How Physicians' Perceptions of Satisfaction and Morale Affect

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How Physicians’ Perceptions of Satisfaction and Morale Affect How Physicians’ Perceptions of Satisfaction and Morale Affect

Retention Retention

Ernest George Britton

Walden University

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Walden University

College of Management and Human Potential

This is to certify that the doctoral study by

Ernest George Britton

has been found to be complete and satisfactory in all respects,

and that any and all revisions required by

the review committee have been made.

Review Committee

Dr. Edward Paluch, Committee Chairperson, Doctor of Business Administration Faculty

Dr. Michael Campo, Committee Member, Doctor of Business Administration Faculty

Chief Academic Officer and Provost

Sue Subocz, Ph.D.

Walden University

2024

Abstract

How Physicians’ Perceptions of Satisfaction and Morale Affect Retention

Ernest George Britton

MBA, University of Findlay, 1999

MS, University of Findlay, 1998

BS, University of Akron, 1994

Doctoral Study Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Business Administration

Walden University

February 2024

Abstract

Physician turnover affects care delivery and contributes to costs, emphasizing the need for

retention to minimize unnecessary costs of hiring, training, and lost productivity among

healthcare organizations. Healthcare leaders tend to be concerned about the negative affects that

physician turnover has on patient care, profitability, and organizational viability. The U.S.

healthcare system may benefit from reduced expenditures associated with retention. Grounded in

Ellenbecker’s job retention model, the purpose of this qualitative multiple-case study was to

explore strategies healthcare organizational leaders use to retain employed primary care and

internal medicine physicians. The participants comprised six physician leaders from three

healthcare organizations in North Carolina. Data were collected through semistructured

interviews and analyzed using thematic analysis and applied interpretative phenomenological

analysis. Two key themes emerged, revealing the need to sustain the financial wants and needs of

physicians by effectively collaborating and communicating with them. To meet financial needs, it

is recommended physicians receive a base salary and additional commission for every extra

patient they see to encourage patient care. Leadership should effectually communicate by

conducting regularly scheduled interactions with physician subordinates in a setting and manner

that allows for open an honest communication. Future research should include other stakeholders

of the healthcare sector to study the phenomenon of interest. The implications for positive social

change include the potential to enhance physician retention, which may lead to improved patient

outcomes, reduced healthcare costs, and the overall well-being of communities.

How Physicians’ Perceptions of Satisfaction and Morale Affect Retention

Ernest George Britton

MBA, University of Findlay, 1999

MS, University of Findlay, 1998

BS, University of Akron, 1994

Doctoral Study Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Business Administration

Walden University

February 2024

Dedication

Those who completed this journey before me know the effort and sacrifice necessary to

succeed. I dedicate this study to my family of my loving wife Mary, my two beautiful and

brilliant children, Miles and Isabelle, my grandfather George Merkt, my parents Ernest and

Shirley Britton, my sister Tamra Britton, and my brother Gregory Britton. My family always

encouraged me to follow my dreams and to persevere and finish what I started. They were my

inspiration to succeed. My final graduation, receiving a doctorate degree, would not be possible

without their love.

Acknowledgments

I am extremely grateful to Dr. Ed Paluch, who served as my mentor and chairperson. I

want to thank him for his guidance, encouragement, and patience with me throughout the doctoral

journey. I wish to thank committee members, specifically Dr. Michael Campo, who were

generous with their expertise and purposeful feedback to guide me to my study completion. I

extend my gratitude to Szamor Williams, who took me under his wing and served as my coach to

keep me focused on completion. When the journey became beyond difficult, he gave me wisdom

and guidance. Thank you to all for your support and continuous motivation.

 
i 
Table of Contents 
List of Tables..........................................................................................................................v 
Section 1: Foundation of the Study ..........................................................................................1 
Background of the Problem ...............................................................................................1 
Problem Statement............................................................................................................2 
Purpose Statement ............................................................................................................2 
Nature of the Study ...........................................................................................................3 
Research Question ............................................................................................................4 
Interview Questions ..........................................................................................................4 
Conceptual Framework .....................................................................................................5 
Operational Definitions .....................................................................................................6 
Assumptions, Limitations, and Delimitations......................................................................7 
Assumptions ............................................................................................................. 7 
Limitations................................................................................................................ 7 
Delimitations............................................................................................................. 8 
Significance of the Study ..................................................................................................8 
Contribution to Business Practice ......................................................................................9 
Implications for Social Change ..........................................................................................9 

 
ii 
A Review of the Professional and Academic Literature .......................................................9 
Organization of the Literature Review........................................................................11 
Research Design and Methodological Issues in the Literature ......................................11 
Literature Rationale and Justification for the Current Study ........................................ 15 
Ellenbecker’s Job Retention Model ........................................................................... 16 
Selye’s Stress Theory ............................................................................................... 17 
Stress, Burnout, and Attrition in Healthcare Professionals .......................................... 18 
Morale, Satisfaction, and Retention in Healthcare Professionals.................................. 30 
Summary and Conclusions ..............................................................................................45 
Transition.......................................................................................................................46 
Section 2: The Project ...........................................................................................................47 
Purpose Statement ..........................................................................................................47 
Role of the Researcher ....................................................................................................48 
Participants ....................................................................................................................49 
Research Method and Design ..........................................................................................51 
Research Method ..................................................................................................... 51 
Research Design ...................................................................................................... 53 
Population and Sampling.................................................................................................53 

 
iii 
Ethical Research .............................................................................................................55 
Data Collection Instruments ............................................................................................56 
Data Collection Technique ..............................................................................................57 
Data Organization Technique...........................................................................................59 
Data Analysis .................................................................................................................60 
Becoming Familiar with the Data.............................................................................. 61 
Generating Coding Categories .................................................................................. 61 
Generating Themes .................................................................................................. 62 
Reviewing Themes .................................................................................................. 62 
Defining and Naming Themes .................................................................................. 62 
Reliability and Validity ...................................................................................................63 
Reliability ............................................................................................................... 63 
Validity… ............................................................................................................. 643 
Transition and Summary .................................................................................................64 
Section 3: Application to Professional Practice and Implications for Change ............................66 
Demographics ................................................................................................................67 
Analysis .........................................................................................................................67 
Presentation of Findings ..................................................................................................68 

 
iv 
Thematic Category 1. Challenges Faced in Retaining Primary Care and IM 
Physicians ................................................................................................... 70 
Thematic Category 2. Retention Strategies in Place.................................................... 74 
Alignment with Conceptual Framework .................................................................... 87 
Applications to Professional Practice ...............................................................................89 
Implications for Social Change ........................................................................................90 
Recommendations for Action ..........................................................................................90 
Recommendations for Future Research ............................................................................91 
Reflections .....................................................................................................................92 
Conclusion .....................................................................................................................92 
References ...........................................................................................................................95

 
v 
List of Tables 
Table 1. Literature Review Sources ....................................................................................... 10 
Table 2. Breakdown of the Participants’ Demographics .......................................................... 67 
Table 3. Breakdown of the Total Number of Themes .............................................................. 68 
Table 4. Breakdown of the Complete Study Themes............................................................... 69 
Table 5. Breakdown of the Themes Addressing Thematic Category 1 ...................................... 71 
Table 6. Breakdown of the Themes Addressing Thematic Category 2 ...................................... 75 
 
 

Section 1: Foundation of the Study

The U.S. Department of Health and Human Services (HHS) expects a physician shortage

of 90,000 physicians by 2025, while the average age and chronic disease prevalence continue to

increase in the United States (Kerschner, 2019; Sinsky et al., 2017; Zhang et al., 2020). Increasing

physician retention may benefit U.S. hospitals (Ahmed & Carmody, 2020; Goode et al., 2019;

Koehler et al., 2016; Petrou et al., 2014). There is a need for a purposeful physician retention

strategy to minimize unnecessary costs of hiring, training, and lost productivity (Barnett et al.,

2023; Fibuch & Ahmed, 2015; Goode et al., 2019; Kirch & Petelle, 2017; Long et al., 2020; Pak

et al., 2023).

