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Linking doctor-patient relationship to medical residents’ work engagement: The influences of role overload and conflict avoidance

Linking doctor-patient relationship to medical residents’ work engagement: The influences of role... Background: Chinese residents’ practical work experiences are different from those described in Western studies. To explore potential mechanisms underlying the effects of doctor-patient relationships on medical residents’ work engagement, verifying a posited mediating effect of role overload, and moderating effect of conflict avoidance, in the Chinese context. Methods: Based on the conservation of resources theory, a composite model was constructed. This study’s data were collected from four different Chinese tertiary hospitals; 195 residents undergoing regularization training took this survey. Hierarchical moderated and mediated regression analyses were utilized. Results: Doctor-patient relationship were found to be positively related to residents’ work engagement (β=0.31, p≤0.001). Role overload partially mediated the effect of these relationships on work engagement, and the moderat - ing role of conflict avoidance in the relationship between doctor-patient relationship and conflict avoidance was negative. Conclusion: Maintaining good doctor-patient relationship can prompt residents to increase their engagement in work in order to meet their patients’ needs. Furthermore, role overload has a particular influence in early career stages. Not only is it necessary for residents to gain a sense of recognition and support while they carry out their job respon- sibilities, especially while dealing with complex doctor-patient relationship, but it is also important to create work environments that can help residents shape their professional competency. Keywords: Doctor-patient relationship, Work engagement, Role overload, Conflict avoidance that work engagement is positively related to enhanc- Introduction ing performance and achieving goals [1, 2]. Kahn (1990) The past five to ten years have witnessed the emergence originally pioneered the concept of personal engagement of a wealth of human resource management research with work as employees “bring in” their personal selves focusing on work engagement, which has demonstrated to their work role, engaging and expressing personal physically, cognitively and emotionally during role per- formances [3], and came to be recognized as an organiza- *Correspondence: cpfeng@hfut.edu.cn School of Management, Hefei University of Technology, Hefei, Anhui tional element that counteracts job burnout and is closely Province 230009, P.R. China related to positive organizational results [4]. More work Full list of author information is available at the end of the article © The Author(s) 2021. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Deng et al. BMC Fam Pract (2021) 22:191 Page 2 of 11 engagement makes work state more effective: higher effi - occurring due to opposition to hospital policies. There - ciency, vigor, dedication, focus and flow state, as well as fore, we introduced the variable of conflict avoidance (see lower turnover intention [5–8]. Thus, we hold that work “The moderating effect of conflict avoidance” section), engagement is a key factor ensuring the success of health which Chinese residents may find important to help organizations and the lasting competitiveness of medical them deal with doctor-patient relationship and tasks. professionals [1, 9]. This makes it a critical issue in medi - To investigate these issues, we adopted the conser- cal education research. The challenges raised by high vation of resources theory and proposed a theoretical burnout rates during medical residency training in vari- model that tried to explore the potential mechanisms ous countries highlight the importance of ensuring high underlying the effect of doctor-patient relationship on work engagement, harmonious doctor-patient relation- residents’ work engagement from the perspective of resi- ship, and reasonable role positioning and task allocation dents and used an empirical research method; in addi- within a complex medical environment [10, 11]. There tion, we attempted to verify the mediating effects of role have been impressive advances in the empirical and theo- overload and the moderating effects of conflict avoidance retical research on work engagement; however, certain in the model (See Fig. 1). aspects remain to be understood, which could lead to a better understanding of its underlying mechanisms. For Theoretical background and hypotheses example, research on the mechanisms underlying work Doctor‑patient relationship and work engagement engagement in the health field is insufficient, particu - Work engagement can be broken down into emotional larly regarding effective work engagement among front- or psychological engagement, essentially the degree to line medical staff [12]. From the perspective of residents’ which the worker wants to contribute, and actual engage- experiences, work engagement-related research involving ment, or the actual energy and effort they do contribute factors operating between individuals and work situa- and the results. Both are directly linked to residents’ per- tions are still lacking, including doctor-patient conflicts, formance [16, 17]. In addition to their work attitudes, role overload, conflict avoidance, and so on. we need to understand residents’ attitudes toward doc- In China, the large, rapidly aging population has tor-patient relationship [18]. In most countries, doctor- strained medical resources; the full liberalization of patient relationship is considered more important than the former two-child policy and growing awareness of any other social relationships except familial relation- increasingly affordable access to public health care have ships [19]. Residents are the direct suppliers of medi- exacerbated this problem [13]. Given the special condi- cal services and reliable sources of health information. tions in China, Chinese residents’ practical work expe- u Th s, the status of the relationships with their patients riences are different from those described in existing, influences the high-quality medical care provision that large Western studies [14]. Chinese residents experience patients experience. Family members are also vital stake- workload and thus they are facing time pressure and holders because, in most cases, they are the patients’ chief stress [15]. Furthermore, because the Chinese standard- supporters and often decision-makers [20, 21]. Thus, the ized training system is still in an exploratory process, role relationships between doctors and patients’ families also overload often occurs because of residents’ unclear role play a key role in treatment and care experience. positioning and unreasonable division of labor (see “The There are several studies using doctor-patient conflict mediating effect of role overload ” section). Like most to represent the doctor-patient relationship, because Asian cultures, China deeply reveres values such as har- conflict is an utmost important relational outcome, mony, collectivism, and social dedication, and Chinese especially in the context of Chinese medical treatment people also support strict government control of pub- [20, 22, 23]. The degree of conflict with patients (and lic hospitals. In many cases, fearing negative effects on their families; henceforth, however, “doctor-patient their future careers, residents deliberately avoid all kinds relationship”) can deeply influence residents’ future of potential doctor-patient conflicts, including those career lives. Training residents to pay greater attention Conflict avoidance Doctor-patient relationships Role overload Work engagement Fig. 1 Holistic hypothetical model D eng et al. BMC Fam Pract (2021) 22:191 Page 3 of 11 to patients and avoid conflict with them during the u Th s, good doctor-patient relationship (that is, lower early periods of their careers could be very beneficial conflict rate between doctors and patients as well as for the patients, the residents themselves, and the med- their families) should positively predict residents’ work ical system as a whole [18]. With experience, residents engagement. may be able to better perceive the degree of doctor- patient conflicts and the status of doctor-patient rela - Hypothesis 1 (H1) tionship; this could considerably influence whether the Doctor-patient relationship positively influences the behavioral strategies they adopt will be patient-cen- work engagement of residents. tered or doctor-centered. In patient-centered behav- ioral strategies, doctors prioritize a more humanistic The mediating effect of role overload spirit, develop greater work engagement, and proac- Role overload describes a condition under which indi- tively provide medical services that can best meet their viduals lack the time or energy to meet their role expec- patients’ needs; this results in higher patient satisfac- tations (whether those expectations originate in others tion [24–26]. In contrast, doctor-centered approaches or in oneself ) [32]. In hospital settings, “role senders” or are paternalistic in nature; in this approach, doctors deciders of residents’ roles are typically supervisors or are more likely to emphasize their own interests and clinical teachers. Because they work at the frontlines of take defensive medical actions to protect themselves. clinical practice, residents have high contact frequency During the diagnosis and treatment processes, they with patients [33]; thus, their roles are also affected by are more likely to have ideas that differ from those of the requirements of and feedback from patients and their their patients, especially with regard to certain medical families: that is, their role expectations of the residents. behaviors, methods, attitudes, and consequences; thus, u Th s, residents must also undertake tasks unrelated to this approach produces a greater degree of doctor- their training [34]; for example, in some tertiary hospitals patient conflict [18]. lacking adequate beds, patients may seek the assistance The conservation of resources theory holds that of residents they have good relationships with to arrange groups