Turnover intention among GPs is a pressing issue that requires prompt attention. Adequate resource allocation for GPs is crucial for ensuring universal and equitable high-quality health care. This study aimed to investigate GPs' turnover intention during the COVID-19 period, with a specific focus on examining the relationships between turnover intention and job satisfaction, workplace violence, and perceived overqualifications.
Turnover intention
In this study, the mean turnover intention score among GPs in Chongqing, China, was 2.68 ± 0.62, and 80.9% of the GPs reported a moderate to high level (56.4%) or high level (24.5%) of turnover intention. This indicates a relatively high level of turnover intention during the COVID-19 epidemic period in Chongqing. Compared to previous studies on GPs in China prior to the COVID-19 pandemic, our findings revealed a greater rate of turnover intention than that reported among national GPs in China (71.1%)[46], GPs in the western region of China (2.47 ± 0.73)[47], and rural doctors in grassroots areas of Chongqing (42.3%)[15]. It is important to consider that the results may vary depending on the research time, sample size and measurement scale.
It has been reported that healthcare workers are facing significant work and mental pressure during the COVID-19 period due to fear and anxiety of contracting the novel coronavirus, as well as an increased workload and working hours [9, 46]. A review of the mental health of GPs during this period revealed that they experienced high stress levels and faced adverse health conditions such as headache, sleep disorders, and fatigue. Some GPs even considered leaving their practice due to anxiety about the risk of COVID-19 infection[49]. In addition, a study conducted in 41 tertiary hospitals in China during the COVID-19 epidemic aimed to investigate turnover intention and associated factors among psychiatrists[16]. The study revealed that heavy workloads, participation in frontline efforts against COVID-19, and insomnia were the primary factors influencing turnover intention. The GPs in this study also faced similar pressures and poor health conditions, which may have contributed to greater turnover intention in these periods than in previous periods. This situation will further exacerbate the scarcity of GP resources in China; greater attention should be devoted to this group, along with strategies sought for mitigating their turnover intention. Additionally, we identified several representative factors significantly associated with increased turnover intention among GPs that can serve as references for targeted interventions.
Predictors of turnover intention
The results of the regression analysis revealed a negative correlation between job satisfaction and turnover intention among GPs, indicating that individuals with lower job satisfaction are more likely to have greater turnover intention. Previous studies have consistently highlighted the significant influence of job satisfaction on turnover intention among GPs in China[20, 48], and our research findings further support this well-established relationship. Notably, Chinese GPs generally experience low levels of job satisfaction, particularly concerning dissatisfaction with income[15, 49]. Based on our study's results, it is evident that GPs express the least amount of contentment regarding their income level, the organizational benefits provided by their employers, and opportunities for career advancement. Consequently, there is an urgent need to increase remuneration and benefits for GPs while simultaneously providing more opportunities for career advancement and progression, which can enhance GPs' job satisfaction and mitigate their turnover intention. Therefore, it is imperative to enhance remuneration, benefits, and career progression opportunities for general practitioners. During the COVID-19 pandemic, there has been a continuous surge in workload, intensity, and occupational hazards faced by general practitioners. Consequently, it becomes even more crucial to establish a more equitable and just system for salary distribution and promotion while strategically planning professional growth. This approach will not only augment the appeal and job satisfaction of GPs but also mitigate their turnover intention.
Additionally, workplace violence emerges as a significant predictor of turnover intention, indicating that encountering workplace violence leads to greater turnover intention among GPs, which aligns with previous empirical findings[53, 54]. On the one hand, GPs who are subjected to workplace violence experience a lack of trust and disapproval from patients and their families, which can lead to diminished self-worth and reduced expectations for the doctor‒patient relationship. On the other hand, employees exposed to such violence may experience detrimental psychological conditions, including fear, anxiety, depression, insomnia, posttraumatic stress disorder (PTSD), and even suicidal tendencies[55, 56]. According to the conservation of resources theory[57], this decline in self-worth and adverse psychological state represents a depletion of resources for GPs, consequently motivating them to opt for leaving as a means to mitigate these losses. Particularly during the COVID-19 pandemic, when GPs faced unprecedented work intensity along with substantial infection risks, instances of violence from patients and their families could exacerbate feelings of work-related distress among GPs while also instilling doubts regarding the value associated with their profession—ultimately increasing their likelihood of turnover intention. Therefore, hospital management departments should prioritize the job security of GPs, implement stronger measures to prevent workplace violence, and establish a safe working environment for them.