Background of the Problem

Medical costs in the United States have increased dramatically, now representing 17.8%

of gross domestic product (GDP) and surpassing the economic growth and inflation rate (Abdulai

et al., 2022; Silverman et al., 2022; Stark & Peacock, 2022; U.S. Centers for Medicare &

Medicaid Services, 2016). The U.S. Department of Health and Human Services (HHS) expects a

physician shortage of 90,000 physicians by 2025, while the average age and chronic disease

prevalence continue to increase in the United States (Kerschner, 2019; Sinsky et al., 2017; Zhang

et al., 2020). There is a need for a purposeful physician retention strategy to minimize

unnecessary costs of hiring, training, and lost productivity (Bashar et al., 2022; Fibuch & Ahmed,

2015; Goode et al., 2019; Kirch & Petelle, 2017; Scott et al., 2021).

Relationships between physicians and their patients have implications for patient health

and well-being, as relationships may improve care quality and physician satisfaction (Henry,

2015; Williams et al., 2020b). Increasing physician retention may benefit U.S. hospitals (Barnett

et al., 2023; Dillon et al., 2020; Goode et al., 2019; Koehler et al., 2016; Petrou et al., 2014).

Healthcare changes have added to stressors for physicians, including enhanced accountability and

scrutiny, time limitations, increasing role definition by nonphysicians, and decreasing workplace

control, all of which contribute to burnout (Attipoe et al., 2023; Deville et al., 2020; Gazelle et al.,

2015; Reith, 2018; Shanafelt et al., 2017). Burnout negatively affects physicians’ well-being,

decreases physician retention, worsens patient care, adds to patient noncompliance, contributes to

low physician morale, and prevents organizational unity (Attipoe et al., 2023; Shanafelt et al.,

2017).

Problem Statement

A physician shortage potentially increases negative outcomes for patients. The HHS

anticipates that the United States will have a physician shortage of 90,000 by 2025 (Malayala et

al., 2021). Physicians are integral to population health and well-being (Cahill et al., 2015; Dewa

et al., 2017; Gazelle et al., 2015; Søvold et al., 2021; Tziner et al., 2015). Physician retention

affects care delivery and contributes to costs, emphasizing need for retention (Abayasekara, 2015;

Fibuch & Ahmed, 2015; Hodkinson et al., 2022; Swensen et al., 2016). Recruiting and retaining

physicians benefits the hiring group, individual hire, and patient (Chen et al., 2016; Jennings et

al., 2022; Olson et al., 2019; Panagioti et al., 2018; Petrou et al., 2014). The general business

problem is that a shortage of physicians negatively affects practice viability and patient care

(Hartzband & Groopman, 2020; Lu et al., 2017). The specific business problem is that some

healthcare leaders lack strategies to maximize physician retention.

Purpose Statement

The purpose of this qualitative multiple case study was to explore the strategies that

healthcare organizational leaders use to retain employed primary care and internal medicine

physicians. This study included practicing employed physician leaders in Alexander, Burke,

Caldwell, and Catawba Counties in North Carolina. I collected data through semi structured

interviews with six physician organizational leaders. Addressing this issue is socially significant

because high physician morale is needed to not only increase retention rates, but also optimize

patient-centered care (Henry, 2015; Underdahl et al., 2018). Maximizing retention and patient-

centered care can lead to a higher quality of service delivery and more efficient healthcare system

(Henry, 2015; Jeong et al., 2021; Underdahl et al., 2018).

Nature of the Study

I used a qualitative research methodology to guide this study. I selected a qualitative

design to explore the strategies that healthcare organizational leaders use to retain employed

primary care and internal medicine physicians. I did not select a quantitative approach because

they did not intend to quantify aspects of participants’ experiences.

I selected a multiple case study design to explore and describe a phenomenon within the

specific context regarding the strategies that healthcare organizational leaders use to retain

employed primary care and internal medicine physicians (Shanafelt, 2021; Yin, 2018). I did not

consider mixed-methods research and ethnography appropriate for the current study because such

methodologies are not equipped to yield rich insight into a phenomenon specifically within the

context in which it exists or to provide practical solutions to a pervading problem. I did not select

other qualitative designs, such as grounded theory and phenomenology, because such designs do

not allow for the same level of focus on a particular case as a multiple case study. I conducted

open-ended interviews via Zoom to gain in-depth insight from experts in the field (Lewis, 2015;

Schonlau et al., 2021). The multiple case study design yielded novel evidence based on these one-

on-one interviews with leaders who have been successful in retaining healthcare professionals.

Research Question

The central research question that guided this study was: What retention strategies do

hospital administrators and physician leaders use to retain primary care and internal medicine

physicians?

Interview Questions

During the face-to-face, semi structured interviews, I asked the participants to

answer the following open-ended questions:

1. What is your role for retaining primary care and internal medicine physicians?

2. What retention strategies do you use to maintain physician staffing in your system of primary

care and internal medicine physicians, and how have these strategies contributed to your

organization?

3. What approaches have you taken to overcome impediments or barriers to implementation of

your retention strategies?

4. What are the internal factors that have aided or hampered retention of primary care and internal

medicine physicians?

5. What are the external factors that have aided or hampered recruitment and retention of primary

care and internal medicine physicians?

6. How have governmental entities or programs helped with retention efforts?

7. What measures do you use to monitor, update, or change retention strategies to ensure ongoing

staffing of primary care and internal medicine physicians?

8. What else can you share about strategies that contribute to successful physician retention?

9. Would you like to share any other relevant information that we have not already discussed?

Conceptual Framework

Several models of stress and burnout exist that apply to the process by which

healthcare workers and physicians develop intentions to quit. I selected Ellenbecker’s

(2004) job retention model as the conceptual framework for this study. Within this

theory, Ellenbecker identified antecedents to job satisfaction of healthcare workers,

which are intrinsic and extrinsic job characteristics. Through the model, Ellenbecker

established that job satisfaction is directly related to retention and indirectly related to

retention through intent to stay. I used Ellenbecker’s model as the theoretical framework

to analyze the perceptions of physician leaders regarding the effects of satisfaction and

morale on physician retention. The antecedents to job satisfaction, as identified by

Ellenbecker (2004), were used as a guide in the current study during the data analysis of

physician leader perceptions.

Selye’s (1936) classic stress theory, which explains the process by which

physicians experience stress and become burnt out, is a contrasting supposition. Based on

an understanding of the biological and psychological nature and how stress manifests and

can lead to burnout and attrition, a theoretical model for morale and satisfaction may be

more effectively applied to conceptualize how retention is maximized in healthcare

professionals. One such model of retention that applies specifically to physicians is

Ellenbecker’s (2004) job retention model. This model identifies both intrinsic and

extrinsic antecedents of job retention and intent to stay among physicians. Specifically,

this model suggests that job retention and intent to stay are predicted by a combination of

factors that the professional finds personally rewarding and those that are extrinsic in

nature (Ellenbecker, 2004). Intrinsically rewarding factors that increase job retention vary

according to personal values, but generally include job satisfaction, meaning associated

with the work, and peer relationships (Ellenbecker, 2004). Extrinsically rewarding factors

that can increase retention include financial incentives, recognition at work, and prestige

associated with the position (Ellenbecker, 2004). Scholars have used Ellenbecker’s theory

to predict retention and attrition in healthcare professionals, including physicians (Chen

et al., 2016; Tarcan et al., 2017 Wang et al., 2022). In conducting the current study, I

drew on Ellenbecker’s (2004) theory to classify leaders’ experiences with morale,

satisfaction, and retention as either intrinsically or extrinsically rewarding.

