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| Journal of the New Zealand Medical Association,
26-July-2002, Vol 115 No 1158
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Morale in general practice: crisis and solutions
Anthony C Dowell, Gregor Coster, Charlotte Maffey.
There is international recognition of low morale and a state
of unhappiness among health professionals1. In
New Zealand general practice difficulties in recruitment and retention
particularly in rural areas2,3, have occurred
at the same time as erosion of incomes and increasing burdens of administration
and paperwork. These difficulties have been recorded in surveys of stress,
psychological symptoms and ‘burnout’. Although GPs may remain
satisfied with their jobs overall, work is perceived as affecting physical
health of nearly half of GPs, over half often contemplate leaving and one third
have a significant level of psychological
symptoms4.
The New Zealand situation is not unique, but the small size
of the available workforce tends to magnify the impact of problems. Similar
studies in the United Kingdom and Australia have also shown that stress levels
amongst GPs is significant5-7. In an Australian
study, 12.8% of respondents showed high levels of psychological symptoms and 53%
had considered leaving general practice because of occupational
stress7.
Although ‘stress’ and ‘morale’ are
terms that are commonly used together or even interchangeably, there are
important differences in their definition and meaning. Stress has been defined
as the ‘perceived inability to cope with demands’. Individual stress
levels are likely to vary with time and to react readily to changes in
circumstances.
Morale can be defined as a ‘feeling of confidence in
one’s situation with a positive hope for the
future5. It is likely to be less variable, less
transient, and more resistant to change than individual stress levels and is
more likely to reflect the individual’s perception of the future of their
group or organisation. Morale has been studied in relation to the socioeconomic
profile of the practice area and type of health system, and found to be
associated with time pressures, small practice isolation and a lack of patient
centredness8. In a UK setting it was also
linked to the structure, management, and expectations of the
NHS.5
While specific measurement scales and instruments have been
used to measure GP stress6,7, morale has not
been evaluated to the same extent, yet is likely to have just as great an impact
on health care and health professionals.
While there has been considerable detailing of the extent
and causes of health professional stress, there has been little exploration of
the potential and actual solutions that might be generated by those health
professionals to overcome their difficulties. Despite present challenges it
seemed likely there would be many individual and group initiatives to try and
decrease individual stress and improve overall morale. The Royal New Zealand
College of General Practitioners (RNZCGP) for example has prepared a resource
for GPs regarding self-care, intended to be used as an educational and audit
tool to help them to better recognise and manage their own stress
levels.
This research thus aims to place individual practitioner
stress and its causes, within the context of the overall morale in the
profession and the solutions that practitioners suggested or had achieved as a
response.
MethodsA postal survey was sent to a
sample of 700 New Zealand GPs, during the year 2000, the sample being obtained
from the RNZCGP database. The initial random sample was weighted to enable
representative responses from both urban and rural GPs.
Non-responding doctors were sent reminder questionnaires after one and two months. The four part questionnaire assessed a priority order for previously identified stressors, levels of psychological symptoms and morale, perceived solutions to work stress and low morale, and demographic data. A list of potential causes of work stress was collated from a RNZCGP survey and the results of previously published studies from the Departments of General Practice in Wellington and Auckland. These were grouped into six categories: non-clinical demands; representation; financial issues; personal issues; workload and consultation structure and length. A further miscellaneous category (other) was created in which respondents could specify stressors that were not listed. Respondents were invited to provide free text detail as to the impact of the sources of stress in each category. The respondents were asked to score the causes of stress using a Likert scale. In the 'non-clinical demands' category respondents were asked to specify organisations that were considered to generate most stress. These responses were collated and ranked by the frequency to which they were referred. Psychological well being was assessed using the 12-item general health questionnaire (GHQ-12).9 Individual scores ranged from 0 to 12. A cut-off of 4 or greater was used to indicate the probable presence of psychological disturbance, while a score greater than 8 indicated the probable presence of more significant psychological symptoms.4,10 Self report levels of perceived stress and morale were measured using a Likert scale previously validated in international settings.5 As well as identifying sources of stress, respondents were asked to provide solutions to the problem of stress and low morale. Respondents were invited to describe solutions for any measures that would lead to decreased stress and increased morale for general practice using the same six categories as in the stress prioritisation question. Free text responses were analysed for themes connected with particular solutions within each category. The frequency of each solution theme was recorded. Demographic data regarding personal and practice details were recorded. ResultsOf 700 questionnaires sent, 42 were
returned indicating the GP was not eligible for entry into the study due to
retirement or locum status. The response rate for completed questionnaires was
448 from 658 eligible (68%). The sample comprised 65% male and 35% female
practitioners with a mean age of 43.7 years. The mean length of time in practice
was 14.6 years. Ninety-nine (22.7%) of the sample worked in solo practice with
219 (50%) being in practices with 3 or more partners. Four hundred and one
(90.9%) doctors worked more than 6 sessions a week in general practice. The
length of appointment offered by the doctors varied from 5-10 minutes (17%) to
more than 15 minutes (13.6%). Nearly 70% offered appointment times of between 11
and 15 minutes.
Table 1. Sources of work stress (n = 448). (Maximum on
Likert scale of 5 means high stress).
Sources of stress.
The most potent sources of job stress are provided in Table 1. Excessive
paperwork had the highest mean score (4.27) on the 5 point Likert scale,
followed by bureaucracy (4.21), the difficulties caused by multiple problems in
the consultation (4.06), time pressures (3.84) and combining work with family
life (3.7).
Major themes identified from respondent comments portrayed a
profession that felt undervalued, at the receiving end of both patient and
organisational pressure, and finding difficulty in coping with the demands of
family and professional life.
