我国五省基层卫生人员离职意愿和工作意愿及其影响因素研究
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摘要
研究背景
基层卫生人员是卫生服务的直接提供者,其数量和质量直接决定着城乡基层卫生服务提供的数量、质量和效果。近年来,我国基层卫生人员的学历结构和职称结构都有一定程度的改善。然而,基层卫生人员学历层次和技术职称水平依然较低,高层次人员比例仍非常低,这大大限制了基层卫生服务提供的质量。而基层卫生服务机构人才招募难、留用难是其中重要的原因：一方面,流入不畅,高层次人才不愿到基层工作；另一方面,流失较多,基层卫生技术人才队伍不稳定。研究显示,从基层卫生服务机构流出的人员多为较高学历、职称的卫生技术人员。因此,如何稳定城乡基层卫生队伍,缓解城乡基层卫生服务机构人才招募难、留用难的问题,对提高基层卫生人员学历和职称水平,改善基层卫生服务质量意义重大。
针对城乡基层卫生服务人力资源存在的招募难、留用难的问题,国内学者开展了比较多的研究。其中,大部分研究主要是对城乡基层卫生服务人力资源现状的描述,并针对发现的问题提出政策建议；有对基层卫生人员激励机制的研究,分析其工作动力和积极性的影响因素；还有研究关注了基层卫生人员的离职意愿或工作意愿,但是这类研究非常少。现有研究存在一些不足：(1)对城乡基层卫生服务人力资源现状的描述,只能发现存在的问题,无法发现深层次的原因并提出有针对性的建议;(2)对基层卫生人员激励机制的研究出发点多是如何激发卫生服务人员的工作热情和积极性,提高卫生服务的效率,对稳定基层卫生人员队伍的借鉴意义不太明显；(3)对基层卫生人员满意度等工作相关的态度的研究,多是对某一项工作态度及其影响因素的研究,缺乏对工作压力、工作倦怠、工作满意度等工作态度及其内部联系的系统研究,不利于发现深层次的问题；(4)国内目前对基层卫生人员离职意愿、工作意愿的研究较少,并且多是简单的描述以及单因素、多因素分析。
本研究在相关研究的基础上,利用结构方程模型对工作相关态度和离职意愿之间内部作用关系进行了分析,构建了其内在作用机制,对系统了解基层卫生人员的离职意愿、提出解决对策具有重要价值。同时,本研究采用离散选择实验的方法研究基层卫生人员的工作意愿,国内外的相关研究很少,具有重要的学术和现实意义。
研究目的
本研究的总体目标是系统研究基层卫生人员的离职意愿与工作意愿,并分析其影响因素,为稳定基层卫生人员队伍提供政策建议。具体研究目的包括：(1)描述基层卫生人员的个人基本情况及工作中面临的问题；(2)分析基层卫生人员工作压力、工作倦怠、工作满意度等工作相关的态度及其影响因素；(3)分析基层卫生人员离职意愿及其影响因素,探讨工作压力、工作倦怠、工作满意度与离职意愿的作用路径,构建基层卫生人员离职意愿的结构方程模型；(4)分析基层卫生人员的工作意愿及其影响因素；(5)提出改善城乡基层卫生服务机构、稳定基层卫生人员队伍的政策建议。
研究对象与方法
本研究的资料来源于国家自然科学基金“公共卫生技术人员行为、支付方式和产出研究”支持的调查数据。采用分层随机整群抽样的方式进行抽样,参考地理位置和经济发展水平,选择了吉林、山东、安徽、陕西、重庆5个省／直辖市,总共调查社区卫生服务人员308人和乡镇卫生院人员403人,所调查人员中包括医生、护士和防保人员。
本研究的调查内容主要包括人员的个人属性(与人员自身相关的人口统计学因素,具体有性别、年龄等变量)、人员的工作属性(与人员当前工作相关的因素,具体有平均月收入、有无养老保险、生活便利程度、单位工作条件等变量)、工作压力、工作倦怠、工作满意度、离职意愿和工作意愿。
数据分析方法包括采用描述性统计分析描述了基层卫生人员个人属性、工作属性、工作压力、工作倦怠、工作满意度、离职意愿的基本情况；采用了单因素分析用于比较不同个人属性、工作属性的基层卫生人员在工作压力、工作倦怠、工作满意度及离职意愿的差异；采用多元线性回归分析的方法分析基层卫生人员工作压力、工作倦怠、工作满意度以及离职意愿的影响因素；采用结构方程模型的方法,在同一个模型框架内构建和检验基层卫生人员工作压力、工作倦怠、工作满意度和离职意愿之间的结构关系；对基层卫生人员工作意愿的研究则采用离散选择实验的方法。
本研究主要采用Stata12.0进行数据的分析,具体包括描述性统计分析、单因素分析、多元线性回归分析、探索性因子分析、离散选择实验分析。采用Amosl7.0进行结构方程模型的分析。
主要研究结果
(1)基层卫生人员学历和职称水平仍然偏低：与以往研究的发现相同,参与本次研究的基层卫生人员学历和职称水平也不高,职称以初级及以下为主(64.12%),副高与高级职称人数占比不足10%；文化程度以大专及以下为主,本科及以上学历人数不足20%。
(2)基层卫生人员面临着收入待遇差、工作量大、培训和职业发展机会少等突出问题：基层卫生人员的收入和福利待遇方面还比较差。参与本次研究的基层卫生人员平均月收入约为1900元；约有半数基层卫生人员没有养老保险,其中乡镇卫生院中有约65%的人员没有养老保险。工作量方面,超过60%的人员认为自己工作量比较多或非常多,几乎没有人员认为自己工作量较少或很少。基层卫生人员的培训机会及职业发展机会仍然较少。有约60%的基层卫生人员认为培训机会较少或很少,仅有约10%的人员认为培训机会较多或很多；有超过半数的人员认为职业发展机会较少或很少。
(3)基层卫生人员的工作压力和工作倦怠：基层卫生人员感到工作压力较大或很大的比例较高,有接近10%感到压力非常大,接近40%感到压力较大,城乡两类机构人员间无显著差异。工作倦怠三个维度分别为情绪耗竭、去人格化倾向、成就感低落,城乡两类机构人员的工作倦怠各维度无显著差异。群众的认可与尊重程度、工作量、生活便利程度是影响基层卫生人员工作压力和工作倦怠的主要因素。
(4)基层卫生人员工作满意度：从满意度各条目来看,基层卫生人员对单位人际关系和群众认可与尊重的满意度最高,而对收入水平、福利状况的满意度最低。从满意度的三个维度来看,基层卫生人员的关系满意度最高,其次为成长满意度,对物质条件的满意度最低,城乡两类机构人员的在三个维度的满意度无显著差异。
(5)基层卫生人员离职意愿：基层卫生人员中有约半数表示不太想要或很不想要离开目前的工作,约1/3的人员表示有些想要或非常想要离开目前的工作,城乡两类机构人员的离职意愿分布情况存在统计学差异,乡镇卫生院人员表示想要离开目前工作的比例高于社区卫生服务机构人员。年龄在30到50岁之间的人员离职意愿最高,而50岁及以上人员的离职意愿最低；职称较高(副高及以上)和学历较高(本科及以上)的人员离职意愿较高。基层卫生人员的离职意愿与其工作压力、工作倦怠均呈现正向相关,与工作满意度呈现负向相关。在控制了个人及工作属性之后,工作压力、工作倦怠中的情绪耗竭、工作满意度对基层卫生人员的离职意愿都具有显著影响。基层卫生人员工作倦怠在工作压力对工作满意度的影响中起中介作用,基层卫生人员的工作满意度在工作倦怠对离职意愿的影响中起中介作用。