Operational Definitions

The following terms are used throughout the current study:

Extrinsic characteristics: Extrinsic characteristics of job satisfaction include stress and

work load, autonomy and control of work hours, autonomy and control of work activities, salary

and benefits, and perception of and real opportunities for jobs elsewhere (Ellenbecker, 2004).

Intrinsic characteristics: Intrinsic characteristics of job satisfaction include autonomy and

independence in patient relationships, autonomy in the profession, group cohesion with peers and

with physicians, and organizational characteristics (Ellenbecker, 2004).

Job satisfaction: Job satisfaction is defined in this study as the level of enjoyment and

fulfilment physicians express regarding their current positions (Jackson et al., 2018).

Retention: Retention is defined in this study as physicians’ expressed intent to remain in

their current positions (Castle et al., 2020).

Assumptions, Limitations, and Delimitations

Assumptions

I assumed that the sample interviewed would represent the population of employed

family and internal medicine physicians in Alexander, Burke, Caldwell, and Catawba counties in

North Carolina. I also assumed that employee satisfaction and morale might create an

environment for improving organizational performance. Finally, I assumed that the respondents

answered the administered questions honestly and not based on how the respondent believed they

should answer.

Limitations

This study was limited in scope to the four counties of Alexander, Burke, Caldwell, and

Catawba Counties in North Carolina. I adopted a convenience sample, which is exposed to risks

of self-selecting bias and expectancy effects (see Williams et al., 2020a). Furthermore, I had

personal biases, which may have an unwanted influence on the findings of the study (see

Williams et al., 2020a). Another limitation of this study was the lack of outside stakeholder

participation, such as patients and vendors who could potentially provide valuable perspectives

on job satisfaction and morale. Another limitation was the geographical area of the study, as the

study population was recruited from a defined area in North Carolina, which limits the findings’

applicability to physicians practicing elsewhere. I did not explore the views of other specialty

physicians or those who have left practice. I triangulated the findings with previous research and

theory and adopted a systematic approach to analyzing data to minimize these potential

limitations.

Delimitations

I conducted a qualitative multiple case study to explore the strategies that healthcare

organizational leaders use to retain employed primary care and internal medicine physicians.

Delimitations reference the choices a researcher makes to arrive at a feasible way to address a

research topic (Ross & Bibler Zaidi, 2019; Yin, 2018). Interviewees were limited to employed

physicians in Alexander, Burke, Caldwell, and Catawba counties in North Carolina. I did not

include participants living outside these counties or those not employed by a larger care

organization. The sample included six physician leaders specializing in family or internal

medicine and employed for at least 2 years in their current institution. I conducted semi structured

interviews to explore the experiences of the interviewees. Patient interviews are outside the scope

of this study. No interviews were conducted with organization administrators and managers

because I sought only to explore retention strategies based on physicians’ perceptions of how

satisfaction and morale affect retention.

Significance of the Study

As this study relates to healthcare, the findings may indirectly influence business

practice. Specifically, the results from this study may improve understanding of factors that

contribute to physicians’ morale and satisfaction. This evidence may lead to higher retention and

reduced costs associated with attrition and burnout. Findings from this study may contribute to

positive social change and/or the improvement of human or social conditions by promoting the

worth, dignity, and development of physicians. By understanding physician experiences in

relation to morale and satisfaction more fully, healthcare leaders can ensure that their staff are

better equipped to meet the needs of patients. The findings of this study may lead to a more

efficient and effective healthcare system with reduced expenditures associated with retention.

Contribution to Business Practice

Physician retention affects care delivery and contributes to costs, emphasizing need for

retention (Abayasekara, 2015; Fibuch & Ahmed, 2015; Smaggus, 2019; Swensen et al., 2016).

Recruiting and retaining physicians benefits the hiring group, individual hire, and patient (Chen et

al., 2016; Panagioti et al., 2018; Petrou et al., 2014; Weigl, 2022). Physician shortages negatively

affect practice viability and patient care (Lu et al., 2017). Increasing physician retention may

benefit U.S. hospitals (Andah et al., 2021; Goode et al., 2019; Koehler et al., 2016; Petrou et al.,

2014).

Implications for Social Change

Findings from this study may contribute to positive social change and/or the

improvement of human or social conditions by promoting the worth, dignity, and development of

physicians. By understanding physician experiences in relation to morale and satisfaction more

fully, healthcare leaders can ensure that their staff are better equipped to meet the needs of

patients. The findings of this study may lead to a more efficient and effective healthcare system

with reduced expenditures associated with retention and may allow healthcare leaders to develop

strategies to maximize physician retention.

A Review of the Professional and Academic Literature

For the literature review, I included peer-reviewed evidence primarily published within

the past 5 years pertaining to strategies used as a means of retaining primary care physicians.

Although an abundance of research has already been performed on this topic, I provide a

contemporary exploration of this issue and seek to extend the findings of the wide body of

literature that has already documented experiences with stress, burnout, and retention/attrition in

physicians. This literature review also contains seminal sources published more than 5 years ago

as theoretical evidence guiding the understanding of stress, burnout, moral, retention, and attrition

in physicians.

I begin the review with a discussion of major trends in the literature related to key

variables and/or constructs of interest, which include stress, burnout, and attrition in healthcare

professionals; stress, burnout and attrition in physicians; morale, satisfaction, and retention in

healthcare professionals; and morale satisfaction, and retention in physicians. Theoretical

foundations relevant to this study are then explored. I then identify the gaps in the literature and

reflect on why these gaps might exist. The relationships between studies are then considered. I

conclude this section with a transition into Section 2.

To identify literature for this review, I used PubMed, MEDLINE, and Google Scholar

databases. The following search terms were used to identify literature related to the topic of

interest: physician, morale, satisfaction, burnout, retention, and attrition. I used Boolean logic to

link search terms to expand or narrow the search as needed. I used the MeSH term function to

identify studies that have utilized similar terminology as the key words used in this search.

Studies were included if search terms were matched and were either (a) published within the past

5 years or (b) seminal in nature. I included both books and peer-reviewed journals as sources for

the current study. Table 1 provides a comprehensive breakdown of the type of sources used in the

literature review and the percentage of sources used that were published in the past 5 years.

Table 1

Literature Review Sources

Publication

TOTAL

Less than 5

years

Greater than

5 years

% Of total

resources

Books

1.19

Peer-reviewed journals

166

107

98.81

TOTAL

168

108

Organization of the Literature Review

Several models of stress and burnout exist that apply to the process by which healthcare

workers and physicians develop intentions to quit. I selected Ellenbecker’s (2004) job retention

model as the framework for the current study. Selye’s (1936) classic stress theory, which explains

the process by which physicians experience stress and become burnt out, is a contrasting

supposition.

Research Design and Methodological Issues in the Literature

A consistent issue that emerged in the literature relating to stress, burnout, and attrition in

healthcare professionals and physicians was the high dependence on self-report instruments to

identify the magnitude of these constructs. In an integrative review of physicians’ intention to

leave direct patient care, Degen et al. (2015) found that many of the 17 studies included in their

research utilized subjective self-report instruments to identify physicians’ perceptions of stress

and satisfaction. While such instruments offer some insight into physicians’ self-perceptions, they

do not actually measure stress or attrition/retention directly and may not be indicative of

physicians’ actual intent to remain in their positions (Englander, 2016; Kim & Kim, 2023). Self-

report instruments include several sources of potential bias (e.g., social desirability,

inauthenticity) that render them only partially effective in addressing the topic of morale,

satisfaction, and retention in physicians (Creswell, 2014; McEwen & Akil, 2020).