with fewer occupational resources [27], such as beds for them in advance. beginner residents, are extremely sensitive to occupa- Most research opinions in the past have indicated tional resource depletion. The gain spiral of resources that, from an organizational management perspective, principle [28, 29] holds that if residents maintain good role overload is harmful, causing stress, exhaustion and relationships with patients, they will receive greater degrading care [35, 36]. In contrast, well-controlled and support and recognition, ideally yielding a conditional -defined roles and adequate discretionary rites can allevi - resource that benefits their work. At the same time, ate these difficulties and even stimulate residents to work recognition received from patients and their families harder, raising their work engagement [37]. The biggest functions as a kind of professional stimulation that can feature of workplace learning is “learning by doing” [38]; promote residents’ sense of achievement and self-satis- in medical environments, residents may experience role faction, which can also be counted as (“personal charac- overload because they often aim to gain more profes- teristic”) resources. Residents possessing more resources sional training and experience accumulation outside the are more likely to acquire new resources and acquire formal scope of their training [39], but at the same time, added value of resources. Investing in these resources, this may be the only way for them to gain certain kinds they may counteract resource loss, and as a result may of experience such as experience with ethical issues and become more dedicated and increase their work engage- may be effective to help them build their professional ment. According to previous research [30, 31], good doc- reputation [40]. tor-patient relationship can be considered as to be a job In addition, the mediation function of role over- resource, which is able to activate a motivational process load may be especially large at the resident stage, the that contributes to the achievement of training goals, it “establishment stage” of this career, which compared to can avoid costly psychological and physical costs, foster ‘maintenance” and “disengagement” stages is marked by residents’ growth, increase career possibility, provide the need to root oneself, learn and become known (the opportunities for residents to learn; and satisfy needs for “grounding” process) and hence by less concern among clinical work autonomy and competence [30, 31]. Good residents for role overload, as they are more focused on doctor-patient relationship can also increase individual achieving success. Role overload may be perceived as less willingness to devote one’s efforts and abilities to the a burden than a challenge or necessary sacrifice, accord - training task, and these perceptions and beliefs increase ing to Jones et  al. [41], residents who are in this period the degree to which residents are willing to invest their are usually eager to build their reputation in medical selves into their role performances [30, 31]. industry by achieving good performance, in most cases, Deng et al. BMC Fam Pract (2021) 22:191 Page 4 of 11 role overload is considered as necessary sacrifice to gain are more likely to view the resources they do have as pre- achievements. cious and to do their best to avoid losing their resources; however, usually, they are unable to do so, and they may Hypothesis 2 (H2) even end up losing more resources [28, 52]. For instance, Role overload mediates the relationship between doc- some residents, who may not be skillful at avoiding con- tor-patient relationship and the work engagement of flicts, may attempt to control their emotions in order to residents. improve doctor-patient relationship in the long term; however, these residents may consequently face more The moderating effect of conflict avoidance negative emotions from themselves as a result of their Conflict avoidance involves refusing to engage in any efforts at self-control. In this way, decreasing conflict may conflict and, furthermore, positively engaging in actions thus lead to resource loss and greater role overload. to solve conflict [42]. The concept of conflict avoidance is highly relevant in many Asian cultures, and especially Hypothesis 3 (H3) in Chinese culture [43, 44]. The Chinese Confucian tradi - The effect of doctor-patient relationship on role overload tion holds harmony to be a core value and thus encour- is negative moderated by conflict avoidance. ages people to tolerate interpersonal disagreements and transgressions [45]. Conversely, pursuing conflicts with Samples and procedures others can cause individuals to lose face in such societies, This study’s data was collected as part of a larger ques - and losing face, in turn, can bring shame to themselves tionnaire survey, which was administered to residents and others [46]. Thus, conflict avoidance helps to protect in five tertiary hospitals (as only such hospitals provide a relationship between two parties of conflict who may residency training in China) located in the southeast and have differing opinions; it lowers the possibility of aggres - central regions of China. Our study included residents sion from either side and maintains the positive images of from the following clinical departments: internal medi- all involved parties [44, 47]. Thus, Chinese people tend to cine, surgery, pediatrics, obstetrics, community medi- do their best to maintain harmonious working relation- cine, intensive care unit (ICU), emergency, psychiatry, ships, viewing this as a mature behavior with high moral and so on. The survey instrument included a large num - value. ber of variables related to residents’ attitudes and per- In Chinese traditional culture, doctors are expected to ceptions, which allowed us to test the above-developed meet high role expectations; to be considered outstand- hypotheses. First, we explained the background and ing, doctors must have high moral standards. Most Chi- goals of our research to residents’ managers or infor- nese people have deeply embedded this mode of value mal resident organizations in hospitals via in-person recognition. Many young residents also perceive their visits, phone, or social networking platforms (e.g., QQ, careers to have high role requirements and expectations; WeChat). After receiving these organizations’ approval, they believe that having conflicts with patients and their we started our field investigation. Participation in this families indicates a lack of professionalism and moral research was voluntary, and anonymity was assured to spirit [48]. It could also affect their professional repu - all participants. The survey interviews happened during tation and future career development, so their aware- residents’ off hours, lasting for an average of 20 minutes, ness of conflict avoidance is very strong. However, some each questionnaire concludes 70 questions and it covered residents show a very weak awareness of conflict avoid - residents’ attitudes, perceptions and their background ance; reasons for this variation include individual- and information. In addition to 31 questionnaires that were cultural-level differences and lack of communication and later mailed to the researchers, 141 were collected on interpersonal skills [48–50]. In situations where they face site. Of these 195 questionnaires (65% response rate), 23 emotional challenges, some residents are unable to access were discarded because of data missing. We examined or use effective emotional management strategies, and it the differences of resident gender, age, marriage, educa - is easy for them to experience conflicts with patients and tion, and doctor qualification between the valid partici - patients’ families [51]. Thus, in this study, the degree of pants and the discarded samples, and the results of t-test conflict avoidance among residents showed variability. showed no significant difference. As stated previously, according to conservation of The demographic profiles of the 172 valid participants resources theory [27], conflict avoidance, as a measuring are presented in terms of the following demographic standard for cultural values, moderates the relationship variables: gender, age, education, and teachers rank. The between residents’ conflicts with patients and role over - average age of respondents was approximately 30 years, load in the Chinese context. Individuals vary in sensitive- 54.1% were female and 45.9% male. Of the respondents, ness to resource losses: those who have fewer resources 33.7% were married and 71.5% had passed the medical D eng et al. BMC Fam Pract (2021) 22:191 Page 5 of 11 qualification exam. Participants also reported that 47.6% Table 1 Confirmatory factor analysis of them had a bachelor’s degree and 51.7% had a master’s Variables Cronbach’s α Factor loading AVE CR degree. doctor-patient relationship 0.81 0.80-0.91 0.73 0.89 Conflict avoidance 0.85 0.71-0.88 0.63 0.90 Variable measurement Role overload 0.84 0.73-0.86 0.62 0.89 All the measurement items were evaluated at the indi- Work engagement 0.88 0.69-0.84 0.58 0.92 vidual level using a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). The scales were translated from English to modern Mandarin, Results and retranslating the final version back into the original Reliability and validity language. This procedure enabled a group of experts to For all multi-item constructs, the reliability and validity ensure the accuracy of the meaning. of measurements were evaluated using confirmatory fac - tor analysis (CFA). Table  1 shows the CFA results. The Cronbach’s α reflects the reliability of the variables. The Work engagement of residents Cronbach’s α value of each construct with multiple items Work engagement was measured with a nine-item scale is higher than 0.7, which suggests high internal consist- adapted from Thomas [53]. An example item from the ency reliability. scale is “I am willing to really push myself to reach chal- The convergent validity was measured by Composite lenging work goals”. Reliability (CR) and Average Variance Extracted (AVE). As shown in Table 1, the value of CR of each construct is Doctor‑patient relationship higher than 0.7, and the value of AVE of every