom or never’ to ‘ = Very often or always’.

The questions constructed by the authors will be validated in the current project, but have not been so previously. Positively and negatively worded response choices were mixed in order to enhance validity, by reduction of acquiescence bias. In calculation of the scores, the negatively worded items were reversed.

Statistics

Comparisons of perceptions of work factors were made with independent t-tests, while demographic characteristics were examined by Chi-square tests. Hierarchical linear regression analysis was used to find predictors and protective factors for foreign-born GPs’ turnover intention. To illustrate differences between native-born and foreign-born GPs, the percentages of the most important dichotomised variables are given in the text. The principle of the dichotomization was that the negative response alternatives ‘Very seldom or never’ and ‘Somewhat seldom’ were merged to a ‘no’- category, and the positive response alternatives ‘Sometimes’, ‘Somewhat often’ and ‘Very often or always’ were merged to a ‘yes’- category. Skewness and kurtosis did not exceed the reference of substantial departure from normality suggested by West et al. [25].

Results

A demographic comparison revealed that there were less senior GPs who were foreign-born (Table 1) and that there were no chief physicians in this group.

Table 1.

Comparison of demographic characteristics among foreign-born and native-born general practitioners. Values are number and (%) of respondents.

Characteristics	Foreign-born	Swedish-born
Number of respondents	73	208
Gender
Male	32 (43.8)	70 (33.7)
Female	41 (56.2)	138 (66.3)
Missing data	0	0
Age group		***
≤44 years	28 (38.4)	86 (41.3)
45–54 years	31 (42.5)	46 (22.1)
≥55 years	14 (19.2)	76 (36.5)
Missing data	0	0
Position		*
Residents	24 (32.9)	55 (26,4)
Specialists	49 (67.1)	131 (63)
Chief physicians	0	22 (10,1)
Missing data	0	0
In a relationship/living with a partner
Yes	62 (84.9)	185 (88.9)
No	11 (15.1)	23 (11.1)
Missing data	0	0
Number of children
0	11 (15.1)	31 (14.9)
1 or 2	43 (58.9)	115 (55.3)
>2	19 (26.0)	62 (29.8)
Missing data	0	0

*p = <.05. **p = <.005. ***p = <.001. p Values measured by Chi-square tests.

The comparisons in Table 2 between the two groups of GPs showed that foreign-born GPs more often reported patient-related stress (t275 = 4.35, p < 0.001), while native-born physicians were more positive toward the leadership than foreign-born physicians (t279 =  −2.45, p = .015). Foreign-born physicians more often experienced threats or violence from patients (21.9% compared with 3.4%) (t279 =  −4.06, p = < .001), and they reported a greater turnover intention than native-born physicians (19.2% compared with 14.9%) (t279 =  −2.41, p = .017). The level of control of work pace did not differ between the two groups.

Table 2.

Comparison of perception of work factors among foreign-born and native-born general practitioners, values are mean and SD.

Work factors	Foreign-born GPs, mean, (SD)	Native-born GPs, mean, (SD)	p
Patient-related stress	2.96 (.76)	2.51 (.75)	***
Missing data	1	3
Threats or violence from patients	1.75(.91)	1.29 (.61)	***
Missing data	0	0
Control of work pace	2.50 (.84)	2.69 (.86)
Missing data	0	0
Empowering leadership	3.06 (.07)	3.38 (.12)	*
Missing data	0	0
Dependent variable: Turnover intention	2.74 (1.14)	2.39 (1.06)	*
Missing data	1	0

*p = <.05. **p = <.005. ***p = <.001. p Values measured by independent t-tests.