In the Degen et al. (2015) review, every study that applied a Likert-based self-report

instrument fallaciously quantified data as if they were interval or ratio in nature; however, such

data are ordinal. Researchers often performed analyses of variance and logistic regressions to

analyze Likert-based data when only rank tests (e.g., Chi squares) can accurately quantify such

data (Creswell, 2014; McEwen & Akil, 2020). The use of variance and logistic regressions to

analyze Likert-based data, when only rank tests can perform this function accurately, was a

consistent gap in the literature that requires further research. Such findings may be expanded

upon through more in-depth multiple case investigations to determine their validity.

Some researchers have conducted reviews to expand the understanding of stress, burnout,

and attrition among healthcare professionals and physicians. While these reviews offer useful

syntheses of the literature, they are also exposed to many of the same sources of bias as

correlational and cross-sectional research (Ahmad et al., 2021; Degen et al., 2015; Dewa et al.,

2017). Existing reviews pertaining to burnout in physicians have demonstrated several research

design and methodological flaws in published studies on this topic. Of the 12 studies included in

Dewa et al. (2017) systematic review, 10 were determined to have at least a moderate risk of bias,

and two were considered to have a high risk of bias. The actual extent to which burnout and its

antecedents are present in practicing physicians is very likely to differ from what has been shown

in the existing body of research. Further investigation of this issue is needed to more fully

understand burnout, stress, morale, satisfaction, and retention in physicians in the United States.

While many researchers have proposed solutions to stress and burnout in physicians, few

have been empirically tested. Gazelle et al. (2015) and Yates (2020) proposed that professional

coaching could help address problems with burnout in physicians and promote greater retention

intentions. The coaching model proposed in this research, however, has not yet been studied using

an empirical design, and its effects on stress, burnout, and attrition or retention are not

understood. Discovering the reasons why such a model may be effective requires in-depth,

multiple case analysis involving experts in the field.

As with the literature pertaining to stress, burnout, and attrition, much of the literature

regarding morale, satisfaction, and retention has been cross-sectional in nature (e.g., Arima et al.,

2016). While such research is beneficial for identifying superficial relationships between factors

that relate to satisfaction and retention, researchers are not able to identify strategies used as a

means of retaining primary care physicians (Khankeh et al., 2015; Thomas et al., 2021). It may be

the case that higher satisfaction with the work environment increases physicians’ perception of

work-life balance because they enjoy being at work and perceive no deficit in their home life as a

result.

The literature pertaining to strategies used as a means of retaining primary care

physicians has largely been retrospective in nature and dependent upon secondary data. Biddison

et al. (2016) and Moffatt-Bruce et al. (2019) demonstrated an important link between worker

morale, engagement, and patient safety culture. These researchers, however, relied on a

retrospective cross-sectional analysis of secondary data. Despite the large sample size and strong

statistical support for these relationships, the findings include numerous sources of bias and do

not clearly show how improving morale can lead to reductions in attrition (Williams et al.,

2020a). Further research is needed to determine the strategies used as a means of retaining

primary care physicians

Much of the literature pertaining to this issue has been limited to argumentative papers,

editorials, and conceptual analyses. Brennan and Monson (2014) presented a conceptual and

argumentative paper on the role of professionalism in the determination of physician satisfaction.

While the findings from the paper and arguments made by the author demonstrate face validity

and illustrate the need to develop professionalism within healthcare organizations to maximize

physician retention, they are not generalizable and require empirical research to identify their

actual significance to practice. Cutter and Miller (2017) also produced a conceptual paper

pertaining to the attrition crisis in contemporary healthcare and strategies to manage this issue.

While these authors presented several potentially valid points regarding the use of temporary

associates and their importance on healthcare quality, they are not necessarily generalizable to the

healthcare industry due to a lack of empiricism. Findings from conceptual papers like those of

Brennan and Monson (2014) and Cutter and Miller (2017) may be important in advancing

knowledge related to satisfaction and retention in physicians, but there is a need for empirical

research to determine their validity and generalizability.

In a systematic review of interventions to recruit and retain physicians, Verma et al.

(2016) also demonstrated that existing interventions designed to achieve this objective were

generally of low methodological quality. Furthermore, interventions failed to fully consider well-

being and work schedules as key contributors to morale and satisfaction, despite a large body of

evidence showing these two variables are the strongest and most consistent predictors of

satisfaction and retention (Cohen et al., 2023; Jackson et al., 2018; Tsai et al., 2016). Additional

research is needed to improve upon both the scientific rigor of interventions designed to recruit

and retain physicians and the focus of such interventions.

Although a large body of research exists pertaining to morale, satisfaction, and retention

in healthcare professionals, some gaps in the literature remain. Much of the literature on this

subject has been cross-sectional in nature (Arima et al., 2016; Jackson et al., 2018; Ramachandran

et al., 2023). While such research is useful for identifying relationships between variables, it does

not determine whether certain factors cause outcomes like satisfaction and retention (Roller,

2019; Williams et al., 2020a; Williams et al., 2020b; Wu et al., 2016). Multiple case investigations

are needed to expand on the relationship between these variables (e.g., work-life balance and job

satisfaction). Through interviewing professionals in the field, researchers can more fully elucidate

why physicians value certain organizational factors and why these factors improve their intent to

remain in their positions.

Literature Rationale and Justification for the Current Study

Based on the evidence presented in this section, the current researcher identified a need to

understand the experiences of physicians regarding morale, satisfaction, and retention in greater

depth. Specifically, the results from this study may improve the understanding of factors that

contribute to physicians’ morale and satisfaction. This evidence may lead to greater retention and

reduced costs associated with attrition and burnout.

Findings from this study may contribute to positive social change and/or the

improvement of human or social conditions by promoting worth, dignity, and development of

physicians. By understanding strategies used as a means of retaining primary care physicians

more fully, healthcare organizations can ensure that physicians are better equipped to meet the

needs of patients. The findings from this study may lead to a more efficient and effective

healthcare system with reduced expenditures associated with retention.

I used Ellenbecker’s (2004) job retention theory as an effective lens through which to

explore and understand the lived experiences of physicians regarding morale, satisfaction, and

retention. Specifically, this model suggests that job retention is predicted by a range of individual

and universal antecedents, all of which can be categorized as intrinsically and extrinsically

rewarding (Ellenbecker, 2004). The physicians in the current study offered responses regarding

strategies used as a means of retaining primary care physicians. This study was informed by

Selye’s (1936) classic stress theory, which serves to offer an explanation as to how stress

manifests and transforms into burnout and, subsequently, attrition in the healthcare profession.

Ellenbecker’s Job Retention Model

Ellenbecker’s (2004) job retention model identifies both intrinsic and extrinsic

antecedents of job retention and intent to stay among physicians. Specifically, this model suggests

that job retention and intent to stay are predicted by a combination of factors that a professional

finds personally rewarding and those that are extrinsic in nature (Al-Harthy & Yusof, 2022;

Ellenbecker, 2004). Intrinsically rewarding factors that increase job retention vary according to

personal values but generally include job satisfaction, meaning associated with the work, and peer

relationships (Ellenbecker, 2004). Extrinsically rewarding factors that can increase retention

include financial incentives, recognition at work, and prestige associated with the position

(Ellenbecker, 2004). Ellenbecker’s theory has been used by other researchers to predict retention

and attrition in healthcare professionals, including physicians (Chen et al., 2016; Mori et al.,

2022; Tarcan et al., 2017). I drew on Ellenbecker’s theory to classify physician leaders’

experiences with morale, satisfaction, and retention as either intrinsically or extrinsically

rewarding. Responses from physician leaders regarding morale and satisfaction supported this

theory’s assumptions that antecedents of retention fit within these two categories.