The respondents were asked to identify specific
organisations that acted as stressors. The most frequently named organisations
were ACC (34% respondents), Pharmac (12.7%) and the insurance companies
(12.7%).
GHQ scores. Of 448
respondents 294 (67%) scored < 4, 143 (33%) scored between 4 and 8, and 43
(10%) scored greater than 8.
Perceived stress and
morale. Overall mean ratings were 3.47 (SD 0.98) for morale, and 4.15
(SD 0.85) for stress, recorded on a 5 point Likert scale. Levels of stress and
morale are recorded in Table 2, with comparison to published Irish and UK
(Northern Ireland) rates.
Table 2. Perceived stress and morale among New Zealand
general practitioners, compared to those in Ireland and United Kingdom (Northern
Ireland).
Solutions to stress and low
morale. The number of respondents who felt that solutions were required
for each category of stressor is given in Table 3 together with the total number
of solutions suggested for each category. In some categories more than one
solution was suggested by some GPs. The non-clinical demands category was
perceived to require solution by most GPs and produced the greatest number of
suggested solutions. Table 4 shows the most frequently suggested solutions
across all categories. Free text solution suggestions collated into common theme
categories are shown. The most commonly suggested solutions were directed at
streamlining and simplifying paperwork. Examples of suggestions included
removing the detail required on special authority documentation for
prescriptions, and an additional grant as recompense for excessive government
driven paperwork.
In other categories there was strong support for increasing
the General Medical Subsidy (GMS), increasing locum provision and providing a
united and realistic representation for the profession.
Table 3. Frequency of perceived need for solutions in
each stress category n = 448.
Table 4. Most frequently suggested solutions to problem
of stress and low morale.
DiscussionThis study builds on previous local
and international surveys of stress and unease in health professionals. It
suggests that potent sources of stress and low morale continue to affect New
Zealand general practice, and that GPs have developed a range of potential
solutions they would like to see implemented.
Given the response rate of 68% and the national sampling
frame, these results are representative of general practice at the time the
survey was undertaken. The distribution of male to female general practitioners
is consistent with the findings of the Medical Council of New Zealand annual
workforce survey. The results of individual psychological symptom scores
interpreted through the GHQ are comparable with previously published New Zealand
work and are of continuing concern. This is the first New Zealand work in which
levels of stress have also been compared with morale. It demonstrates high
levels of psychological symptoms, self-reported high stress levels of over 50%,
and over a quarter of respondents reporting morale to be very poor or poor. This
is a challenging matrix and one that provides further evidence of the crisis
present in primary health care in New Zealand. The levels of morale are somewhat
better than Northern Ireland, which operates under the National Health Service
‘free to patients’ funding system, but worse than Ireland, another
OECD country with a partial fee for service
system.5 We believe that the relationship
between individual work stress, psychological disorder, low morale and the
‘unhappiness among doctors’ that received widespread international
comment1 deserves further local
debate.
Despite the difficulties described by the respondents and
the identification of persistent stressors there is evidence of considerable
energy and innovation in defining and promoting solutions. This is the first
recorded survey that has collated the suggestions of a health workforce in this
way. We could only find evidence of one study that has previously asked GPs for
solutions to workload stress. A questionnaire based study in England concerning
the need for a stress support service for GPs showed that 78.8% of GPs asked
were in favour of such a service especially one with “independently
accessed counsellors and stress management
groups”.11
We believe that the wide range of solutions generated in
this study goes beyond a wish list and should form the basis for continuing
discussion with health-related organisations and government. Raising the GMS and
reducing the difficulties associated with excessive paperwork and bureaucracy
are the two responses that doctors feel would provide the greatest boost to
morale. There is a creditable realism to many of the responses and recognition
that some paperwork is necessary in modern medicine. The plea for streamlining
bureaucratic processes and reducing the overall administrative burden should not
go unheard.
It should be noted that in the last year there has been
progress in some of these challenging areas. In an attempt to meet rural
workforce needs there have been a number of innovative funding schemes and
incentives. If these kind of initiatives are sustained and linked to long term
recruitment strategies it may alleviate the present rural workforce crisis. A
further request from GPs was for united representation. In the last two years
there has been a greater level of collaboration between the RNZCGP, NZMA, IPA
and non IPA groupings and university departments of general practice to
establish common ground and advocacy for the profession. The three year
additional funding for primary care also has the potential to address some of
the issues raised by doctors in this survey.
While these initiatives are welcome, more is required.
Support for both rural and urban doctors is not solely defined in financial
terms. Many of the doctors felt undervalued and under pressure from both the
public, government and government organisations. New Zealand has a high quality
system of general practice and primary care that should be recognised and
celebrated. That public and political recognition would not cost much in
financial terms but would mean a great deal to the morale of the respondents of
this survey.
Author Information:
Anthony C Dowell, Professor of General Practice, Wellington School of Medicine,
University of Otago, Wellington; Gregor Coster, Elaine Gurr Professor of General
Practice, Department of General Practice and Primary Health Care, University of
Auckland; Charlotte Maffey, Medical Student, Faculty of Medical and Health
Sciences, University of Auckland, Auckland.
Acknowledgements:
The authors acknowledge the general practitioners who completed the
questionnaire. Charlotte Maffey was funded with a summer studentship from the
Auckland Faculty of the RNZCGP.
Correspondence:
Professor Tony Dowell, Department of General Practice, Wellington School
of Medicine, PO Box 7343, Wellington South. Fax: (04) 385 5539; email: tonyd@wnmeds.ac.nz.
References:
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