(6)基层卫生人员工作意愿：纳入研究的六项工作属性对基层卫生人员的工作选择均具有显著性影响,即基层卫生人员在选择一项工作时,会考虑包括收入、福利、工作条件、居民的认可和尊重、培训机会和职业发展机会等工作属性,并且这些属性的情况会决定基层卫生人员是否会选择该项工作。除收入外,群众的认可与尊重程度、单位福利状况、单位工作条件都是影响基层卫生人员工作意愿的重要因素,培训机会及职业发展机会对基层卫生人员工作意愿的影响较低。
结论与政策建议
基层卫生人员学历和职称水平仍然较低,同时基层卫生人员还面临着工资和待遇较低、工作量大、培训机会和职业发展机会少等突出问题。
基层卫生人员面临的工作压力较大,群众的认可与尊重程度、工作量和生活便利程度是影响基层卫生人员工作压力和工作倦怠的主要因素。另外,基层卫生人员的对关系的满意度最高,其次为成长满意度,对物质条件的满意度最低。研究还发现,基层卫生人员中有约1/3的人员表示有些想要或非常想要离开目前的工作,可见当前基层卫生人员还有相当的潜在不稳定性。而且基层卫生人员中有离职意愿的多是年富力强、学历和职称较高的人员,这一部分人如果离职,将会给城乡基层卫生服务机构带来很大的人才损失。工作压力、工作倦怠、工作满意度与离职意愿之间有着紧密的联系,工作满意度是离职意愿的直接前因变量；工作倦怠既对离职意愿有直接影响,同时还通过工作满意度这一中介变量影响离职意愿；工作压力对离职意愿也具有直接影响,同时通过工作倦怠、工作满意度的中介效应影响离职意愿。
基层卫生人员在选择一项工作时,并不是仅仅看重收入、福利等经济因素,同时还会考虑包括工作条件、居民的认可和尊重、培训机会和职业发展机会等工作属性,并且会在这些属性之间进行权衡以做出最终的决定。群众的认可与尊重程度、单位福利状况、单位工作条件都是影响基层卫生人员工作意愿的重要因素。
基于以上结论,为稳定城乡基层卫生队伍,缓解城乡卫生服务机构人才招募难、留用难的问题,提出如下的政策建议：(1)卫生投入应该优先用于提高城乡基层卫生人员的收入水平、福利保障,对于解决基层卫生人员的生存需要、稳定基层卫生队伍至关重要；(2)城乡基层卫生服务机构应努力为基层卫生人员提供便利的生活条件,如建设员工休息住所、职工食堂、增设交通班车等；(3)为适当减轻基层卫生人员工作量,政策制定者应评估基层卫生人员开展基本公共卫生服务的能力,合理分配其他卫生服务机构(如疾控中心、结防所等)开展相应服务；(4)政策制定者应努力提高基层卫生机构和人员卫生服务提供的能力和质量,包括改善基层卫生机构基本设施和设备配备、改善基层卫生人员的培训机会等,从而提升患者对基层卫生机构和人员的信任,改善群众的认可与尊重程度；(5)政策制定者应该制定符合基层卫生人员的职称晋升等职业发展政策。
创新与不足
本研究的创新之处：(1)本研究以城乡基层卫生人员的稳定为出发点,系统和全面研究了其离职意愿和工作意愿,在国内尚未发现类似研究；(2)本研究通过结构方程模型构建了基层卫生人员离职意愿的结构框架,对深入理解基层卫生人员离职意愿的产生机制有重要意义；(3)本研究运用离散选择实验的方法调查和分析了基层卫生人员的工作意愿,可以弥补传统调查方法的不足,目前类似研究在国内比较少见。
本研究的不足之处与研究展望：(1)本研究对工作压力以及离职意愿的调查均采用单一问题,容易造成结果的不稳定性,在未来的研究中可以根据相关理论,选用多个问题从不同角度对其进行调查,提高结果的可靠性；(2)由于离散选择实验方法本身的局限性,本研究在研究基层卫生人员工作意愿时只纳入了6个最为重要的工作属性,无法反映其他工作属性对工作意愿的影响。同时,由于离散选择实验调查的是卫生服务人员的工作意愿,而非实际做出的工作选择,将来的研究可以比较研究结果与卫生服务人员实际的工作选择是否一致。
Background
Primary health workers are direct providers of health services. Thus, their quantity and competency directly decide the quantity, quality and outcomes of primary health services. In recent years, the overall educational level and professional title of primary health workers in China have improved. However, the overall competency of primary health workers in China is still at a low level. The small proportion of primary health workers who are well-educated and have relatively high professional title greatly limits the quality of primary health services. One of the major causes that lead to this situation is that primary health institutions have their difficulties in recruiting and retaining primary health workers with high competency. On one hand, students from medical schools are not willing to work in primary health institutions. On the other hand, primary health workers are not stable. Research shows that those primary health workers who leave primary health institutions tend to be more experienced and qualified. As a consequence, stabilizing primary health workers and alleviating primary health institutions'difficulties in recruiting and retaining qualified primary health workers are of great significance to improve the overall competency of primary health workers and to improve the quality of primary health services.