Ellenbecker’s (2004) job retention theory was an effective lens by which to explore and

understand the phenomena under study, specifically through the examination of lived experiences

of physicians regarding morale, satisfaction, and retention. Analysis of this model suggested that

job retention is predicted by several factors, which are categorized as intrinsically and

extrinsically rewarding (Ellenbecker, 2004). I guided this study using Selye’s (1936) classic stress

theory, which is used to explain how stress manifests and transforms into burnout and attrition in

the healthcare profession.

Selye’s Stress Theory

Selye’s (1936) theory suggests that stress results in agitation and—without relief or when

too severe—can result in exhaustion and burnout. Ellenbecker’s (2004) theory suggests that

intrinsic motivation is associated with higher rates of retention. Selye’s classic stress theory is

used to aptly explain the process by which physicians experience stress and become burnt out.

This theory suggests that environmental conditions that exceed an individual’s resources can

cause cellular damage in the brain and remainder of the body, which, over time, causes fatigue,

illness, and psychological symptoms such as depression (Selye, 1936). Using Selye’s classic

stress theory, Mravec et al. (2020) and Tan and Yip (2018) proposed that stress is present in an

individual throughout the entire period of exposure to a nonspecific demand. Although this stress

can produce positive adaptations when the individual is allowed to rest, a lack of rest exposes the

individual to conditions that they are not capable of coping with; therefore, the individual must

exit those conditions or die (Selye, 1936).

Other researchers have conducted research with the use of Selye’s (1936) stress theory as

a foundation (Amirkhan et al., 2020; Dartey-Baah et al., 2020; Larosa & Wong, 2022; McEwen &

Akil, 2020). Amirkhan et al. (2020) explored the most stressful years in college. Regression

analyses showed stress overload related to poorer performance and avoidance coping related to

greater stress overload. Dartey-Baah et al. (2020) explored occupational stress, job satisfaction,

and gender difference among bank tellers. Using a cross-sectional survey approach, Dartey-Baah

et al. (2020) used questionnaires to collect data from bank tellers in Ghana and found that tellers

are more likely to exhibit counterproductive behaviors, such as job dissatisfaction, due to work-

related stress.

Selye’s (1936) stress theory has been used by several researchers in the healthcare

profession to explain stress and burnout and how these factors reduce morale and satisfaction

(Bliese et al., 2017; McEwen & Akil, 2020; Mullen et al., 2018). Morale, satisfaction, and

retention cannot be fully understood without a theoretical and conceptual cognizance of how

stress manifests biologically and psychologically in healthcare professionals. As can be

understood from stress theory, physicians are subject to burnout, which may reduce retention

rates. According to the stress theory, when individuals are exposed to a stressor, the initial

reaction is to be taken off guard; the person then often attempts to resist the change by

maintaining homeostasis (Juarez-Garcia et al., 2023; Tan & Yip, 2018). In the final phase, a

person eventually falls victim to exhaustion in countering the stressor (Tan & Yip, 2018).

Stress, Burnout, and Attrition in Healthcare Professionals

This section includes a discussion of stress, burnout, and attrition in healthcare

professionals. While I focused on physicians, much of the research guiding retention efforts of

physicians has drawn from the field of nursing. The current discussion begins with stress in

healthcare professionals, followed by burnout and attrition. The focus then narrows to physicians,

and any distinctions between general healthcare professionals and physicians in relation to these

factors are discussed. In the following section, I analyze morale, satisfaction, and retention, which

is guided by an understanding of those factors that reduce morale and satisfaction gained from the

literature review presented in this first section.

Stress in Healthcare Professionals

Stress is a perpetual problem affecting healthcare professionals, including physicians.

Professionals in the healthcare industry exhibit the highest levels of chronic stress of any

occupation, and this problem has increased over the past several decades (Burton et al., 2017;

Denovan et al., 2019). This has led researchers to explore a range of different strategies to reduce

stress, including mindfulness-based interventions (Burton et al., 2017). Evidence has only

partially supported the efficacy of these interventions, and it is apparent that researchers still lack

a thorough understanding of the factors that contribute to stress versus satisfaction in healthcare

professionals and do not know how to fully address this problem (Burton et al., 2017; Linzer et

al., 2017; Ross & Van Bockstaele, 2021). The degree to which individual versus organizational

factors contribute to stress and its prevention is still under investigation within the healthcare

industry.

While research involving stress, burnout, and attrition in physicians is scarce, a large

body of evidence on this topic exists regarding general healthcare practice. Many of the

organizational strategies that have been implemented to address the needs of physicians have

been drawn from general healthcare literature. Linzer et al. (2017) explored ways in which work

conditions influence healthcare practitioner performance. The authors performed a cluster

randomized controlled trial of 34 clinics in the United States and combined this methodology

with a case study of three primary care clinicians to determine the importance of quality

improvement projects in improving individual and organizational performance. Following a 6-

month intervention, the results showed that improvements in work conditions did not

significantly reduce errors or improve quality of care; however, the intervention did improve

stress levels and was associated with reduced symptoms of burnout. The authors concluded that

improving work conditions might improve job satisfaction and well-being, even if this does not

immediately result in improvements in work-related performance (Bashir et al., 2020; Lu et al.,

2017). Organizational strategies may be less important than addressing personal, psychological,

and emotional factors in improving performance-related outcomes; however, the relationship

between such interventions and retention versus attrition is not yet clear. Future research is

needed to determine how organizational versus individual strategies influence stress and intent to

remain within an organization.

Stress in health professionals has been a consistent problem during the COVID-19

pandemic. Garcia et al. (2022) assessed the prevalence of depression, anxiety, and stress

symptoms in health professionals in the COVID-19 pandemic context. The researchers performed

the assessment using the Depression, Anxiety, and Stress Scale (DASS-21) and calculated the

prevalence of symptoms severity by point and 95% confidence interval. A total of 529 health

professionals participated in this study. Regarding prevalence, moderate to extremely severe

symptoms of depression, anxiety, and stress were found in 48.6%, 55.0% and 47.9% of the

participants, respectively. Garcia et al. (2022) highlighted the continued prevalence of stress

among healthcare professionals.

Burnout in Healthcare Professionals

Stress is closely related to burnout. Chronic stress increases the risk of burnout in

healthcare professionals, which can negatively influence job performance and lead to attrition and

undesirable rates of turnover (Malhotra et al., 2018). Despite a large body of research identifying

burnout as a significant threat to the healthcare industry, practitioners and policymakers still do

not fully understand the factors that contribute to this state (Keller et al., 2020; Malhotra et al.,

2018). Burnout is not only a threat to the healthcare industry by leading to attrition, but it is also a

significant health risk for healthcare professionals (Dyrbye et al., 2017). Burnout increases the

risk for chronic disease and co-morbidities, including obesity, diabetes, cardiovascular disease,

dementia, and even some forms of cancer (Darvishmotevali & Ali, 2020; Dyrbye et al., 2017). As

researchers become increasingly aware of the problems associated with burnout, a comprehensive

effort is needed to address this growing concern to protect workers in the healthcare industry and

to reduce the costs associated with attrition. The issue of attrition is discussed in more detail in

the following subsection.