construct This variable was assessed with three items developed is greater than 0.5, implying high convergent validity of by Lee et al. [20]. We measured the degree of differences the measurements. and disagreements between residents and patients on The indicator factor loading of every item is higher personal issues, patient care issues and the way work is than 0.6, showing that discriminant validity is adequate. done. A sample item included “For residents and patients In addition, the discriminant validity was also tested by or their families, how would you rate the degree to which the comparison between the correlations among con- there are disagreements over personal issues”. structs and square root of the AVE. In Table 2, the values of the square root of AVE are on the diagonal. Each con- struct’s correlations with other constructs is lower than Role overload the square root of AVE scores of this construct, which It was measured with the unidimensional scale of role means a high discriminant validity of the measurements overload [32]. It consists of six items. An example item is in this study. “I have to do things that I do not really have the time and energy for”. Common method bias First, we adopted Harman’s one-factor test [56]. The result showed that all items were categorized into four Conflict avoidance factors, with eigenvalues greater than 1.0, which accounts We adopted the scales of Park and Nawakitphaitoon [43], for 62.39% of the total variance, and the first factor which is based on the research of Morris [54]. An exam- accounts for 27.56% of the variance. Then, we performed ple item is “I believe it is better to keep negative opinions confirmatory factor analysis and compared the model fit to ourselves rather than create hard feelings”. among the measurement model, one-factor model, and measurement model with method factor [57]. The results Control variables showed that the fit of our measurement model (χ [183] = Following Becker et  al.’s [55] recommendation, we con- 335.79, CFI =0.91, RMSEA = 0.07, RMR=0.05) was sig- trolled five variables that are theoretically related or have nificantly better than the fit of the model with only one been found to be empirically related to residents. For method factor (χ [189] = 1097.64, CFI = 0.43, RMSEA examples, gender was measured as 1=Female, 2=Male; = 0.17, RMR=0.12). Also, we included a common education level indicates the degree level of residents, method factor in the measurement model. The results including 1=below college diploma, 2=college diploma, of the measurement model with both constructs and a 3=bachelor, 4=master and above; marriage was operated method factor (χ [162] = 286.25, CFI = 0.92, RMSEA = as 1=Yes, 2=No. 0.07, RMR=0.04) marginally improved the model fit of Deng et al. BMC Fam Pract (2021) 22:191 Page 6 of 11 Table 2 Correlations and discriminant validity Variables Means S.D. 1 2 3 4 5 6 7 8 9 1 Gender 1.43 0.49 - 2 Age 2.36 0.65 0.05 - *** 3 Marriage 1.58 0.47 0.52 -0.01 - 4 Education 2.37 0.54 -0.03 0.19 -0.02 - ** *** 5 Doctor qualification 1.06 0.56 0.26 -0.01 0.39 0.02 - 6 doctor-patient relationship 3.46 0.66 0.14 -0.06 0.16 0.05 0.12 (0.85) 7 Conflict avoidance 3.56 0.71 -0.02 -0.01 -0.07 -0.17 -0.08 0.07 (0.80) ** ** 8 Role overload 3.48 0.72 0.06 -0.12 0.07 -0.02 -0.03 0.24 0.20 (0.79) *** ** ** 9 Work engagement 3.71 0.57 0.10 0.01 0.10 -0.06 0.14 0.32 0.23 0.21 (0.76) Note: n =172. *p ≤ 0.05; **p ≤ 0.01; ***p ≤0.001; The relationship between doctor‑patient relationship the measurement model with only constructs (∆CFI= and work engagement 0.01, ∆RMR=0.01). The path coefficients and their sig - First, we reported all control variables with the depend- nificance were similar between the two measurement ent variable. Model 1 includes only the control variables models. Therefore, common method bias is not a serious (i.e. gender, age, marriage, education, doctor qualifica - problem for our study [58]. tion) and explains a relatively small part of the variance in the dependent variable (R =0.04). The results of Model 1 showed that gender (β=0.03, p>0.05), age (β=0.03, Hypotheses tests p>0.05), marriage (β=0.05, p>0.05), education (β=- To test our hypotheses, we employed hierarchi- 0.09, p>0.05), doctor qualification (β=0.14, p>0.05) do cal regression analyses via SPSS 22. We reported the not have significant effect on work engagement. Sub - standardized coefficients in Table  3. To reduce the sequently, we added the independent variable to test issue of multicollinearity, we mean-centered and the main effect. As predicted, the results of Model 2 in standardized the independent and moderator vari- Table  3 shows that doctor-patient relationship is posi- ables before calculating the interaction term [59]. And tively related to doctors’ work engagement (β=0.31, the variance inflation factors (VIFs) are all below 2.0 p≤0.001). Thus, H1 was supported, which means that in these models, also suggesting that multicollinearity the better doctor-patient relationship, the higher level of issue is not significant in this study. work engagement. Table 3 Results of the regression analysis Work engagement Role overload Independent variables Model1 Model2 Model3 Model4 Model5 Model6 Model7 Controls Gender 0.03 0.01 0.00 0.05 0.03 0.03 -0.00 Age 0.03 0.05 0.07 -0.13 -0.11 -0.11 -0.12 Marriage 0.05 0.01 0.01 0.05 0.02 0.03 0.06 Education -0.09 -0.10 -0.10 0.01 0.00 0.04 0.03 Doctor qualification 0.14 0.12 0.13 -0.06 -0.08 -0.07 -0.09 *** ** ** ** ** Doctor-patient relationship (DPR) 0.31 0.27 0.25 0.23 0.24 * * Conflict avoidance (CA) 0.19 0.18 Role overload 0.16 DPR*CA -0.16 R 0.04 0.13 0.15 0.03 0.09 0.12 0.15 ∆R 0.04 0.09 0.02 0.03 0.06 0.03 0.03 ** ** * * ** F 1.10 3.28 3.49 0.77 2.09 2.63 2.86 *** * ** * * ∆F 1.10 15.79 4.45 0.77 9.77 5.93 4.29 Note: n=172. *p ≤ 0.05; **p ≤ 0.01; ***p ≤0.001 D eng et al. BMC Fam Pract (2021) 22:191 Page 7 of 11 The mediating effect of role overload overload. We adopted hierarchical moderated regression H2 predicted the effect of doctor-patient relationship analyses to test this hypothesis. First we entered control on work engagement is mediated by role overload. We variables and independent variable (i.e. doctor-patient used the steps of Baron and Kenny [60]. First, it has been relationship) into the regression. Then the moderator (i.e. confirmed that doctor-patient relationship is positively conflict avoidance) was incorporated. Finally, we added related to doctors’ work engagement (β=0.31, p≤0.001, the interaction between doctor-patient relationship and Model 2), indicating that the independent variable is conflict avoidance into the regression. Results in Table  3 significantly related to the dependent variable. In Model showed that the interaction between doctor-patient rela- 4, the results showed that the control variables do not tionship and conflict avoidance was negatively related to have significant effect on role overload (gender: β=0.05, role overload (β=-0.16, p≤0.05, Model 7). Accordingly, p>0.05; age: β=-0.13, p>0.05; marriage: β=0.05, p>0.05; H3 was supported. education: β=0.01, p>0.05; doctor qualification: β=-0.06, To further explore the patterns of the significant inter - p>0.05). Then, doctor-patient relationship is positively action effects that supported the hypotheses, we plot - related to their role overload (β=0.25, p≤0.01, Model 5), ted the significant interaction effects using one standard suggesting that the independent variable is significantly deviation above and below the mean to represent high related to the mediator. Next, we entered role over- and low levels of the moderating variables [59]. Figure  2 load as the mediating factor in Model 3, and found that shows that the slopes are much steeper when conflict role overload is positively related to work engagement avoidance is low than high. We also tested the statisti- (β=0.16, p≤0.05, Model 3), showing that the mediator cal significance of these two slopes [62]. When conflict is significantly related to the dependent variable. Finally, avoidance is one standard deviation below the mean, the when role overload was incorporated into the regression coefficient of doctor-patient relationship on role over - in which work engagement was the dependent variable, load (β=0.34, t=3.67) is significantly higher than coeffi - the effect of doctor-patient relationship on work engage - cient when conflict avoidance is one standard deviation ment remained significant, but the coefficient of doctor- above the mean (β=0.15, t=1.73). The results confirmed patient relationship became smaller (β=0.27, p≤0.01, that conflict avoidance negatively moderated the effect of Model 3) than coefficient in Model 2 when role overload doctor-patient relationship on role overload. was not included (β=0.31, p≤0.001, Model 2). The results show that the role overload partly mediated the effect of Discussion and Conclusion doctor-patient relationship on work engagement. There - Discussion fore, H2 was supported. Past studies have shown that doctor-patient relation- In addition, to further confirm the mediating effect, we ship can influence health outcomes [63, 64]; however, also conducted a bias-corrected bootstrapping procedure few researchers have explored the impact and underlying [61]. The results were shown in Table  4. The results of mechanisms of conflicts with regard to residents’ occu - bootstrapping suggest that the indirect effect of doctor- pational behaviors. Our study’s empirical results showed patient relationship on work engagement via role over- that maintaining good doctor-patient relationship signifi - load was significant and positive (95 per cent CI = 0.0013 cantly improved residents’ work engagement. The find - to 0.0834; excluding 0; indirect effect = 0.0352). There - ings suggest that maintenance of good doctor-patient fore, Hypothesis 2 was supported. relationship could trigger a sense of reciprocity among residents and patients, thus leading residents to work The moderating effect of conflict avoidance better in an effort to meet their patients’ needs. u Th s, H3 proposed that conflict avoidance moderated the rela - hospitals can use effective control of doctor-patient con - tionship between doctor-patient relationship and role flicts as an important method of achieving