Facing the problem that primary health institutions have difficulties in recruiting and retaining qualified primary health workers, researchers have conducted plenty of relative studies. Most of these studies are descriptive studies about human resources of primary health. There are also studies on incentive mechanisms and work-related attitudes of primary health workers. Few studies are found which focused on turnover intention and job preferences of primary health workers. There are some limitations of existing studies:Firstly, those descriptive studies about human resources of primary health can only find existing problems, but they are unable to find insightful reasons and thus can not give specific suggestions. Secondly, the aim of those studies on incentive mechanisms of primary health workers is to find an effective way to motivate their passion and enthusiasm, and to improve the efficiency of health services. Thus the findings of these studies are not so relevant on consideration of stabilizing primary health workers. Thirdly, most of the studies on primary health workers'work-related attitudes, such as job pressure, job burnout and job satisfaction, are focused on one attitude and its influencing factors. Systematic studies on work-related attitudes and their relationships are scarce. Last but not least, studies on turnover intention and job preferences of primary health workers are also scarce. The study methods of existing studies are traditional methods, such as descriptive study, univariate analysis and multivariate analysis.
Based on existing relative studies, this study analysed the relationship among work-related attitudes and turnover intention of primary health workers in China. This study used structural equation model to establish the internal mechanism of turnover intention and work-related attitudes. Thus, the findings of this study are valuable to understand primary health workers'turnover intention and to propose effective solutions. Moreover, this study used discrete choice experiment to analyse primary health workers' job preferences. Relative studies both at home and abroad are scarce. Thus, this study has both academic significance and practical significance.
Objectives
The overall objective of this study is to systematically analyse primary health workers' turnover intention and job preferences and their influencing factors, offering policy recommendations on stabilizing primary health workers. Specifically, the research objectives of this study include:to describe primary health workers'basic information and work-related problems; to analyse primary health workers'job pressure, job burnout, job satisfaction and their influencing factors; to analyse primary health workers'turnover intention and its influencing factors, to explore the internal mechanism of turnover intention and work-related attitudes, and to establish structural equation model of primary health workers'turnover intention; to analyse primary health workers'job preferences and its influencing factors; to propose policy recommendations on improving primary health institutions and stabilizing primary health workers.
Data and Methods
The data of this study are derived from the project "Study on Public Health Workers' Behavior, Payment and Outcomes" that was funded by National Natural Science Grant awarded by National Natural Science Foundation of China. This study used a multistage sampling design. First, five provinces, namely Jilin, Shandong, Anhui, Chongqing and Shaanxi were selected in consideration of geographical location and economic development. Then, within each province, one urban district and two rural counties were chosen based on the representativeness of their socioeconomic status and health care development. Finally,5community health organizations were chosen in each urban district and3township health centers were chosen in each rural county. All the doctors, nurses and public health workers were investigated in these institutions. The final sample consists of308primary health workers in community health organizations and403primary health workers in township health centers.
The major contents of the investigation of this study include:primary health workers' personal attributes (demographic factors such as gender, age), primary health workers' work attributes (work-related factors such as monthly income, living condition), primary health workers'job pressure, job burnout, job satisfaction, turnover intention and job preferences.
Data analysis methods consist of:descriptive analysis was used to analyse the basic information of primary health workers'personal attributes, work attributes, job pressure, job burnout, job satisfaction and turnover intention; univariate analysis was used to compare the differences of primary health workers'job pressure, job burnout, job satisfaction and turnover intention among different personal attributes and work attributes; multivariate analysis was used to analyse the influencing factors of primary health workers'job pressure, job burnout, job satisfaction and turnover intention; structural equation model was used to establish and verify the structural relationship among primary health workers' job pressure, job burnout, job satisfaction and turnover intention; discrete choice experiment was used to analyse primary health workers'job preferences.
Stata12.0was used to conduct most of the analysis in this study, including descriptive analysis, univariate analysis, multivariate analysis, exploratory factor analysis and discrete choice experiment analysis. Amos17.0was used to conduct structural equation model.
Results
(1) The overall competency of primary health workers was still low:Similar with the finding of relative studies, the educational level and professional title of the primary health workers that participated in this study were not high. The major proportion of primary health workers have a primary professional title (64.12%), no more than10%of primary health workers have an associate senior professional title or a senior professional title. In terms of educational level, the major proportion of primary health workers have college degrees or lower, while only around20%have bachelor degrees or higher.