Attrition in Healthcare Professionals

The attrition problem in healthcare is significant because of the increasing demand for

healthcare services. Services are in need for a range of factors, one of which is globalization of

healthcare (Fisher, 2016; Rech et al., 2022). Migration from areas around the world, especially

Central and South America, along with globalization have led to an increased need for healthcare

access in nations that experience high levels of immigration like the United States and have stable

economies (Abayasekara, 2015; Jackson et al., 2018). Migration combined with a perpetually

increasing population has led to a steadily rising need for healthcare services (Fisher, 2016;

Lebano et al., 2020). In Canada and European countries where healthcare is partially or fully

covered by government funding, this shortage of healthcare professionals increases costs in

several ways, including the lack of ability to prevent and control diseases on a macro level based

on limited public health professionals to incite the necessary legislation in which to engage in

societal disease prevention efforts.

Immigration and healthcare reforms have been the primary contributors to the healthcare

crisis and physician shortage in the United States. Somewhat ironically, however, scholars have

also posited that healthcare worker immigration may be a valid solution to this problem. Fisher

(2016) and Gandhi et al. (2021) noted that implementing reform to allow more prevalent

healthcare worker immigration into the United States would play an important role in restoring

the physician pipeline and addressing the current healthcare worker shortage. Fisher found that

the federal immigration system is outdated and poorly equipped to meet contemporary population

needs, particularly with respect to healthcare. By allowing more qualified foreign healthcare

professionals, including physicians, to enter and remain in the United States, the nation would

save money by preventing the high costs associated with attrition and turnover (Fisher, 2016;

Woolhandler et al., 2021). The extent to which such policy would affect the healthcare system is

unknown, but increasing the number of physicians within existing clinics can have significant

positive effects on work-life balance and job satisfaction and may reduce turnover intentions

(Adriano & Callaghan, 2020; Azmi et al., 2021; Mullen et al., 2018; Murale et al., 2015;

Underdahl et al., 2018). Macro-level solutions like immigration reform may serve as components

of the general strategy to improve physician morale in the United States and prevent turnover and

attrition.

Costs may be incurred primarily because of the inability to access and provide care for a

substantial portion of the population (e.g., low socioeconomic groups, minorities, undocumented

immigrants), which increases health risks for the entire country (Abayasekara, 2015; Fisher,

2016; Salles et al., 2019). The average age of the population continues to increase due to longer

life expectancies (Jackson et al., 2018). This increasing average age may be partially a testament

to advancements in healthcare quality, although this trend also perpetuates the cycle of imbalance

in the supply and demand of qualified healthcare professionals to meet population needs (De

Biasi et al., 2020; Jackson et al., 2018). As a result, researchers have turned their focus to

addressing these workforce shortages on micro levels in many regards (Leong et al., 2021; Super.

2020).

Because of this attrition crisis, scholars have begun to consider the fact that the United

States currently resides in a healthcare economic bubble where asset prices of care are much

higher than underlying fundamentals. Evidence from a switching regression model of healthcare

bubble episodes in the United States pertaining to macroeconomic variables and public financing

has shown that the nation is in a bubble (Chen et al., 2016). This bubble has been caused by a

misallocation of resources, which does not align with the growing imbalance in supply of

healthcare professionals and the demand for services (Chen et al., 2016). Monetary and fiscal

policies, while playing critical roles in determining healthcare provider deviation and inflation,

have not accurately reflected healthcare professionals’ need for wage growth (Chen et al., 2016).

This bubble, which has been building for at least 3 decades, reflects an increasing societal need

for healthcare services (Chen et al., 2016). Researchers remain uncertain regarding how to

manage this bubble and to restore balance in the supply and demand of workers (Ambrogio et al.,

2022; Kaufman, 2011; Satiani & Prakash, 2017). This problem is exacerbated by attrition and

high rates of turnover, which are partially caused by a lack of consideration of wage growth needs

and reduced job satisfaction by healthcare professionals throughout the country (Kaufman, 2011;

Satiani & Prakash, 2017). Practitioners, policymakers, and researchers have begun to increasingly

focus on how to achieve a balance in workforce supply and demand and prevent high rates of

attrition.

One way in which researchers have explored how to address clinician workforce

shortages is in underserved areas. Abayasekara (2015) reviewed secondary data regarding

healthcare service demand and shortages underserved areas. Abayasekara estimated that based on

trends analyzed up until 2014, the shortage of qualified healthcare professionals would increase

by 20,000 full-time equivalent professionals in the United States by 2020. The shortage in

qualified healthcare professionals also places an added burden on existing professionals who are

already under severe duress and face demanding shifts and work conditions (MacLeod, 2015;

Rawal et al., 2020). This high demand contributes to stress in existing professionals, which can

lead to low job satisfaction and, eventually, burnout (Massachusetts Medical Society, 2013;

Rawal et al., 2020). Burnout negatively influences retention rates, which the healthcare industry

cannot afford during the current healthcare professional shortage crisis (Chesak et al., 2020; Terry

& Brown, 2016). While it has been suggested that an increase in the supply of physicians can be

expected in the next decade, these new professionals will still be exposed to extremely

demanding conditions and may suffer from similar risks of stress, low morale, and low intent to

remain in the field. A need exists to understand the experiences of existing professionals in

relation to their work environments, specifically with respect to morale, satisfaction, and

retention.

Attrition has also potentially contributed to an unexpected reduction in healthcare quality

in some places where turnover is high because of the time spent training and retraining new staff

members. Healthcare organizations have turned to short-term staffing options, such as temporary

agencies, to fill vacant positions (Chesak et al., 2020; Cutter & Miller, 2017). Healthcare worker

attrition has also led to increased travel for existing healthcare professionals to fill vacancies,

adding to the stress they already experience and detracting from their work-life balance (Cutter &

Miller, 2017). Despite advancements in healthcare technology and practice, high levels of stress

and burnout in existing healthcare professionals impede these professionals’ ability to provide

optimal patient-centered care (de Vries et al., 2023; Tarcan et al., 2017). A need exists to not only

reduce attrition, but also to smooth the transition process between professionals in settings with

high turnover.

The average age of the population has increased, which has contributed to increased

strain on existing practitioners and professionals within the U.S. healthcare system. The growing

and aging U.S. population places burdens on healthcare with increasingly frustrated physicians

leaving practice (Collins & Beauregard, 2020; Hariharan, 2014; McGrail et al., 2017). Changes in

healthcare practice have added to stressors for physicians, including enhanced accountability and

scrutiny, time limitations, increasing role definition by nonphysicians, and decrease in workplace

control contributing to burnout (Gazelle et al., 2015; Wangmo et al., 2019; Willard-Grace et al.,

2019). Willard-Grace et al. (2019) found that burnout has negative implications on physician

well-being, morale, and retention. A focus on physician retention is likely to benefit the hiring

group, employees, and patients (Han et al., 2019; Petrou et al., 2014; Wangmo et al., 2019).

Stress and burnout are two factors that have been demonstrated above as causes of

attrition. Several additional correlates of these variables have been identified in the literature,

many of which are distinct from other industries beyond healthcare (Rao et al., 2020;

Skarzauskiene, 2010; Swensen et al., 2016). Work hours have been shown to strongly predict

attrition in healthcare professionals (Neumann et al., 2018; Sander et al., 2015; Shanafelt et al.,

2022). Most healthcare workers already report moderate to high levels of satisfaction with their

careers and the financial incentivization associated with the profession (Lyubarova et al., 2023;

Neumann et al., 2018; Sander et al., 2015). Many healthcare professionals develop stress and

burnout largely due to the demanding schedules and long shifts, which can have unavoidable

negative cognitive consequences (Lyubarova et al., 2023; Neumann et al., 2018; Sander et al.,

2015). Eventually, the demanding hours and chronic stress produce burnout and increase

professionals’ intent to quit their current environments (Neumann et al., 2018; Sander et al., 2015;

Shanafelt et al., 2022). Even despite financial incentives and increases in compensation, the

attrition problem has only increased in recent years in the healthcare industry. Healthcare workers

value additional factors beyond compensation, and it is scheduling and lack of work-life balance

that largely predict attrition in the healthcare industry. The degree to which these factors are

distinct between healthcare professionals in general and physicians in particular has been the

subject of recent research and is discussed in more detail in the following subsection.

