Several individual characteristics were positively and significantly associated with engagement including age,21,22 sex,21,22,24 experience,21 marital status,21,22 and the presence or absence of children.24 Although younger physicians, in the age group “26–35” reported the highest engagement scores compared with their older colleagues,21,22 years of experience was also significantly and positively associated with engagement, such that the more experience a physician had, the higher their engagement.21 Male psychiatrists were more highly engaged than their female colleagues.21,22 Male physicians with children perceived higher levels of engagement than their female colleagues, however, for physicians without children, no sex difference was found.24 Single physicians were more engaged than married physicians.21,22 One study by Mache et al,24 identified a significant negative association between work-family conflict and engagement, therefore the higher a physician’s work-family conflict, the lower their engagement was and vice versa.
Personal attributes positively and significantly associated with engagement included resiliency, self-efficacy, and optimism,21,32 agreeableness,16 neuroticism,16 and affectivity, an emotion-based trait dimension that determines a cognitive bias through which individuals address the experiences and may influence how they live and evaluate their jobs.28 A significant negative association was identified between pessimism and engagement,20,22 thus the more pessimistic a physician was, the lower their engagement.
Work Environment Characteristics/Work-related factors
Work environment characteristics positively and significantly associated with engagement included quality of life.20 Task combinations (ie, the combination or teaching, research, and patient care) were shown to be negatively associated with engagement.27 For example, respondents with only teaching responsibilities demonstrated higher engagement than respondents who combined teaching and research, teaching and patient care, or all three.27 A significant negative association was also identified between perceived job stress and engagement.24 Additional negative associations were identified between job demands and engagement, specifically the quantity of work, emotional demands, and requirement for overtime.24
Job resources were also associated with engagement. Job resources refer to those physical, psychological, social, or institutional aspects of the job that either reduce job demands and the associated physiological and psychosocial costs, are functional in achieving work goals, or stimulate personal growth, learning, and development.33 Two studies identified that the following job resources had a significant positive association with engagement: influence at work; possibilities for development; degree of freedom at work; sense of community; feedback; quality of leadership; and social support.20,21 Influence at work refers to the amount of influence one has concerning their work, such as the amount of work assigned to them or influence with regard to the tasks one performs.34 A third study identified that making patients healthy and happy was also positively and significantly associated with engagement.26 A fourth study identified that job control, supervisory support, possibilities for development, and social climate were positively and significantly associated with engagement, however, this study also identified a significant negative association between access to information and engagement.24 A fifth study suggested professional fulfillment, the satisfying inner experience of being useful and developing, motivated physician engagement.30 Finally, organizational support such as protection from “convenient visits” and other systemic measures at the hospital level, were associated with physician engagement.17 Convenient visits refer to emergency visits for nonemergency problems or emergency consultation for nonemergency symptoms.17
Engagement was positively and significantly associated with work ability,19,22 defined as the sum of factors enabling an employed person in a certain situation to manage his/her working demands successfully.35 An association was identified between engagement and job satisfaction.20,24 Negative association was identified between engagement and medical errors.31 In other words, this study found that the lower a physician’s engagement, the increased likelihood of medical error.
Tools Used to Measure Engagement
The Utrecht Work Engagement Scale (WES), a validated and reliable tool, was the most common tool identified to measure engagement.16,17,19–29,31 The tool varied in number of items (17 and 9 items) and language (English, Greek, Japanese, and Italian). Finally, one qualitative study used only interviews, no instrument.30 These data are presented in Table 3.
This review identifies the potential complexity of interrelationships involved in understanding and enhancing physician engagement. The predominance of cross-sectional studies, conducted at only one point in time, warrants mention as this only identifies mere associations. RCT data are required to identify causality among the factors identified in this review. The 2 RCTs were able to identify that the psychosocial and mental health training programs investigated did not have significant effects on physician engagement. In addition, qualitative and mixed methods would provide deeper insight into better understanding physician engagement. Both RCT and additional qualitative work would assist in identifying and developing actual strategies to enhance physician engagement. The importance of capturing and reporting hospital type and specialty is important for hospital leadership who wish to enhance physician engagement in their specific hospitals and departments. An unexpected finding was that most of the studies are European. This may be attributed to the fact that the UWES was developed in Europe, however, it signifies the importance of additional validity and reliability testing on other continents with different health care systems.
Factors related to hospital-physician engagement were synthesized into three major categories, which include individual characteristics, work environment, and work outcomes. As indicated in the results section, the predominant number of studies examined individual characteristics. Age and experience are positively associated with engagement. Additional qualitative work would be beneficial to determine the cause for this—is it because senior physicians are more established and perhaps have more say in the work that they do? Although there may be little that hospital leadership can do to alter individual characteristics such as employee age, sex, marital status, or number of children, individual characteristics enable the identification of vulnerable physicians. The identification of protective factors such as work environment enables leadership to know how to intervene, but it is the characteristic of the individual more at risk that enables the identification of the most pertinent targets of such intervention.