Our study also revealed that certain personal and job characteristics significantly influence GP turnover intention. Male GPs had a greater rate of turnover intention than female GPs did, which is consistent with the findings of previous studies[47]. This may be attributed to the traditional notion that men are expected to be breadwinners and provide for their families, as well as to have greater financial pressure, achievement motivation, and an adventurous spirit than women[58]. Furthermore, we found that individuals with a bachelor's degree are more likely to leave their job than are those with a specialist degree. The reason may be that more highly educated individuals have higher income expectations and greater career opportunities[4]. Younger age is positively associated with greater turnover intention, which may be attributed to factors such as lower income, limited career development opportunities such as training and promotion, and a wider range of job options available15]. We also found that those with high professional titles who also take on managerial roles had greater turnover intentions. Individuals with high professional titles often bear management responsibilities and hold positions of greater professional status. This implies facing heavier workloads and pressures[59]. Moreover, professionals in higher positions and those who undertake managerial responsibilities on a part-time basis typically possess strong professional capabilities, exhibit high overall qualities and may have greater career aspirations, making it easier for them to obtain more job opportunities[60]. Additionally, turnover intention is greater among temporary employees, which is consistent with the findings of previous research44]. This could be attributed to lower income and welfare benefits, as well as limited opportunities for career advancement[61]. Moreover, an increase in weekly working hours positively correlates with turnover intention, indicating a current shortage of manpower in primary healthcare. Prolonged working hours may lead to fatigue, tension, and burnout[62], which are also indirectly associated with insomnia, anxiety, depression, and other related factors[16], thereby influencing turnover intention.
Notably, our study did not uncover a significant predictive effect of perceived overqualification on turnover intention. This finding contradicts the findings of previous research, which has demonstrated a positive predictive effect of perceived overqualification on employees' turnover intention[39, 41, 63]. One possible explanation for this discrepancy is that perceived overqualification may not directly predict turnover intention; rather, it might indirectly influence turnover intention through mediating variables. Prior studies have suggested that empowering individuals with a perceived surplus of qualifications mitigates the previously observed positive correlation between perceived overqualification and turnover intention[37]. Regrettably, this study did not account for these mediating variables. Moreover, previous research has shown a negative association between perceived overqualification and job satisfaction[60]. Considering the established link between job satisfaction and turnover intention, we hypothesize that the relationship between perceived overqualification and turnover intention in this study may be mediated by job satisfaction. Furthermore, although the scale employed in this study demonstrated high reliability and validity, it should be acknowledged that it is a translated version lacking localization adjustments, which may introduce potential inaccuracies into our research findings. Future endeavors should prioritize enhancing the cultural adaptation of the scale and conducting more comprehensive investigations.
Limitations
This study has several limitations. First, as a cross-sectional study, it precludes the establishment of causal relationships between variables. Second, the use of random sampling may impact the representativeness of our research findings; however, we ensured that the questionnaire included questions from all districts and counties where GPs are located to enhance representation. The data analysis indicated that GPs are distributed throughout Chongqing, which reasonably ensures sample representativeness. Furthermore, self-administered questionnaires were administered to participants, potentially introducing memory bias and social desirability bias; nevertheless, we aimed to mitigate these biases through well-designed questionnaires and anonymous responses. Additionally, our questionnaire did not include items related to COVID-19 or fully encompass other potential factors. Finally, our data are limited to one region of the country; thus, generalizability may be restricted.