Stress, Burnout, and Attrition Specifically in Physicians

Burnout affects physicians for similar reasons as healthcare professionals, although

researchers have identified some distinctions between the factors that predict burnout in

physicians versus other members of the healthcare industry. Researchers have also begun to

explore how physician burnout affects healthcare organizations differently than burnout in other

healthcare professionals. Dewa et al. (2017) conducted a systematic review of the relationship

between physician burnout and healthcare quality in civilian settings. Based on their research,

Dewa et al. (2017) found that physician burnout is inversely and significantly associated with

patient safety and safety culture. These authors also found that physician burnout had a stronger

negative influence on patient safety and safety culture than general health practitioner burnout. A

significant need exists to prevent burnout in physicians and to identify those factors that improve

morale and satisfaction in these professionals. The findings from this study support those within

the general healthcare literature but also illustrate an increasing need to prioritize stress in

physicians and maximize work-life balance (Shanafelt & Noseworthy, 2017; Verret et al., 2021).

Based on evidence of burnout in physicians, some practitioners and researchers have

proposed strategies for addressing this issue once it is experienced. While preventative methods

are likely to be more effective longitudinally, a need also exists to address burnout as it occurs in

physicians to prevent attrition (Gazelle et al., 2015; Karakash et al., 2019). At least one in four

physicians are believed to experience burnout across all specializations in the healthcare industry

(Gazelle et al., 2015; Karakash et al., 2019). Because of the high correlation between burnout and

attrition and the exorbitant costs associated with recruitment and training new staff, this problem

can be financially detrimental to healthcare organizations (Hariharan, 2014; Karakash et al.,

2019). Researchers have offered professional coaching as a potential ex post facto solution for

burnout in physicians (Karakash et al., 2019). This process involves promoting self-awareness of

predispositions to burnout due to traits like self-denial and compulsiveness and the reinforcement

of increasing physicians’ internal loci of control (Gazelle et al., 2015; Karakash et al., 2019).

Professional coaching can be used to change perspectives and professional orientations so that

personal and professional values are more aligned (Gazelle et al., 2015). While this approach of

professional coaching has not yet been empirically tested and the importance of professional

coaching on burnout and attrition in physicians is not yet known, this research illustrates the

increasing interest in addressing this issue in contemporary healthcare.

Work stress of physicians has a range of direct and indirect influences on both individuals

and organizations. Tziner et al. (2015) investigated how work stress, burnout, satisfaction at

work, and turnover intention were related in a sample of 124 hospital physicians. These

researchers hypothesized that a positive and significant relationship would be found between

burnout and work-related stress, while a negative (i.e., inverse) and significant relationship would

exist between work-related satisfaction and burnout as well as work-related satisfaction and

turnover intention. A structural equation model showed that all hypotheses were confirmed, with

burnout partially mediating the relationship between work satisfaction and stress. Work-related

satisfaction partially mediated the relationship between intent to quit and burnout. These findings

support previous research showing the strong and significant relationship between work stress,

burnout, and turnover intentions (Nantha, 2013; Schrijver, 2016; Wang et al., 2020). This

evidence suggests that healthcare organizations must strive to reduce work stress experienced by

physicians if they seek to address the persistent problem of burnout and attrition.

Researchers have begun to explore how attrition among physicians has influenced the

healthcare industry based on growing evidence of the shortage and imbalance in the supply and

demand of these professionals. Degen et al. (2015) performed an integrative review of physicians’

intent to leave the direct patient care setting. Drawing on a previously validated and systematic

process of integrative review, these authors located 17 studies from five countries that matched

their inclusion criteria to identify factors that contributed to physicians’ intent to leave. These

researchers found that variables that strongly predicted intent to leave included being of a higher

age, being female, poor work-life balance, longer total work hours and longer shift duration, and

differing career aspirations. These findings support the literature pertaining to general healthcare,

illustrating that many of the factors that contribute to attrition are modifiable on an organizational

level (Dodek et al., 2016; Filho et al., 2016; Lee et al., 2021; Nantha, 2013). Leaders of

organizations, while unable to adjust for age and gender, can work to improve work-life balance

and restructure shift and total work hours to improve satisfaction and increase the likelihood that

physicians will remain in their positions.

Debates exist in the literature with respect to how national healthcare policy, such as the

Affordable Care Act, has affected physicians’ turnover rates. Henry (2015) used critical medical

anthropology to analyze the policy’s importance in a range of industry outcomes, including

physician intention rates. Henry noted that the policy was implemented to suggest strategies to

add new physicians but lacked guidance on how this would be funded. The policy also included

ambiguous language regarding the roles of new hires within medically underserved populations.

A need exists to establish more collaborative care teams and focus on patient-provider

relationships to mitigate any concerns about how adding new staff members will influence

existing healthcare organizations (Anandarajah et al., 2018; Hoffman & Cowdery, 2021).

There is little question that physician turnover and attrition is expensive for healthcare

organizations, and these expenses outweigh the costs of improving work conditions for existing

practitioners. The reasons why healthcare organizations have not been more proactive in

implementing strategies to prevent turnover is not clear. While many of the factors that predict

physician turnover are unmodifiable on an organizational level (e.g., age, gender, career

aspirations), other factors can be controlled by healthcare facilitates to mitigate the costly effects

of attrition (Attenello et al., 2018; Degen et al., 2015; Fibuch & Ahmed, 2015; Rotenstein et al.,

2021). Estimates of the physician shortage crisis vary according to different reports, although

some suggest that by 2020, the United States will have nearly 100,000 fewer physicians than

what is ideally needed to meet population needs (Attenello et al., 2018; Butzner & Cuffee, 2021;

Fibuch & Ahmed, 2015). Some researchers expect this amount to reach more than 130,000 by

2025 if actions are not taken at the time of writing. Every time a physician leaves their position

within a healthcare organization, researchers estimate that the annual replacement cost is between

$300,000 and $500,000 (Attenello et al., 2018; Fibuch & Ahmed, 2015; Mahoney et al., 2020).

Small incentives and efforts to promote work-life balance and satisfaction, including scheduling

flexibility and continuing education, can potentially have substantial cost-saving effects across

the healthcare industry.

Scholars have continued to document the extent of the physician attrition crisis in the

United States with the aim of identifying the determinants of this problem. Such researchers have

supported decades of previous literature showing that satisfaction is a primary determinant of

intent to remain within an organization (Filho et al., 2016; Rotenstein et al., 2017; Wright et al.,

2022). Jackson et al. (2018) conducted an investigation of job satisfaction and attrition among

surgeons in the United States that closely resembled many previous studies on this topic. Using a

cross-sectional survey – as have numerous previous researchers on this issue – Jackson et al.

identified that personal factors were more highly correlated with intent to remain or quit a

position than organizational or occupational factors. These findings reinforce the importance of

addressing psychological and emotional needs in physicians to maximize retention. Examples

include reducing stress and increasing well-being and happiness. The findings from this study

support previous research showing that reducing physician work hours can increase well-being,

happiness, satisfaction, and intent to remain in the organization (Tsai et al., 2016; Wright et al.,

2022). While organizational factors are important correlates of retention, healthcare facilities may

more efficiently allocate their resources toward addressing physicians’ personal needs to address

problems with attrition and increase physician retention.