What can be modified, however, is the work environment. These factors enable leadership to know how to intervene. For example, hospital leadership have the ability to modify schedules, divide labor, determine whether all physicians participate in research or education, improve support, grant more autonomy, provide timely and constructive feedback, or create opportunities for professional development.
Findings also suggest that although promising, there is very little evidence linking engagement with work outcomes in hospital physicians. The only outcomes identified in this review include job satisfaction, ability to work and medical error. Consistent with a recent examination of the work psychology of personal support workers working in long-term care and home and community care settings in Ontario,36 job satisfaction is related to engagement. Additional research into successful methods of enhancing job satisfaction in hospital physicians may prove beneficial in identifying new approaches for hospital leadership to enhance physician engagement.
The most common tool identified in this review is the Utrecht WES, specifically the short 9-item version of the Utrecht WES. Since the majority of the studies were conducted in Europe, additional reliability and validity testing is required on other continents in other health care systems. The use of a validated and reliable tool is important in order to ensure researchers and leadership are accurately measuring what they intended to measure, and be able to generalize and compare findings across sites. This, in addition to RCT data, will enable leadership to accurately identify outcomes associated with engagement.
Several potential implications arise from this review related to practice, the conceptualization of physician engagement as well as implications for theory. Gaps in the literature and future areas for research have also been identified.
Leadership. This review enables information sharing, saving individual hospitals time and resources by identifying and summarizing research in this area. Findings provide insight into environmental characteristics that hospital administrative leaders may wish to further investigate as potential opportunities to enhance physician engagement. This preliminary work provides a foundation for future work that will enable evidence-based decision making in this area, with the potential to improve hospital-physician alignment, retention, quality of care, patient safety, and other important outcomes. This work is the first step in enabling hospital leadership to work with physicians to develop customized plans to address individual needs related to physician engagement. Hospitals in the process of recruiting physicians could consider how candidate expectations of the work environment may influence engagement. Finally, this research identifies the Utrecht WES (9-item) is a commonly used, short instrument, which hospital leadership may consider using to measure engagement in their institutions.
Frontline Physicians. Preliminary findings support healthy work environments, which include a good work-life balance, fair scheduling, as well as decreased job stress and job demands such as work overload and/or overtime. Results also highlight the importance of adequate job resources such as development opportunities, quality of leadership, organizational support, autonomy, workload, and social climate. Since a large number of environmental characteristics appear to be associated with engagement, individuals thinking of joining a new organization may find value in first investigating the work environment. Additional inquiry into the association between low engagement and suicide ideation is warranted if further investigation could potentially lead to early identification and timely support for those in need.
Implications for the Conceptualization of Physician Engagement
This work contributes to and advances the science and body of literature on physician engagement. It highlights current factors examined and found to be significantly related to hospital-physician engagement.
Theoretical Implications and Research Gaps
Studies identified in this review are limited to examinations of simple dyadic relationships. The model created as a result of this review suggests that physician engagement may be more complex. The interrelationships between hospital-physician engagement, individual characteristics, the work environment, and work outcomes remain poorly understood and underexplored. In order to establish causality, future RCT research exposing these intricate relationships can help hospital leadership determine where best to focus resources in order to develop strategies that positively influence work-related behaviors that aid in attaining organizational goals. Additional mixed methods studies would be helpful in gaining a more fulsome understanding of engagement. It would be interesting to further investigate physician engagement with respect to task combination (eg, teaching, research, and patient care requirements), emotional intelligence, generational differences, employee status (eg, whether the physicians were contract or permanent employees), financial viability of the organization, and different funding or care models.
Because of limited research in this area, there are a small number of studies in total, and an even smaller number of studies that examine any one factor. Because of time and resource restrictions, we were unable to translate one article.
This scoping review provides a strong evidence-based platform to further advance knowledge around physician engagement. The identification of environmental factors assist hospital administrative leaders in understanding how they might intervene to affect engagement. By understanding how individual and work characteristics impact engagement, hospital administrator leaders are better positioned to positively approach physician engagement within their hospitals. Finally, by understanding which outcomes are linked to physician engagement, it allows health care organizations to create a knowledge translation platform, identifying and sharing the most successful strategies to enhance physician engagement and ultimately improve patient outcomes.
The authors would like to thank The Ontario Hospital Association, Members of the OHA’s Physician Provincial Leadership Council, and the Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto.
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Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
hospital; physician; engagement; scoping review