(2) Primary health workers faced problems such as poor income and welfare benefit, heavy workload, poor opportunities for training and career development:Primary health workers' income and welfare benefit were rather poor. The average monthly income of the primary health workers that participated in this study was about1900
RMB; half of them did not have pension insurance,65%of primary health workers in township health centers had no pension insurance. In terms of workload, more than60%of primary health workers considered their workload as heavy or very heavy, hardly any primary health workers thought their workload as light. Opportunities for training and career development of primary health workers were also poor. About60%of primary health workers considered their opportunities for training as insufficient, only10%considered their opportunities for training as sufficient; more than half of primary health workers considered their opportunities for career development as insufficient.
(3) Primary health workers'job pressure and job burnout:The proportion of primary health workers who felt heavy job pressure was high, around10%felt fairly heavy pressure in work, while around40%felt heavy job pressure. The three dimensions of job burnout are emotional exhaustion, depersonalization and reduced personal accomplishment. There were no significant differences in job pressure and job burnout between primary health workers in community health organizations and township health centers. Respect from the community, workload and living conditions are the major influencing factors of primary health workers'job pressure and job burnout.
(4) Primary health workers'job satisfaction:From the11terms of job satisfaction, primary health workers'satisfaction on interpersonal relationships at work and respect from the community were the highest, and their satisfaction on salary and welfare benefit were the lowest. From the3dimensions of job satisfaction, primary health workers' satisfaction on relationship was the highest, followed by satisfaction on personal development, their satisfaction on basic needs was the lowest. There were no significant differences in job satisfaction between primary health workers in community health organizations and township health centers.
(5) Primary health workers'turnover intention:There were almost half of the primary health workers that participated in this study who did not want to leave their current jobs, about one third of them had turnover intention. There were significant differences in turnover intention between primary health workers in community health organizations and township health centers. The proportion of primary health workers who wanted to leave their current jobs in township health centers was higher than those in community health organizations. In terms of age, primary health workers older than30and younger than50had the highest turnover intention, and those older than50had the lowest turnover intention. Primary health workers with higher professional title (associate senior or higher) and higher educational level (bachelor degree or higher) had higher turnover intention. Primary health workers'turnover intention was positively correlative with their job pressure and job burnout, and was negatively correlative with their job satisfaction. Controlling for personal attributes and work attributes, primary health workers'job pressure, emotional exhaustion and job satisfaction affected their turnover intention significantly. Primary health workers' job burnout played as a mediator between job pressure and job satisfaction, and job satisfaction played as a mediator between job burnout and turnover intention.
(6) Primary health workers' job preferences:All the six job attributes that were included in this study significantly influenced primary health workers'job choices. In other words, primary health workers considered not only monetary factors but also nonmonetary factors such as working conditions and respect from the community when choosing a job. Other than salary, respect from the community, welfare benefit and working condition were major factors that influenced primary health workers'job preferences, the impact of opportunities for training and career development on primary health workers'job preferences were small.
Conclusions and Policy Implications
The overall competency of primary health workers are still low, and primary health workers confront problems such as poor income and welfare benefit, heavy workload, poor opportunities for training and career development.
Primary health workers'job pressure was at a high level, respect from the community, workload and living conditions were the major influencing factors of primary health workers'job pressure and job burnout. Moreover, primary health workers'satisfaction on relationship was the highest, their satisfaction on basic needs was the lowest. This study also found that about one third of primary health workers had turnover intention, which implied the potential instability of primary health workers. Besides, those who had turnover intention tended to be younger and more qualified. The relationship of job pressure, job burnout, job satisfaction and turnover intention are tight, job satisfaction is the direct antecedent variable of turnover intention; job burnout has both direct effect on turnover intention and indirect effect on turnover intention through job satisfaction; job pressure has both direct effect on turnover intention and indirect effect on turnover intention through job burnout and job satisfaction.
When choosing a job, primary health workers considered not only monetary factors but also nonmonetary factors such as working conditions and respect from the community. Respect from the community, welfare benefit and working condition were major factors that influenced primary health workers'job preferences.
The following policy implications can be drawn and proposed based on the findings of this study:(1) Improving primary health workers'income and welfare benefit should be the priority of health investments;(2) Primary health institutions should make efforts to offer primary health workers with convenient living condition, such as building staff lounge and staff canteen, launching staff bus and so on;(3) In order to lighten primary health workers'workload to an appropriate level, policy makers should assess primary health workers'competency of providing primary public health services and distribute some of the services to other related health institutions (such as center for disease control, tuberculosis dispensary and so on);(4) In order to increase patients'trust on primary health institutions and primary health workers, policy makers should try to improve the competency of primary health institutions and primary health workers, such as improving the infrastructure and equipment of primary health institutions, and improving primary health workers' opportunities for training;(5) Policy makers should also formulate policies on career development that are more suitable for primary health workers.
Innovations and Limitations
The innovations of this study:(1) This study laid the stability of primary health workers as the springboard, analysed primary health workers' turnover intention and job preferences systematically. No similar studies have been found;(2) This study established the structural framework of primary health workers' turnover intention using structural equation model, thus is of great importance to understand the generation mechanisms of primary health workers' turnover intention;(3) This study investigated and analysed primary health workers' job preferences using discrete choice experiment, thus can remedy the limitations of traditional methods. Similar studies are scarce.
The limitations of the research:(1) In this study, the investigation of job pressure and turnover intention both used single question, this may lead to instability of the results. Future studies can add investigation questions from different perspectives to improve reliability of the results;(2) Due to the limitation of discrete choice experiment, we included only6job attributes when analysing primary health workers' job preferences, as a result, we are unable to know the effects of other job attributes on job preferences. Meanwhile, as with all stated preference studies, the job choices we presented to the respondents were hypothetical, and further research needs to compare these results with results based on actual behavior.