improvements and positive results in residents’ professional training. Residents themselves must improve their doctor-patient Table 4 Indirect effects of doctor-patient relationship on work relationship and reduce conflicts by improving their own engagement clinical ability, communication and interpersonal skills, Path: Doctor‑patient relationship ‑ Role overload ‑ Work and so on; for their part, hospitals should build a positive engagement atmosphere for doctor-patient relationship, as this is vital to improve residency programs and training performance Bootstrap—indirect effect 0.0352 [65]. Standard error 0.0211 Unexpectedly, we identified role overload as a potential Lower limit 95% CI 0.0013 positive mediator between doctor-patient relationship Upper limit 95% CI 0.0834 Note: n=172; 5000 resamples Deng et al. BMC Fam Pract (2021) 22:191 Page 8 of 11 3.5 2.5 Low conflict avoidance High conflict avoidance 1.5 Low doctor-patient High doctor-patient relationship relationship Fig. 2 Moderating role of conflict avoidance and residents’ work engagement; as the saying goes, Unlike previous research [67, 68], this study treated “with great power comes great responsibility,” and resi- conflict avoidance as more than just an emotional man - dents faced with overload may find themselves motivated agement strategy for individuals in the medical field, to engage more deeply and improve their relationships. verifying its negative moderating effect on doctor- Role overload variables have been used not only in patient conflicts in the Chinese medical environment. research dealing with job burnout but also in research This research used a key forecasting factor and discussed related to doctor-patient relationship and work engage- conflict avoidance by proposing and testing a theoreti - ment. Although the role overload phenomenon may cal model under which conflict avoidance affected the seem very obvious from the viewpoint of residents, we relationship between doctor-patient conflict and role still need to determine whether these results can be gen- overload. The findings expand the scope of research on eralized to medical workers beyond the research par- mechanisms affecting doctor-patient relationship and ticipants here. Nevertheless, our current results can spur help explain the function of conflict avoidance with more fundamental theorizing on how role overload can regard to the boundary condition of this relationship help increase residents’ enthusiasm and energy at work in the Chinese cultural background. These researchers’ and help residents grow professionally and personally. results show that administration departments are respon- This approach is more practically meaningful than simply sible for medical residents should place more attention discussing reasons for residents’ job burnout. The con - on individual-level differences in conflict avoidance [9]. servation of resources theory holds that positive power is For residents with low conflict avoidance, this negative the vital motive that allows residents to continue devel- work experience may be even more pronounced. There - oping in their career lives [66]. This perspective leads to fore, we must realize that, at this early stage of standard- some key questions: how can immature physicians gain ized residency training in China, we cannot ignore these a sense of recognition and support from work by dealing differences. with complex doctor-patient relationship; how can they use missions in the work sphere to shape their profes- Conclusion sional ability; and how can they accumulate experience This paper utilized an empirical research method to from interactions with patients in order to build better explore the potential mechanisms underlying the effect competence. of doctor-patient relationship on medical residents’ work Role overload D eng et al. BMC Fam Pract (2021) 22:191 Page 9 of 11 engagement and verified the mediating effect of role departments to improve their training results and, at the overload and the moderating effect of conflict avoidance same time, provide young physicians with new methods in the model. Doctor-patient relationship in China is fac- to improve their work engagement and keep good rela- ing challenges, and residents are being subjected to over- tionships with patients and patients’ families. load and overtimes; researchers, educators, and clinical The findings suggested that teachers should understand leaders must recognize the complex situations and take and help each resident build a targeted relationship; effective actions to build good doctor-patient relation - guide residents to their best practices for doctor-patient ship and maintain physicians’ work engagement at an intimacy, appreciation and attention, feedback and criti- optimum level. cism, and crisis emotional support. We also suggest that health care policy makers work with residents to develop Theoretical contributions a common strategy in order to make residents get the The theoretical contributions of our study to the litera - most effective interaction for patients, individuals, teams ture placed at the intersection between doctor-patient and the residency programs, let residents propose their relationship and medical human resource management. thoughts on the aspects of assignment arrangements Under the conservation of resources theory, we went and role behaviors. Integrate doctor-patient relationship beyond the well-explored traditional doctor-patient rela- building and engagement training into current residency tionship or employee engagement study [28, 29]. This is programs, develop specific, measurable and compre - the first to empirically investigate residents’ employee hensive performance criteria, in order to make the new engagement as an outcome of doctor-patient relation- requirement of capability operate, and develop a path ship. Also, very little is known concerning the roles that helps residents achieve their career ideals and high of mediator and moderator variables in the relation- level of dedication status. ship between doctor-patient relationship and residents’ engagement. The empirical model suggests that the effect Limitations of doctor-patient relationship on resident behavior is not Although this study possesses a number of strengths, as straightforward as expected. It cannot be overlooked there are some limitations. First, the study is cross- that what really matters is the role of role overload and sectional in design, thus any causal conclusions drawn conflict avoidance plays. Thus, the results also spur more should be viewed with caution. Future research could fundamental theorizing on how doctor-patient interac- employ a longitudinal study and multi-level data from tion serves as a mechanism to integrate residents into multiple respondents to extend our findings. Second, clinical practice and to help them to grow. the generalizability of this study may be limited because the sample was restricted to Chinese tertiary hospitals Practice implications from the south-east region and the central region. Hence, The problem of doctor-patient conflicts has been it could be recommended that future research should resolved in some successful health organizations; how- be expanded the sample source and size to address this ever, until recently, there has been little academic drawback. Third, although this study considered several research on the mechanisms underlying non-conflicting objective control variables, future research may include doctor-patient relationship. Since the problem-directed a more comprehensive list of control variables, includ- research model still forms a core aspect of academic ing training levels, departments, length of time, training research, it is necessary to develop a clear understanding satisfaction, and so on. Finally, the findings suggest that of why we need to emphasize doctor-patient relationship good doctor-patient relationship can prompt residents to management and how it can improve residents’ work increase their engagement. To test more potential mech- engagement. We identified factors that could explain res - anisms, future research should include self- and other- idents’ work engagement improvement and stated how report of doctor-patient relationship and residents’ work these factors can be utilized in Chinese medical settings engagement, as well as potential mediators such as big in the future. The model we created does not include all five personality, person-organization fit of residents. potential mediating and modifying variables, but it pro- vides a systematic, logical explanation of doctor-patient Abbreviations relationship, physician burnout, work engagement, and ICU: Intensive Care Unit; CFA: Confirmatory Factor Analysis; CR: Composite Reli- mechanisms among them in this setting. This knowledge ability; AVE: Average Variance Extracted; VIFs: Variance Inflation Factors; DPR: Doctor-Patient Relationship; CA: Conflict Avoidance. could be useful in increasing medical departments’ moti- vation to improve doctor-patient relationship and reduce Acknowledgements conflicts; furthermore, it can yield solutions for training The authors thank all study participants for their contribution to the research. Deng et al. BMC Fam Pract (2021) 22:191 Page 10 of 11 Authors’ contributions 11. Frajerman A, Morvan Y, Krebs M, et al. Burnout in medical students DG introduced the concept of this paper. CW performed date analysis. DG and before residency: A systematic review and meta-analysis. Eur Psychiatr. FC wrote the first draft. YM, LJ, MX and LL reviewed the paper and provided 2019;55(1):36–42. critical revisions. All authors drafted and critically reviewed this manuscript 12. Willard-Grace R, Knox M, Huang B, et al. Burnout and health care work- and approved the final version. force turnover. Ann Fam Med. 2019;17(1):36–41. 13. Wu L, Qi L, Li Y. Challenges faced by young Chinese doctors. Lancet. Funding 2016;387(10028):1617. This research is supported by National Natural Science Foundation of China 14. Low Z, Yeo K, Sharma V, et al. Prevalence of burnout in medical and (Nos. 71971072, 71601062, 71771074, 71971074). The funding body did not surgical residents: A meta-analysis. 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Linking doctor-patient relationship to medical residents’ work engagement: The influences of role overload and conflict avoidance