The regression analysis displaying the factors associated with turnover intention among the foreign-born GPs in Table 3 (model 3) revealed that an empowering leadership and control of work pace were related to decreased turnover intention, while threats or violence from patients was related to elevated turnover intent. The first model in Table 3; ‘patient-related stress’ and ‘threats or violence’, explained altogether 21% of the variance. The second model, where ‘control of work pace’ and ‘empowering leadership’ were added, explained 38% of the variance, and the third model, where gender, age and position were added, explained in total 40% of the variance in turnover intent. In model 1, only the variable ‘patient-related stress’ was significant. But once the additional factors – ‘control of work pace’ and ‘empowering leadership’ – were put in the regression (see Table 3, model 2), the contribution of ‘patient-related stress’ became non-significant, while ‘threats or violence’ emerged as a significant predictor for turnover intention, with 38% explained variance altogether in the model. The addition of the control variables gender, age and position in the last step only slightly increased the explained variance with 2%, to a 40% explained variance in total for model 3.

Table 3.

Standardized beta coefficients from linear hierarchical regression analysis and turnover intention among foreign-born GPs.

	Model 1	p	Model 2	p	Model 3	p
Patient-related stress	0.78	***	0.22		0.12
Threats or violence from patients	0.19		0.13	*	0.24	*
Control work pace			−0.34	**	−0.40	***
Empowering leadership			−0.28	**	−0.27	*
Gender					−0.17
Age					−0.06
Position					−0.11
Adjusted R2	0.21		0.38		0.40

*p = <.05. **p = <.005. ***p = <.001.

Discussion

In the present study, foreign-born GPs were more often exposed to threats or violence from patients, and they were also more likely to have turnover intentions than native-born GPs. Control of work pace and an empowering leadership were associated with a decreased level of turnover intentions, while threats or violence from patients was associated with an increased turnover intention.

This is the first study to show that foreign-born GPs in Sweden experience threats and/or violence from patients. Additionally, foreign-born GPs experience this to a significantly higher degree than native-born GPs. Insufficient mastery of the native language is common among physicians who have graduated abroad [26]. Communication difficulties, for example the GP not understanding what the patient says, might therefore be a possible explanation for why patients show aggression toward GPs. We have previously seen that foreign-born GPs experience harassment from colleagues [27], and the experience of patient aggression might be a related problem. This question needs to be studied in further detail, especially due to possible differences between merely foreign-born GPs and foreign-born GPs who also graduated abroad, as the experiences and possible interaction with patients of these two groups are likely to differ.

Control of work pace is a factor that ultimately may reduce turnover intention among foreign-born GPs. The results go hand in hand with previous research showing that control has a buffering effect on turnover intentions for physicians who have experienced workplace violence [21]. Control may thus be especially important for foreign-born GPs, given that they experience threats and/or violence more often. In our study data, there are, however, less senior GPs who are foreign-born and none who are chief physicians, positions normally associated with a higher level of control.

In line with previous research [18,20-22], the result of the present study also suggests that empowering leadership may aid retention of GPs in the health care setting.

Limitations

The number of foreign-born GPs was limited to 73. This implies a smaller effect size of the associations in the regression. However, the number of participants was enough for a reliable regression model [28].

We did not ask about country of graduation, this might be a flaw and should be accounted for in future studies. We have furthermore used a single item for the measurement of threats and/or violence. This subject needs to be researched more extensively, with multiple items distinguishing threats from violence for example. The time frame of these experiences should also be specified.

Finally, it should be pointed out that the study is based on cross-sectional data, which implies that causality in the direction of associations cannot be determined.

Conclusions

Foreign-born GPs are more likely to consider job turnover. The present study shows that this may be associated with threats and/or violence from patients, which is experienced by 22% in this group compared with 3% of native-born GPs. The ability to have control over their own work pace, and to be directed by empowering leaders, could however reduce GPs’ turnover intention. This issue of threats and/or violence from patients has not previously been studied in a Swedish context, and the higher levels reported by foreign-born GPs are alarming. Being exposed to threats or violence at work could be detrimental for the individual, and it is essential that those offering care are adequately protected. We suggest that this study is followed up with a more thorough investigation on the experiences of exposed GPs.