基层卫生人员是卫生服务的直接提供者,其数量和质量直接决定着城乡基层卫生服务提供的数量、质量和效果。近年来,我国基层卫生人员的学历结构和职称结构都有一定程度的改善。然而,基层卫生人员学历层次和技术职称水平依然较低,高层次人员比例仍非常低,这大大限制了基层卫生服务提供的质量。而基层卫生服务机构人才招募难、留用难是其中重要的原因：一方面,流入不畅,高层次人才不愿到基层工作；另一方面,流失较多,基层卫生技术人才队伍不稳定。研究显示,从基层卫生服务机构流出的人员多为较高学历、职称的卫生技术人员。因此,如何稳定城乡基层卫生队伍,缓解城乡基层卫生服务机构人才招募难、留用难的问题,对提高基层卫生人员学历和职称水平,改善基层卫生服务质量意义重大。
针对城乡基层卫生服务人力资源存在的招募难、留用难的问题,国内学者开展了比较多的研究。其中,大部分研究主要是对城乡基层卫生服务人力资源现状的描述,并针对发现的问题提出政策建议；有对基层卫生人员激励机制的研究,分析其工作动力和积极性的影响因素；还有研究关注了基层卫生人员的离职意愿或工作意愿,但是这类研究非常少。现有研究存在一些不足：(1)对城乡基层卫生服务人力资源现状的描述,只能发现存在的问题,无法发现深层次的原因并提出有针对性的建议;(2)对基层卫生人员激励机制的研究出发点多是如何激发卫生服务人员的工作热情和积极性,提高卫生服务的效率,对稳定基层卫生人员队伍的借鉴意义不太明显；(3)对基层卫生人员满意度等工作相关的态度的研究,多是对某一项工作态度及其影响因素的研究,缺乏对工作压力、工作倦怠、工作满意度等工作态度及其内部联系的系统研究,不利于发现深层次的问题；(4)国内目前对基层卫生人员离职意愿、工作意愿的研究较少,并且多是简单的描述以及单因素、多因素分析。
本研究在相关研究的基础上,利用结构方程模型对工作相关态度和离职意愿之间内部作用关系进行了分析,构建了其内在作用机制,对系统了解基层卫生人员的离职意愿、提出解决对策具有重要价值。同时,本研究采用离散选择实验的方法研究基层卫生人员的工作意愿,国内外的相关研究很少,具有重要的学术和现实意义。
研究目的
本研究的总体目标是系统研究基层卫生人员的离职意愿与工作意愿,并分析其影响因素,为稳定基层卫生人员队伍提供政策建议。具体研究目的包括：(1)描述基层卫生人员的个人基本情况及工作中面临的问题；(2)分析基层卫生人员工作压力、工作倦怠、工作满意度等工作相关的态度及其影响因素；(3)分析基层卫生人员离职意愿及其影响因素,探讨工作压力、工作倦怠、工作满意度与离职意愿的作用路径,构建基层卫生人员离职意愿的结构方程模型；(4)分析基层卫生人员的工作意愿及其影响因素；(5)提出改善城乡基层卫生服务机构、稳定基层卫生人员队伍的政策建议。
研究对象与方法
本研究的资料来源于国家自然科学基金“公共卫生技术人员行为、支付方式和产出研究”支持的调查数据。采用分层随机整群抽样的方式进行抽样,参考地理位置和经济发展水平,选择了吉林、山东、安徽、陕西、重庆5个省／直辖市,总共调查社区卫生服务人员308人和乡镇卫生院人员403人,所调查人员中包括医生、护士和防保人员。
本研究的调查内容主要包括人员的个人属性(与人员自身相关的人口统计学因素,具体有性别、年龄等变量)、人员的工作属性(与人员当前工作相关的因素,具体有平均月收入、有无养老保险、生活便利程度、单位工作条件等变量)、工作压力、工作倦怠、工作满意度、离职意愿和工作意愿。
数据分析方法包括采用描述性统计分析描述了基层卫生人员个人属性、工作属性、工作压力、工作倦怠、工作满意度、离职意愿的基本情况；采用了单因素分析用于比较不同个人属性、工作属性的基层卫生人员在工作压力、工作倦怠、工作满意度及离职意愿的差异；采用多元线性回归分析的方法分析基层卫生人员工作压力、工作倦怠、工作满意度以及离职意愿的影响因素；采用结构方程模型的方法,在同一个模型框架内构建和检验基层卫生人员工作压力、工作倦怠、工作满意度和离职意愿之间的结构关系；对基层卫生人员工作意愿的研究则采用离散选择实验的方法。
本研究主要采用Stata12.0进行数据的分析,具体包括描述性统计分析、单因素分析、多元线性回归分析、探索性因子分析、离散选择实验分析。采用Amosl7.0进行结构方程模型的分析。
主要研究结果
(1)基层卫生人员学历和职称水平仍然偏低：与以往研究的发现相同,参与本次研究的基层卫生人员学历和职称水平也不高,职称以初级及以下为主(64.12%),副高与高级职称人数占比不足10%；文化程度以大专及以下为主,本科及以上学历人数不足20%。
(2)基层卫生人员面临着收入待遇差、工作量大、培训和职业发展机会少等突出问题：基层卫生人员的收入和福利待遇方面还比较差。参与本次研究的基层卫生人员平均月收入约为1900元；约有半数基层卫生人员没有养老保险,其中乡镇卫生院中有约65%的人员没有养老保险。工作量方面,超过60%的人员认为自己工作量比较多或非常多,几乎没有人员认为自己工作量较少或很少。基层卫生人员的培训机会及职业发展机会仍然较少。有约60%的基层卫生人员认为培训机会较少或很少,仅有约10%的人员认为培训机会较多或很多；有超过半数的人员认为职业发展机会较少或很少。
(3)基层卫生人员的工作压力和工作倦怠：基层卫生人员感到工作压力较大或很大的比例较高,有接近10%感到压力非常大,接近40%感到压力较大,城乡两类机构人员间无显著差异。工作倦怠三个维度分别为情绪耗竭、去人格化倾向、成就感低落,城乡两类机构人员的工作倦怠各维度无显著差异。群众的认可与尊重程度、工作量、生活便利程度是影响基层卫生人员工作压力和工作倦怠的主要因素。
(4)基层卫生人员工作满意度：从满意度各条目来看,基层卫生人员对单位人际关系和群众认可与尊重的满意度最高,而对收入水平、福利状况的满意度最低。从满意度的三个维度来看,基层卫生人员的关系满意度最高,其次为成长满意度,对物质条件的满意度最低,城乡两类机构人员的在三个维度的满意度无显著差异。
(5)基层卫生人员离职意愿：基层卫生人员中有约半数表示不太想要或很不想要离开目前的工作,约1/3的人员表示有些想要或非常想要离开目前的工作,城乡两类机构人员的离职意愿分布情况存在统计学差异,乡镇卫生院人员表示想要离开目前工作的比例高于社区卫生服务机构人员。年龄在30到50岁之间的人员离职意愿最高,而50岁及以上人员的离职意愿最低；职称较高(副高及以上)和学历较高(本科及以上)的人员离职意愿较高。基层卫生人员的离职意愿与其工作压力、工作倦怠均呈现正向相关,与工作满意度呈现负向相关。在控制了个人及工作属性之后,工作压力、工作倦怠中的情绪耗竭、工作满意度对基层卫生人员的离职意愿都具有显著影响。基层卫生人员工作倦怠在工作压力对工作满意度的影响中起中介作用,基层卫生人员的工作满意度在工作倦怠对离职意愿的影响中起中介作用。