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Abstract

Background: Chinese residents’ practical work experiences are different from those described in Western studies. To explore potential mechanisms underlying the effects of doctor-patient relationships on medical residents’ work engagement, verifying a posited mediating effect of role overload, and moderating effect of conflict avoidance, in the Chinese context. Methods: Based on the conservation of resources theory, a composite model was constructed. This study’s data were collected from four different Chinese tertiary hospitals; 195 residents undergoing regularization training took this survey. Hierarchical moderated and mediated regression analyses were utilized. Results: Doctor-patient relationship were found to be positively related to residents’ work engagement (β=0.31, p≤0.001). Role overload partially mediated the effect of these relationships on work engagement, and the moderat - ing role of conflict avoidance in the relationship between doctor-patient relationship and conflict avoidance was negative. Conclusion: Maintaining good doctor-patient relationship can prompt residents to increase their engagement in work in order to meet their patients’ needs. Furthermore, role overload has a particular influence in early career stages. Not only is it necessary for residents to gain a sense of recognition and support while they carry out their job respon- sibilities, especially while dealing with complex doctor-patient relationship, but it is also important to create work environments that can help residents shape their professional competency. Keywords: Doctor-patient relationship, Work engagement, Role overload, Conflict avoidance that work engagement is positively related to enhanc- Introduction ing performance and achieving goals [1, 2]. Kahn (1990) The past five to ten years have witnessed the emergence originally pioneered the concept of personal engagement of a wealth of human resource management research with work as employees “bring in” their personal selves focusing on work engagement, which has demonstrated to their work role, engaging and expressing personal physically, cognitively and emotionally during role per- formances [3], and came to be recognized as an organiza- *Correspondence: cpfeng@hfut.edu.cn School of Management, Hefei University of Technology, Hefei, Anhui tional element that counteracts job burnout and is closely Province 230009, P.R. China related to positive organizational results [4]. More work Full list of author information is available at the end of the article © The Author(s) 2021. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Deng et al. BMC Fam Pract (2021) 22:191 Page 2 of 11 engagement makes work state more effective: higher effi - occurring due to opposition to hospital policies. There - ciency, vigor, dedication, focus and flow state, as well as fore, we introduced the variable of conflict avoidance (see lower turnover intention [5–8]. Thus, we hold that work “The moderating effect of conflict avoidance” section), engagement is a key factor ensuring the success of health which Chinese residents may find important to help organizations and the lasting competitiveness of medical them deal with doctor-patient relationship and tasks. professionals [1, 9]. This makes it a critical issue in medi - To investigate these issues, we adopted the conser- cal education research. The challenges raised by high vation of resources theory and proposed a theoretical burnout rates during medical residency training in vari- model that tried to explore the potential mechanisms ous countries highlight the importance of ensuring high underlying the effect of doctor-patient relationship on work engagement, harmonious doctor-patient relation- residents’ work engagement from the perspective of resi- ship, and reasonable role positioning and task allocation dents and used an empirical research method; in addi- within a complex medical environment [10, 11]. There tion, we attempted to verify the mediating effects of role have been impressive advances in the empirical and theo- overload and the moderating effects of conflict avoidance retical research on work engagement; however, certain in the model (See Fig. 1). aspects remain to be understood, which could lead to a better understanding of its underlying mechanisms. For Theoretical background and hypotheses example, research on the mechanisms underlying work Doctor‑patient relationship and work engagement engagement in the health field is insufficient, particu - Work engagement can be broken down into emotional larly regarding effective work engagement among front- or psychological engagement, essentially the degree to line medical staff [12]. From the perspective of residents’ which the worker wants to contribute, and actual engage- experiences, work engagement-related research involving ment, or the actual energy and effort they do contribute factors operating between individuals and work situa- and the results. Both are directly linked to residents’ per- tions are still lacking, including doctor-patient conflicts, formance [16, 17]. In addition to their work attitudes, role overload, conflict avoidance, and so on. we need to understand residents’ attitudes toward doc- In China, the large, rapidly aging population has tor-patient relationship [18]. In most countries, doctor- strained medical resources; the full liberalization of patient relationship is considered more important than the former two-child policy and growing awareness of any other social relationships except familial relation- increasingly affordable access to public health care have ships [19]. Residents are the direct suppliers of medi- exacerbated this problem [13]. Given the special condi- cal services and reliable sources of health information. tions in China, Chinese residents’ practical work expe- u Th s, the status of the relationships with their patients riences are different from those described in existing, influences the high-quality medical care provision that large Western studies [14]. Chinese residents experience patients experience. Family members are also vital stake- workload and thus they are facing time pressure and holders because, in most cases, they are the patients’ chief stress [15]. Furthermore, because the Chinese standard- supporters and often decision-makers [20, 21]. Thus, the ized training system is still in an exploratory process, role relationships between doctors and patients’ families also overload often occurs because of residents’ unclear role play a key role in treatment and care experience. positioning and unreasonable division of labor (see “The There are several studies using doctor-patient conflict mediating effect of role overload ” section). Like most to represent the doctor-patient relationship, because Asian cultures, China deeply reveres values such as har- conflict is an utmost important relational outcome, mony, collectivism, and social dedication, and Chinese especially in the context of Chinese medical treatment people also support strict government control of pub- [20, 22, 23]. The degree of conflict with patients (and lic hospitals. In many cases, fearing negative effects on their families; henceforth, however, “doctor-patient their future careers, residents deliberately avoid all kinds relationship”) can deeply influence residents’ future of potential doctor-patient conflicts, including those career lives. Training residents to pay greater attention Conflict avoidance Doctor-patient relationships Role overload Work engagement Fig. 1 Holistic hypothetical model D eng et al. BMC Fam Pract (2021) 22:191 Page 3 of 11 to patients and avoid conflict with them during the u Th s, good doctor-patient relationship (that is, lower early periods of their careers could be very beneficial conflict rate between doctors and patients as well as for the patients, the residents themselves, and the med- their families) should positively predict residents’ work ical system as a whole [18]. With experience, residents engagement. may be able to better perceive the degree of doctor- patient conflicts and the status of doctor-patient rela - Hypothesis 1 (H1) tionship; this could considerably influence whether the Doctor-patient relationship positively influences the behavioral strategies they adopt will be patient-cen- work engagement of residents. tered or doctor-centered. In patient-centered behav- ioral strategies, doctors prioritize a more humanistic The mediating effect of role overload spirit, develop greater work engagement, and proac- Role overload describes a condition under which indi- tively provide medical services that can best meet their viduals lack the time or energy to meet their role expec- patients’ needs; this results in higher patient satisfac- tations (whether those expectations originate in others tion [24–26]. In contrast, doctor-centered approaches or in oneself ) [32]. In hospital settings, “role senders” or are paternalistic in nature; in this approach, doctors deciders of residents’ roles are typically supervisors or are more likely to emphasize their own interests and clinical teachers. Because they work at the frontlines of take defensive medical actions to protect themselves. clinical practice, residents have high contact frequency During the diagnosis and treatment processes, they with patients [33]; thus, their roles are also affected by are more likely to have ideas that differ from those of the requirements of and feedback from patients and their their patients, especially with regard to certain medical families: that is, their role expectations of the residents. behaviors, methods, attitudes, and consequences; thus, u Th s, residents must also undertake tasks unrelated to this approach produces a greater degree of doctor- their training [34]; for example, in some tertiary hospitals patient conflict [18]. lacking adequate beds, patients may seek the assistance The conservation of resources theory holds that of residents they have good relationships with to arrange groups with fewer occupational resources [27], such as beds for them in advance. beginner residents, are extremely sensitive to occupa- Most research opinions in the past have indicated tional resource depletion. The gain spiral of resources that, from an organizational management perspective, principle [28, 29] holds that if residents maintain good role overload is harmful, causing stress, exhaustion and relationships with patients, they will receive greater degrading care [35, 36]. In contrast, well-controlled and support and recognition, ideally yielding a conditional -defined roles and adequate discretionary rites can allevi - resource that benefits their work. At the same time, ate these difficulties and even stimulate residents to work recognition received from patients and their families harder, raising their work engagement [37]. The biggest functions as a kind of professional stimulation that can feature of workplace learning is “learning by doing” [38]; promote residents’ sense of achievement and self-satis- in medical environments, residents may experience role faction, which can also be counted as (“personal charac- overload because they often aim to gain more profes- teristic”) resources. Residents possessing more resources sional training and experience accumulation outside the are more likely to acquire new resources and acquire formal scope of their training [39], but at the same time, added value of resources. Investing in these resources, this may be the only way for them to gain certain kinds they may counteract resource loss, and as a result may of experience such as experience with ethical issues and become more dedicated and increase their work engage- may be effective to help them build their professional ment. According to previous research [30, 31], good doc- reputation [40]. tor-patient relationship can be considered as to be a job In addition, the mediation function of role over- resource, which is able to activate a motivational process load may be especially large at the resident stage, the that contributes to the achievement of training goals, it “establishment stage” of this career, which compared to can avoid costly psychological and physical costs, foster ‘maintenance” and “disengagement” stages is marked by residents’ growth, increase career possibility, provide the need to root oneself, learn and become known (the opportunities for residents to learn; and satisfy needs for “grounding” process) and hence by less concern among clinical work autonomy and competence [30, 31]. Good residents for role overload, as they are more focused on doctor-patient relationship can also increase individual achieving success. Role overload may be perceived as less willingness to devote one’s efforts and abilities to the a burden than a challenge or necessary sacrifice, accord - training task, and these perceptions and beliefs increase ing to Jones et  al. [41], residents who are in this period the degree to which residents are willing to invest their are usually eager to build their reputation in medical selves into their role performances [30, 31]. industry by achieving good performance, in most cases, Deng et al. BMC Fam Pract (2021) 22:191 Page 4 of 11 role overload is considered as necessary sacrifice to gain are more likely to view the resources they do have as pre- achievements. cious and to do their best to avoid losing their resources; however, usually, they are unable to do so, and they may Hypothesis 2 (H2) even end up losing more resources [28, 52]. For instance, Role overload mediates the relationship between doc- some residents, who may not be skillful at avoiding con- tor-patient relationship and the work engagement of flicts, may attempt to control their emotions in order to residents. improve doctor-patient relationship in the long term; however, these residents may consequently face more The moderating effect of conflict avoidance negative emotions from themselves as a result of their Conflict avoidance involves refusing to engage in any efforts at self-control. In this way, decreasing conflict may conflict and, furthermore, positively engaging in actions thus lead to resource loss and greater role overload. to solve conflict [42]. The concept of conflict avoidance is highly relevant in many Asian cultures, and especially Hypothesis 3 (H3) in Chinese culture [43, 44]. The Chinese Confucian tradi - The effect of doctor-patient relationship on role overload tion holds harmony to be a core value and thus encour- is negative moderated by conflict avoidance. ages people to tolerate interpersonal disagreements and transgressions [45]. Conversely, pursuing conflicts with Samples and procedures others can cause individuals to lose face in such societies, This study’s data was collected as part of a larger ques - and losing face, in turn, can bring shame to themselves tionnaire survey, which was administered to residents and others [46]. Thus, conflict avoidance helps to protect in five tertiary hospitals (as only such hospitals provide a relationship between two parties of conflict who may residency training in China) located in the southeast and have differing opinions; it lowers the possibility of aggres - central regions of China. Our study included residents sion from either side and maintains the positive images of from the following clinical departments: internal medi- all involved parties [44, 47]. Thus, Chinese people tend to cine, surgery, pediatrics, obstetrics, community medi- do their best to maintain harmonious working relation- cine, intensive care unit (ICU), emergency, psychiatry, ships, viewing this as a mature behavior with high moral and so on. The survey instrument included a large num - value. ber of variables related to residents’ attitudes and per- In Chinese traditional culture, doctors are expected to ceptions, which allowed us to test the above-developed meet high role expectations; to be considered outstand- hypotheses. First, we explained the background and ing, doctors must have high moral standards. Most Chi- goals of our research to residents’ managers or infor- nese people have deeply embedded this mode of value mal resident organizations in hospitals via in-person recognition. Many young residents also perceive their visits, phone, or social networking platforms (e.g., QQ, careers to have high role requirements and expectations; WeChat). After receiving these organizations’ approval, they believe that having conflicts with patients and their we started our field investigation. Participation in this families indicates a lack of professionalism and moral research was voluntary, and anonymity was assured to spirit [48]. It could also affect their professional repu - all participants. The survey interviews happened during tation and future career development, so their aware- residents’ off hours, lasting for an average of 20 minutes, ness of conflict avoidance is very strong. However, some each questionnaire concludes 70 questions and it covered residents show a very weak awareness of conflict avoid - residents’ attitudes, perceptions and their background ance; reasons for this variation include individual- and information. In addition to 31 questionnaires that were cultural-level differences and lack of communication and later mailed to the researchers, 141 were collected on interpersonal skills [48–50]. In situations where they face site. Of these 195 questionnaires (65% response rate), 23 emotional challenges, some residents are unable to access were discarded because of data missing. We examined or use effective emotional management strategies, and it the differences of resident gender, age, marriage, educa - is easy for them to experience conflicts with patients and tion, and doctor qualification between the valid partici - patients’ families [51]. Thus, in this study, the degree of pants and the discarded samples, and the results of t-test conflict avoidance among residents showed variability. showed no significant difference. As stated previously, according to conservation of The demographic profiles of the 172 valid participants resources theory [27], conflict avoidance, as a measuring are presented in terms of the following demographic standard for cultural values, moderates the relationship variables: gender, age, education, and teachers rank. The between residents’ conflicts with patients and role over - average age of respondents was approximately 30 years, load in the Chinese context. Individuals vary in sensitive- 54.1% were female and 45.9% male. Of the respondents, ness to resource losses: those who have fewer resources 33.7% were married and 71.5% had passed the medical D eng et al. BMC Fam Pract (2021) 22:191 Page 5 of 11 qualification exam. Participants also reported that 47.6% Table 1 Confirmatory factor analysis of them had a bachelor’s degree and 51.7% had a master’s Variables Cronbach’s α Factor loading AVE CR degree. doctor-patient relationship 0.81 0.80-0.91 0.73 0.89 Conflict avoidance 0.85 0.71-0.88 0.63 0.90 Variable measurement Role overload 0.84 0.73-0.86 0.62 0.89 All the measurement items were evaluated at the indi- Work engagement 0.88 0.69-0.84 0.58 0.92 vidual level using a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). The scales were translated from English to modern Mandarin, Results and retranslating the final version back into the original Reliability and validity language. This procedure enabled a group of experts to For all multi-item constructs, the reliability and validity ensure the accuracy of the meaning. of measurements were evaluated using confirmatory fac - tor analysis (CFA). Table  1 shows the CFA results. The Cronbach’s α reflects the reliability of the variables. The Work engagement of residents Cronbach’s α value of each construct with multiple items Work engagement was measured with a nine-item scale is higher than 0.7, which suggests high internal consist- adapted from Thomas [53]. An example item from the ency reliability. scale is “I am willing to really push myself to reach chal- The convergent validity was measured by Composite lenging work goals”. Reliability (CR) and Average Variance Extracted (AVE). As shown in Table 1, the value of CR of each construct is Doctor‑patient relationship higher than 0.7, and the value of AVE of every construct This variable was assessed with three items developed is greater than 0.5, implying high convergent validity of by Lee et