(6)基层卫生人员工作意愿：纳入研究的六项工作属性对基层卫生人员的工作选择均具有显著性影响,即基层卫生人员在选择一项工作时,会考虑包括收入、福利、工作条件、居民的认可和尊重、培训机会和职业发展机会等工作属性,并且这些属性的情况会决定基层卫生人员是否会选择该项工作。除收入外,群众的认可与尊重程度、单位福利状况、单位工作条件都是影响基层卫生人员工作意愿的重要因素,培训机会及职业发展机会对基层卫生人员工作意愿的影响较低。
结论与政策建议
基层卫生人员学历和职称水平仍然较低,同时基层卫生人员还面临着工资和待遇较低、工作量大、培训机会和职业发展机会少等突出问题。
基层卫生人员面临的工作压力较大,群众的认可与尊重程度、工作量和生活便利程度是影响基层卫生人员工作压力和工作倦怠的主要因素。另外,基层卫生人员的对关系的满意度最高,其次为成长满意度,对物质条件的满意度最低。研究还发现,基层卫生人员中有约1/3的人员表示有些想要或非常想要离开目前的工作,可见当前基层卫生人员还有相当的潜在不稳定性。而且基层卫生人员中有离职意愿的多是年富力强、学历和职称较高的人员,这一部分人如果离职,将会给城乡基层卫生服务机构带来很大的人才损失。工作压力、工作倦怠、工作满意度与离职意愿之间有着紧密的联系,工作满意度是离职意愿的直接前因变量；工作倦怠既对离职意愿有直接影响,同时还通过工作满意度这一中介变量影响离职意愿；工作压力对离职意愿也具有直接影响,同时通过工作倦怠、工作满意度的中介效应影响离职意愿。
基层卫生人员在选择一项工作时,并不是仅仅看重收入、福利等经济因素,同时还会考虑包括工作条件、居民的认可和尊重、培训机会和职业发展机会等工作属性,并且会在这些属性之间进行权衡以做出最终的决定。群众的认可与尊重程度、单位福利状况、单位工作条件都是影响基层卫生人员工作意愿的重要因素。
基于以上结论,为稳定城乡基层卫生队伍,缓解城乡卫生服务机构人才招募难、留用难的问题,提出如下的政策建议：(1)卫生投入应该优先用于提高城乡基层卫生人员的收入水平、福利保障,对于解决基层卫生人员的生存需要、稳定基层卫生队伍至关重要；(2)城乡基层卫生服务机构应努力为基层卫生人员提供便利的生活条件,如建设员工休息住所、职工食堂、增设交通班车等；(3)为适当减轻基层卫生人员工作量,政策制定者应评估基层卫生人员开展基本公共卫生服务的能力,合理分配其他卫生服务机构(如疾控中心、结防所等)开展相应服务；(4)政策制定者应努力提高基层卫生机构和人员卫生服务提供的能力和质量,包括改善基层卫生机构基本设施和设备配备、改善基层卫生人员的培训机会等,从而提升患者对基层卫生机构和人员的信任,改善群众的认可与尊重程度；(5)政策制定者应该制定符合基层卫生人员的职称晋升等职业发展政策。
创新与不足
本研究的创新之处：(1)本研究以城乡基层卫生人员的稳定为出发点,系统和全面研究了其离职意愿和工作意愿,在国内尚未发现类似研究；(2)本研究通过结构方程模型构建了基层卫生人员离职意愿的结构框架,对深入理解基层卫生人员离职意愿的产生机制有重要意义；(3)本研究运用离散选择实验的方法调查和分析了基层卫生人员的工作意愿,可以弥补传统调查方法的不足,目前类似研究在国内比较少见。
本研究的不足之处与研究展望：(1)本研究对工作压力以及离职意愿的调查均采用单一问题,容易造成结果的不稳定性,在未来的研究中可以根据相关理论,选用多个问题从不同角度对其进行调查,提高结果的可靠性；(2)由于离散选择实验方法本身的局限性,本研究在研究基层卫生人员工作意愿时只纳入了6个最为重要的工作属性,无法反映其他工作属性对工作意愿的影响。同时,由于离散选择实验调查的是卫生服务人员的工作意愿,而非实际做出的工作选择,将来的研究可以比较研究结果与卫生服务人员实际的工作选择是否一致。
Background
Primary health workers are direct providers of health services. Thus, their quantity and competency directly decide the quantity, quality and outcomes of primary health services. In recent years, the overall educational level and professional title of primary health workers in China have improved. However, the overall competency of primary health workers in China is still at a low level. The small proportion of primary health workers who are well-educated and have relatively high professional title greatly limits the quality of primary health services. One of the major causes that lead to this situation is that primary health institutions have their difficulties in recruiting and retaining primary health workers with high competency. On one hand, students from medical schools are not willing to work in primary health institutions. On the other hand, primary health workers are not stable. Research shows that those primary health workers who leave primary health institutions tend to be more experienced and qualified. As a consequence, stabilizing primary health workers and alleviating primary health institutions'difficulties in recruiting and retaining qualified primary health workers are of great significance to improve the overall competency of primary health workers and to improve the quality of primary health services.
Facing the problem that primary health institutions have difficulties in recruiting and retaining qualified primary health workers, researchers have conducted plenty of relative studies. Most of these studies are descriptive studies about human resources of primary health. There are also studies on incentive mechanisms and work-related attitudes of primary health workers. Few studies are found which focused on turnover intention and job preferences of primary health workers. There are some limitations of existing studies:Firstly, those descriptive studies about human resources of primary health can only find existing problems, but they are unable to find insightful reasons and thus can not give specific suggestions. Secondly, the aim of those studies on incentive mechanisms of primary health workers is to find an effective way to motivate their passion and enthusiasm, and to improve the efficiency of health services. Thus the findings of these studies are not so relevant on consideration of stabilizing primary health workers. Thirdly, most of the studies on primary health workers'work-related attitudes, such as job pressure, job burnout and job satisfaction, are focused on one attitude and its influencing factors. Systematic studies on work-related attitudes and their relationships are scarce. Last but not least, studies on turnover intention and job preferences of primary health workers are also scarce. The study methods of existing studies are traditional methods, such as descriptive study, univariate analysis and multivariate analysis.
Based on existing relative studies, this study analysed the relationship among work-related attitudes and turnover intention of primary health workers in China. This study used structural equation model to establish the internal mechanism of turnover intention and work-related attitudes. Thus, the findings of this study are valuable to understand primary health workers'turnover intention and to propose effective solutions. Moreover, this study used discrete choice experiment to analyse primary health workers' job preferences. Relative studies both at home and abroad are scarce. Thus, this study has both academic significance and practical significance.
Objectives
The overall objective of this study is to systematically analyse primary health workers' turnover intention and job preferences and their influencing factors, offering policy recommendations on stabilizing primary health workers. Specifically, the research objectives of this study include:to describe primary health workers'basic information and work-related problems; to analyse primary health workers'job pressure, job burnout, job satisfaction and their influencing factors; to analyse primary health workers'turnover intention and its influencing factors, to explore the internal mechanism of turnover intention and work-related attitudes, and to establish structural equation model of primary health workers'turnover intention; to analyse primary health workers'job preferences and its influencing factors; to propose policy recommendations on improving primary health institutions and stabilizing primary health workers.
Data and Methods
The data of this study are derived from the project "Study on Public Health Workers' Behavior, Payment and Outcomes" that was funded by National Natural Science Grant awarded by National Natural Science Foundation of China. This study used a multistage sampling design. First, five provinces, namely Jilin, Shandong, Anhui, Chongqing and Shaanxi were selected in consideration of geographical location and economic development. Then, within each province, one urban district and two rural counties were chosen based on the representativeness of their socioeconomic status and health care development. Finally,5community health organizations were chosen in each urban district and3township health centers were chosen in each rural county. All the doctors, nurses and public health workers were investigated in these institutions. The final sample consists of308primary health workers in community health organizations and403primary health workers in township health centers.
The major contents of the investigation of this study include:primary health workers' personal attributes (demographic factors such as gender, age), primary health workers' work attributes (work-related factors such as monthly income, living condition), primary health workers'job pressure, job burnout, job satisfaction, turnover intention and job preferences.
Data analysis methods consist of:descriptive analysis was used to analyse the basic information of primary health workers'personal attributes, work attributes, job pressure, job burnout, job satisfaction and turnover intention; univariate analysis was used to compare the differences of primary health workers'job pressure, job burnout, job satisfaction and turnover intention among different personal attributes and work attributes; multivariate analysis was used to analyse the influencing factors of primary health workers'job pressure, job burnout, job satisfaction and turnover intention; structural equation model was used to establish and verify the structural relationship among primary health workers' job pressure, job burnout, job satisfaction and turnover intention; discrete choice experiment was used to analyse primary health workers'job preferences.
Stata12.0was used to conduct most of the analysis in this study, including descriptive analysis, univariate analysis, multivariate analysis, exploratory factor analysis and discrete choice experiment analysis. Amos17.0was used to conduct structural equation model.
Results
(1) The overall competency of primary health workers was still low:Similar with the finding of relative studies, the educational level and professional title of the primary health workers that participated in this study were not high. The major proportion of primary health workers have a primary professional title (64.12%), no more than10%of primary health workers have an associate senior professional title or a senior professional title. In terms of educational level, the major proportion of primary health workers have college degrees or lower, while only around20%have bachelor degrees or higher.