al. [20]. We measured the degree of differences the measurements. and disagreements between residents and patients on The indicator factor loading of every item is higher personal issues, patient care issues and the way work is than 0.6, showing that discriminant validity is adequate. done. A sample item included “For residents and patients In addition, the discriminant validity was also tested by or their families, how would you rate the degree to which the comparison between the correlations among con- there are disagreements over personal issues”. structs and square root of the AVE. In Table 2, the values of the square root of AVE are on the diagonal. Each con- struct’s correlations with other constructs is lower than Role overload the square root of AVE scores of this construct, which It was measured with the unidimensional scale of role means a high discriminant validity of the measurements overload [32]. It consists of six items. An example item is in this study. “I have to do things that I do not really have the time and energy for”. Common method bias First, we adopted Harman’s one-factor test [56]. The result showed that all items were categorized into four Conflict avoidance factors, with eigenvalues greater than 1.0, which accounts We adopted the scales of Park and Nawakitphaitoon [43], for 62.39% of the total variance, and the first factor which is based on the research of Morris [54]. An exam- accounts for 27.56% of the variance. Then, we performed ple item is “I believe it is better to keep negative opinions confirmatory factor analysis and compared the model fit to ourselves rather than create hard feelings”. among the measurement model, one-factor model, and measurement model with method factor [57]. The results Control variables showed that the fit of our measurement model (χ [183] = Following Becker et  al.’s [55] recommendation, we con- 335.79, CFI =0.91, RMSEA = 0.07, RMR=0.05) was sig- trolled five variables that are theoretically related or have nificantly better than the fit of the model with only one been found to be empirically related to residents. For method factor (χ [189] = 1097.64, CFI = 0.43, RMSEA examples, gender was measured as 1=Female, 2=Male; = 0.17, RMR=0.12). Also, we included a common education level indicates the degree level of residents, method factor in the measurement model. The results including 1=below college diploma, 2=college diploma, of the measurement model with both constructs and a 3=bachelor, 4=master and above; marriage was operated method factor (χ [162] = 286.25, CFI = 0.92, RMSEA = as 1=Yes, 2=No. 0.07, RMR=0.04) marginally improved the model fit of Deng et al. BMC Fam Pract (2021) 22:191 Page 6 of 11 Table 2 Correlations and discriminant validity Variables Means S.D. 1 2 3 4 5 6 7 8 9 1 Gender 1.43 0.49 - 2 Age 2.36 0.65 0.05 - *** 3 Marriage 1.58 0.47 0.52 -0.01 - 4 Education 2.37 0.54 -0.03 0.19 -0.02 - ** *** 5 Doctor qualification 1.06 0.56 0.26 -0.01 0.39 0.02 - 6 doctor-patient relationship 3.46 0.66 0.14 -0.06 0.16 0.05 0.12 (0.85) 7 Conflict avoidance 3.56 0.71 -0.02 -0.01 -0.07 -0.17 -0.08 0.07 (0.80) ** ** 8 Role overload 3.48 0.72 0.06 -0.12 0.07 -0.02 -0.03 0.24 0.20 (0.79) *** ** ** 9 Work engagement 3.71 0.57 0.10 0.01 0.10 -0.06 0.14 0.32 0.23 0.21 (0.76) Note: n =172. *p ≤ 0.05; **p ≤ 0.01; ***p ≤0.001; The relationship between doctor‑patient relationship the measurement model with only constructs (∆CFI= and work engagement 0.01, ∆RMR=0.01). The path coefficients and their sig - First, we reported all control variables with the depend- nificance were similar between the two measurement ent variable. Model 1 includes only the control variables models. Therefore, common method bias is not a serious (i.e. gender, age, marriage, education, doctor qualifica - problem for our study [58]. tion) and explains a relatively small part of the variance in the dependent variable (R =0.04). The results of Model 1 showed that gender (β=0.03, p>0.05), age (β=0.03, Hypotheses tests p>0.05), marriage (β=0.05, p>0.05), education (β=- To test our hypotheses, we employed hierarchi- 0.09, p>0.05), doctor qualification (β=0.14, p>0.05) do cal regression analyses via SPSS 22. We reported the not have significant effect on work engagement. Sub - standardized coefficients in Table  3. To reduce the sequently, we added the independent variable to test issue of multicollinearity, we mean-centered and the main effect. As predicted, the results of Model 2 in standardized the independent and moderator vari- Table  3 shows that doctor-patient relationship is posi- ables before calculating the interaction term [59]. And tively related to doctors’ work engagement (β=0.31, the variance inflation factors (VIFs) are all below 2.0 p≤0.001). Thus, H1 was supported, which means that in these models, also suggesting that multicollinearity the better doctor-patient relationship, the higher level of issue is not significant in this study. work engagement. Table 3 Results of the regression analysis Work engagement Role overload Independent variables Model1 Model2 Model3 Model4 Model5 Model6 Model7 Controls Gender 0.03 0.01 0.00 0.05 0.03 0.03 -0.00 Age 0.03 0.05 0.07 -0.13 -0.11 -0.11 -0.12 Marriage 0.05 0.01 0.01 0.05 0.02 0.03 0.06 Education -0.09 -0.10 -0.10 0.01 0.00 0.04 0.03 Doctor qualification 0.14 0.12 0.13 -0.06 -0.08 -0.07 -0.09 *** ** ** ** ** Doctor-patient relationship (DPR) 0.31 0.27 0.25 0.23 0.24 * * Conflict avoidance (CA) 0.19 0.18 Role overload 0.16 DPR*CA -0.16 R 0.04 0.13 0.15 0.03 0.09 0.12 0.15 ∆R 0.04 0.09 0.02 0.03 0.06 0.03 0.03 ** ** * * ** F 1.10 3.28 3.49 0.77 2.09 2.63 2.86 *** * ** * * ∆F 1.10 15.79 4.45 0.77 9.77 5.93 4.29 Note: n=172. *p ≤ 0.05; **p ≤ 0.01; ***p ≤0.001 D eng et al. BMC Fam Pract (2021) 22:191 Page 7 of 11 The mediating effect of role overload overload. We adopted hierarchical moderated regression H2 predicted the effect of doctor-patient relationship analyses to test this hypothesis. First we entered control on work engagement is mediated by role overload. We variables and independent variable (i.e. doctor-patient used the steps of Baron and Kenny [60]. First, it has been relationship) into the regression. Then the moderator (i.e. confirmed that doctor-patient relationship is positively conflict avoidance) was incorporated. Finally, we added related to doctors’ work engagement (β=0.31, p≤0.001, the interaction between doctor-patient relationship and Model 2), indicating that the independent variable is conflict avoidance into the regression. Results in Table  3 significantly related to the dependent variable. In Model showed that the interaction between doctor-patient rela- 4, the results showed that the control variables do not tionship and conflict avoidance was negatively related to have significant effect on role overload (gender: β=0.05, role overload (β=-0.16, p≤0.05, Model 7). Accordingly, p>0.05; age: β=-0.13, p>0.05; marriage: β=0.05, p>0.05; H3 was supported. education: β=0.01, p>0.05; doctor qualification: β=-0.06, To further explore the patterns of the significant inter - p>0.05). Then, doctor-patient relationship is positively action effects that supported the hypotheses, we plot - related to their role overload (β=0.25, p≤0.01, Model 5), ted the significant interaction effects using one standard suggesting that the independent variable is significantly deviation above and below the mean to represent high related to the mediator. Next, we entered role over- and low levels of the moderating variables [59]. Figure  2 load as the mediating factor in Model 3, and found that shows that the slopes are much steeper when conflict role overload is positively related to work engagement avoidance is low than high. We also tested the statisti- (β=0.16, p≤0.05, Model 3), showing that the mediator cal significance of these two slopes [62]. When conflict is significantly related to the dependent variable. Finally, avoidance is one standard deviation below the mean, the when role overload was incorporated into the regression coefficient of doctor-patient relationship on role over - in which work engagement was the dependent variable, load (β=0.34, t=3.67) is significantly higher than coeffi - the effect of doctor-patient relationship on work engage - cient when conflict avoidance is one standard deviation ment remained significant, but the coefficient of doctor- above the mean (β=0.15, t=1.73). The results confirmed patient relationship became smaller (β=0.27, p≤0.01, that conflict avoidance negatively moderated the effect of Model 3) than coefficient in Model 2 when role overload doctor-patient relationship on role overload. was not included (β=0.31, p≤0.001, Model 2). The results show that the role overload partly mediated the effect of Discussion and Conclusion doctor-patient relationship on work engagement. There - Discussion fore, H2 was supported. Past studies have shown that doctor-patient relation- In addition, to further confirm the mediating effect, we ship can influence health outcomes [63, 64]; however, also conducted a bias-corrected bootstrapping procedure few researchers have explored the impact and underlying [61]. The results were shown in Table  4. The results of mechanisms of conflicts with regard to residents’ occu - bootstrapping suggest that the indirect effect of doctor- pational behaviors. Our study’s empirical results showed patient relationship on work engagement via role over- that maintaining good doctor-patient relationship signifi - load was significant and positive (95 per cent CI = 0.0013 cantly improved residents’ work engagement. The find - to 0.0834; excluding 0; indirect effect = 0.0352). There - ings suggest that maintenance of good doctor-patient fore, Hypothesis 2 was supported. relationship could trigger a sense of reciprocity among residents and patients, thus leading residents to work The moderating effect of conflict avoidance better in an effort to meet their patients’ needs. u Th s, H3 proposed that conflict avoidance moderated the rela - hospitals can use effective control of doctor-patient con - tionship between doctor-patient relationship and role flicts as an important method of achieving improvements and positive results in residents’ professional training. Residents themselves must improve their doctor-patient Table 4 Indirect effects of doctor-patient relationship on work relationship and reduce conflicts by improving their own engagement clinical ability, communication and interpersonal skills, Path: Doctor‑patient relationship ‑ Role overload ‑ Work and so on; for their part, hospitals should build a positive engagement atmosphere for doctor-patient relationship, as this is vital to improve residency programs and training performance Bootstrap—indirect effect 0.0352 [65]. Standard error 0.0211 Unexpectedly, we identified role overload as a potential Lower limit 95% CI 0.0013 positive mediator between doctor-patient relationship Upper limit 95% CI 0.0834 Note: n=172; 5000 resamples Deng et al. BMC Fam Pract (2021) 22:191 Page 8 of 11 3.5 2.5 Low conflict avoidance High conflict avoidance 1.5 Low doctor-patient High doctor-patient relationship relationship Fig. 2 Moderating role of conflict avoidance and residents’ work engagement; as the saying goes, Unlike previous research [67, 68], this study treated “with great power comes great responsibility,” and resi- conflict avoidance as more than just an emotional man - dents faced with overload may find themselves motivated agement strategy for individuals in the medical field, to engage more deeply and improve their relationships. verifying its negative moderating effect on doctor- Role overload variables have been used not only in patient conflicts in the Chinese medical environment. research dealing with job burnout but also in research This research used a key forecasting factor and discussed related to doctor-patient relationship and work engage- conflict avoidance by proposing and testing a theoreti - ment. Although the role overload phenomenon may cal model under which conflict avoidance affected the seem very obvious from the viewpoint of residents, we relationship between doctor-patient conflict and role still need to determine whether these results can be gen- overload. The findings expand the scope of research on eralized to medical workers beyond the research par- mechanisms affecting doctor-patient relationship and ticipants here. Nevertheless, our current results can spur help explain the function of conflict avoidance with more fundamental theorizing on how role overload can regard to the boundary condition of this relationship help increase residents’ enthusiasm and energy at work in the Chinese cultural background. These researchers’ and help residents grow professionally and personally. results show that administration departments are respon- This approach is more practically meaningful than simply sible for medical residents should place more attention discussing reasons for residents’ job burnout. The con - on individual-level differences in conflict avoidance [9]. servation of resources theory holds that positive power is For residents with low conflict avoidance, this negative the vital motive that allows residents to continue devel- work experience may be even more pronounced. There - oping in their career lives [66]. This perspective leads to fore, we must realize that, at this early stage of standard- some key questions: how can immature physicians gain ized residency training in China, we cannot ignore these a sense of recognition and support from work by dealing differences. with complex doctor-patient relationship; how can they use missions in the work sphere to shape their profes- Conclusion sional ability; and how can they accumulate experience This paper utilized an empirical research method to from interactions with patients in order to build better explore the potential mechanisms underlying the effect competence. of doctor-patient relationship on medical residents’ work Role overload D eng et al. BMC Fam Pract (2021) 22:191 Page 9 of 11 engagement and verified the mediating effect of role departments to improve their training results and, at the overload and the moderating effect of conflict avoidance same time, provide young physicians with new methods in the model. Doctor-patient relationship in China is fac- to improve their work engagement and keep good rela- ing challenges, and residents are being subjected to over- tionships with patients and patients’ families. load and overtimes; researchers, educators, and clinical The findings suggested that teachers should understand leaders must recognize the complex situations and take and help each resident build a targeted relationship; effective actions to build good doctor-patient relation - guide residents to their best practices for doctor-patient ship and maintain physicians’ work engagement at an intimacy, appreciation and attention, feedback and criti- optimum level. cism, and crisis emotional support. We also suggest that health care policy makers work with residents to develop Theoretical contributions a common strategy in order to make residents get the The theoretical contributions of our study to the litera - most effective interaction for patients, individuals, teams ture placed at the intersection between doctor-patient and the residency programs, let residents propose their relationship and medical human resource management. thoughts on the aspects of assignment arrangements Under the conservation of resources theory, we went and role behaviors. Integrate doctor-patient relationship beyond the well-explored traditional doctor-patient rela- building and engagement training into current residency tionship or employee engagement study [28, 29]. This is programs, develop specific, measurable and compre - the first to empirically investigate residents’ employee hensive performance criteria, in order to make the new engagement as an outcome of doctor-patient relation- requirement of capability operate, and develop a path ship. Also, very little is known concerning the roles that helps residents achieve their career ideals and high of mediator and moderator variables in the relation- level of dedication status. ship between doctor-patient relationship and residents’ engagement. The empirical model suggests that the effect Limitations of doctor-patient relationship on resident behavior is not Although this study possesses a number of strengths, as straightforward as expected. It cannot be overlooked there are some limitations. First, the study is cross- that what really matters is the role of role overload and sectional in design, thus any causal conclusions drawn conflict avoidance plays. Thus, the results also spur more should be viewed with caution. Future research could fundamental theorizing on how doctor-patient interac- employ a longitudinal study and multi-level data from tion serves as a mechanism to integrate residents into multiple respondents to extend our findings. Second, clinical practice and to help them to grow. the generalizability of this study may be limited because the sample was restricted to Chinese tertiary hospitals Practice implications from the south-east region and the central region. Hence, The problem of doctor-patient conflicts has been it could be recommended that future research should resolved in some successful health organizations; how- be expanded the sample source and size to address this ever, until recently, there has been little academic drawback. Third, although this study considered several research on the mechanisms underlying non-conflicting objective control variables, future research may include doctor-patient relationship. Since the problem-directed a more comprehensive list of control variables, includ- research model still forms a core aspect of academic ing training levels, departments, length of time, training research, it is necessary to develop a clear understanding satisfaction, and so on. Finally, the findings suggest that of why we need to emphasize doctor-patient relationship good doctor-patient relationship can prompt residents to management and how it can improve residents’ work increase their engagement. To test more potential mech- engagement. We identified factors that could explain res - anisms, future research should include self- and other- idents’ work engagement improvement and stated how report of doctor-patient relationship and residents’ work these factors can be utilized in Chinese medical settings engagement, as well as potential mediators such as big in the future. The model we created does not include all five personality, person-organization fit of residents. potential mediating and modifying variables, but it pro- vides a systematic, logical explanation of doctor-patient Abbreviations relationship, physician burnout, work engagement, and ICU: Intensive Care Unit; CFA: Confirmatory Factor Analysis; CR: Composite Reli- mechanisms among them in this setting. This knowledge ability; AVE: Average Variance Extracted; VIFs: Variance Inflation Factors; DPR: Doctor-Patient Relationship; CA: Conflict Avoidance. could be useful in increasing medical departments’ moti- vation to improve doctor-patient relationship and reduce Acknowledgements conflicts; furthermore, it can yield solutions for training The authors thank all study participants for their contribution to the research. Deng et al. BMC Fam Pract (2021) 22:191 Page 10 of 11 Authors’ contributions 11. Frajerman A, Morvan Y, Krebs M, et al. Burnout in medical students DG introduced the concept of this paper. CW performed date analysis. DG and before residency: A systematic review and meta-analysis. Eur Psychiatr. FC wrote the first draft. YM, LJ, MX and LL reviewed the paper and provided 2019;55(1):36–42. critical revisions. All authors drafted and critically reviewed this manuscript 12. Willard-Grace R, Knox M, Huang B, et al. Burnout and health care work- and approved the final version. force turnover. Ann Fam Med. 2019;17(1):36–41. 13. Wu L, Qi L, Li Y. Challenges faced by young Chinese doctors. Lancet. Funding 2016;387(10028):1617. This research is supported by National Natural Science Foundation of China 14. Low Z, Yeo K, Sharma V, et al. Prevalence of burnout in medical and (Nos. 71971072, 71601062, 71771074, 71971074). The funding body did not surgical residents: A meta-analysis. 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Journal

BMC Family PracticeSpringer Journals

Published: Sep 24, 2021

Keywords: Doctor-patient relationship; Work engagement; Role overload; Conflict avoidance

References