(2) Primary health workers faced problems such as poor income and welfare benefit, heavy workload, poor opportunities for training and career development:Primary health workers' income and welfare benefit were rather poor. The average monthly income of the primary health workers that participated in this study was about1900
RMB; half of them did not have pension insurance,65%of primary health workers in township health centers had no pension insurance. In terms of workload, more than60%of primary health workers considered their workload as heavy or very heavy, hardly any primary health workers thought their workload as light. Opportunities for training and career development of primary health workers were also poor. About60%of primary health workers considered their opportunities for training as insufficient, only10%considered their opportunities for training as sufficient; more than half of primary health workers considered their opportunities for career development as insufficient.
(3) Primary health workers'job pressure and job burnout:The proportion of primary health workers who felt heavy job pressure was high, around10%felt fairly heavy pressure in work, while around40%felt heavy job pressure. The three dimensions of job burnout are emotional exhaustion, depersonalization and reduced personal accomplishment. There were no significant differences in job pressure and job burnout between primary health workers in community health organizations and township health centers. Respect from the community, workload and living conditions are the major influencing factors of primary health workers'job pressure and job burnout.
(4) Primary health workers'job satisfaction:From the11terms of job satisfaction, primary health workers'satisfaction on interpersonal relationships at work and respect from the community were the highest, and their satisfaction on salary and welfare benefit were the lowest. From the3dimensions of job satisfaction, primary health workers' satisfaction on relationship was the highest, followed by satisfaction on personal development, their satisfaction on basic needs was the lowest. There were no significant differences in job satisfaction between primary health workers in community health organizations and township health centers.
(5) Primary health workers'turnover intention:There were almost half of the primary health workers that participated in this study who did not want to leave their current jobs, about one third of them had turnover intention. There were significant differences in turnover intention between primary health workers in community health organizations and township health centers. The proportion of primary health workers who wanted to leave their current jobs in township health centers was higher than those in community health organizations. In terms of age, primary health workers older than30and younger than50had the highest turnover intention, and those older than50had the lowest turnover intention. Primary health workers with higher professional title (associate senior or higher) and higher educational level (bachelor degree or higher) had higher turnover intention. Primary health workers'turnover intention was positively correlative with their job pressure and job burnout, and was negatively correlative with their job satisfaction. Controlling for personal attributes and work attributes, primary health workers'job pressure, emotional exhaustion and job satisfaction affected their turnover intention significantly. Primary health workers' job burnout played as a mediator between job pressure and job satisfaction, and job satisfaction played as a mediator between job burnout and turnover intention.
(6) Primary health workers' job preferences:All the six job attributes that were included in this study significantly influenced primary health workers'job choices. In other words, primary health workers considered not only monetary factors but also nonmonetary factors such as working conditions and respect from the community when choosing a job. Other than salary, respect from the community, welfare benefit and working condition were major factors that influenced primary health workers'job preferences, the impact of opportunities for training and career development on primary health workers'job preferences were small.
Conclusions and Policy Implications
The overall competency of primary health workers are still low, and primary health workers confront problems such as poor income and welfare benefit, heavy workload, poor opportunities for training and career development.
Primary health workers'job pressure was at a high level, respect from the community, workload and living conditions were the major influencing factors of primary health workers'job pressure and job burnout. Moreover, primary health workers'satisfaction on relationship was the highest, their satisfaction on basic needs was the lowest. This study also found that about one third of primary health workers had turnover intention, which implied the potential instability of primary health workers. Besides, those who had turnover intention tended to be younger and more qualified. The relationship of job pressure, job burnout, job satisfaction and turnover intention are tight, job satisfaction is the direct antecedent variable of turnover intention; job burnout has both direct effect on turnover intention and indirect effect on turnover intention through job satisfaction; job pressure has both direct effect on turnover intention and indirect effect on turnover intention through job burnout and job satisfaction.
When choosing a job, primary health workers considered not only monetary factors but also nonmonetary factors such as working conditions and respect from the community. Respect from the community, welfare benefit and working condition were major factors that influenced primary health workers'job preferences.
The following policy implications can be drawn and proposed based on the findings of this study:(1) Improving primary health workers'income and welfare benefit should be the priority of health investments;(2) Primary health institutions should make efforts to offer primary health workers with convenient living condition, such as building staff lounge and staff canteen, launching staff bus and so on;(3) In order to lighten primary health workers'workload to an appropriate level, policy makers should assess primary health workers'competency of providing primary public health services and distribute some of the services to other related health institutions (such as center for disease control, tuberculosis dispensary and so on);(4) In order to increase patients'trust on primary health institutions and primary health workers, policy makers should try to improve the competency of primary health institutions and primary health workers, such as improving the infrastructure and equipment of primary health institutions, and improving primary health workers' opportunities for training;(5) Policy makers should also formulate policies on career development that are more suitable for primary health workers.
Innovations and Limitations
The innovations of this study:(1) This study laid the stability of primary health workers as the springboard, analysed primary health workers' turnover intention and job preferences systematically. No similar studies have been found;(2) This study established the structural framework of primary health workers' turnover intention using structural equation model, thus is of great importance to understand the generation mechanisms of primary health workers' turnover intention;(3) This study investigated and analysed primary health workers' job preferences using discrete choice experiment, thus can remedy the limitations of traditional methods. Similar studies are scarce.
The limitations of the research:(1) In this study, the investigation of job pressure and turnover intention both used single question, this may lead to instability of the results. Future studies can add investigation questions from different perspectives to improve reliability of the results;(2) Due to the limitation of discrete choice experiment, we included only6job attributes when analysing primary health workers' job preferences, as a result, we are unable to know the effects of other job attributes on job preferences. Meanwhile, as with all stated preference studies, the job choices we presented to the respondents were hypothetical, and further research needs to compare these results with results based on actual behavior.
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