Morale, Satisfaction, and Retention in Healthcare Professionals

The previous section included a review of literature pertaining to stress, burnout, and

attrition. Based on the evidence presented in this previous section, a more informed

understanding of morale, satisfaction, and retention can be gained. This section includes a review

of literature pertaining to morale, satisfaction, and retention in the general healthcare population

first, as there is a large body of evidence on this subject. A narrower focus on morale, satisfaction,

and retention specifically in physicians is then provided. This section is followed by a

consideration of theoretical models of stress and retention as well as gaps in the literature and a

justification for the current study.

Morale in Healthcare Professionals

Improving morale in healthcare professionals offers several benefits to employees,

patients, and healthcare organizations. In a study by Biddison et al. (2016), improvements in

healthcare worker morale led to improved safety within a large cohort of inpatient hospital units

in the United States. Based on a retrospective analysis of secondary data using the Safety

Attitudes Questionnaire with more than 2,000 participants in the U.S. healthcare system, the

researchers’ findings indicated moderate to strong and significant correlations between worker

morale and safety culture (Biddison et al., 2016). This relationship was mediated by increased

employee engagement (Biddison et al., 2016). These findings suggest that working to boost

healthcare workers’ morale can increase their engagement and positively influence their attitudes

toward safety and patient care (Biddison et al., 2016). The research conducted by Biddison et al.

(2016) is supported by previous evidence that increasing morale and positively influencing

organizational attitudes has benefits for not only healthcare workers, but also patients and

healthcare organizations (Rosenstein, 2017; Tziner et al., 2015). Though correlational and

retrospective in nature, these findings produced by Biddison et al. (2016) add to the literature

demonstrating the necessity to focus on improving the work climate for healthcare professionals,

particularly physicians, to achieve organizational outcomes like patient safety and optimal

patient-centered care while also reducing attrition and costs associated with turnover.

Satisfaction in Healthcare Professionals

An additional benefit of improving job satisfaction in healthcare professionals is that

doing so may increase care outcomes, healthcare quality, and patient satisfaction. There is

evidence suggesting that higher levels of healthcare professional satisfaction are associated with a

more patient-centered culture and greater patient satisfaction (Cliff, 2012; Downing et al., 2018;

Owoc et al., 2022). Although research linking healthcare professional satisfaction directly with

patient satisfaction is scarce and this relationship is mediated by several factors, there is sufficient

evidence to suggest that increasing worker satisfaction can facilitate improvements in healthcare

quality (Cliff, 2012; Downing et al., 2018). Healthcare organizations are often bounded by strict

budgets that prevent them from implementing long-term strategies to increase professional

satisfaction via incentives, although Tziner et al. (2015) suggested that trying to retain existing

employees is significantly more cost-effective than managing high levels of turnover. Leaders of

organizations are more likely to reduce total costs longitudinally when they optimize the work

and patient care culture and provide incentives to high-performing professionals to ensure that

they remain within the organization (Fibuch & Ahmed, 2015; Folbre et al., 2021). By increasing

morale and satisfaction, healthcare professionals consistently show greater intent to remain in

their positions, thus improving patient care outcomes and reducing costs associated with

educating and training new and/or temporary employees.

Retention in Healthcare Professionals

Another factor that has been demonstrated in the literature to facilitate higher levels of

retention is the recruitment process. In the highly competitive market for qualified physicians

where a perpetual shortage exists, healthcare organizations often resort to long-term recruiting

strategies and incentive packages to lure the most skilled graduates (Hariharan, 2014; Wiederhold

et al., 2018). According to Hariharan (2014), “In order to overcome the inevitable physician

shortage, physician groups and hospitals must acknowledge and incorporate effective recruiting

techniques into their practices” (p. 14). As a result, researchers have recently begun to investigate

how the recruitment process influences retention rates over time (Block, 2016). Although still

primarily anecdotal in nature, Block (2016) proposed several factors that may lead to more

effective and efficient recruitment of skilled professionals and thereby reduce attrition and

increase retention rates. Scholars have shown that skill building, continuous learning

opportunities, active engagement with recruits and relationship development, and incentivization

can all increase retention longitudinally (Block, 2016). However, these researchers do not

currently understand why these factors influence retention.

Early recruitment helps to instill organizational values into potential employees and

increase their identification with the work environment (Block, 2016). This instillation of

organizational values may translate to improved perceptions of job satisfaction. No known studies

have centered on the relationship between organizational identification and perceptions of job

satisfaction in physicians. Much of the literature pertaining to retention used in the healthcare

industry has drawn from general organizational literature. The work of George (2015), which

involved the retention of professional workers, has been cited by numerous healthcare researchers

because of its pertinence to general organizational factors that determine worker satisfaction and

morale. Based on a cross-sectional design involving 138 workers in the UK, George sought to

identify consistent factors related to retention. The findings showed that retention factors could be

categorized into two dimensions: organizational factors and job-level factors. A combination of

these two factors most strongly predicted retention intentions, as did each independently.

Maximizing retention in general workers requires both organizational and job-related strategies,

although addressing each one individually will also likely have a positive effect on retention in

any organization (George, 2015).

Morale, Satisfaction, and Retention Specifically in Physicians

As a result of the physician shortage crisis in the United States, researchers have begun to

explore ways in which to increase retention and restore the physician pipeline. Previous

researchers have identified several challenges that may impede this process, despite best efforts

by healthcare organizations and policymakers. Daye et al. (2015) provided an editorial paper and

review of challenges that still exist concerning filling this gap in qualified physicians.

Specifically, the length of training and lack of administrative support have been identified as

perpetual problems that negatively influence retention in physicians (Daye et al., 2015). These

problems are exacerbated by the rapidly changing and evolving nature of the medical field, which

requires consistent and vigorous continuing education (Daye et al., 2015; Seehusen et al., 2018).

The retention of physicians is, therefore, crucial for providing optimal patient-centered care and

meeting the increasing population need for healthcare services (Daye et al., 2015; Seehusen et al.,

2018). Because of the limited funding of the National Institutes of Health, stakeholders play an

increasingly important role in supporting healthcare organizations and providing incentives to

increase those factors that boost the likelihood that physicians will remain in their positions

(Gazelle et al., 2015). Researchers have only recently begun to investigate what this support

encompasses.

Despite generally limited research in the area of physician satisfaction, some preliminary

reviews on the subject exist. Hoff et al. (2015) conducted a narrative review of the issue of

physician satisfaction in the United States. Hoff et al. explored research published over a 5-year

period between 2008 and 2013 and compared their findings with literature published between

1970 and 2007 to identify trends and changing physician needs during these periods. Based on 22

studies that matched the inclusion criteria, these authors found that physicians experience

moderate to high average levels of work-related stress. Interestingly, physician satisfaction

appears to have remained stable between 1970 and 2007 despite evidence suggesting gradually

declining levels of this outcome. This finding is surprising given the large number of researchers

and practitioners suggesting that high rates of turnover are caused by low satisfaction (Hoff et al.,

2015; Jackson et al., 2018). The results from the review conducted by Hoff et al. (2015)

suggested that factors beyond satisfaction are contributing to the undesirable rates of turnover that

exist within the healthcare industry, specifically among physicians. Specifically, demographic

factors and healthcare policies may have stronger influences than just job-related factors in

predicting attrition, turnover, and retention.

Work-life balance is a particularly strong determinant of satisfaction in physicians.

Women appear to be more strongly influenced by this variable than men (Arima et al., 2016).

Arima et al. (2016) performed a cross-sectional study involving 2,159 physicians to determine

their levels of satisfaction with the work environment and factors that contributed to satisfaction.

The results showed that work-life balance was a significant predictor of job satisfaction in both

men and women, although the percentage of women reporting this factor as a source of

satisfaction was significantly higher than that of men. Conversely, men more highly valued salary

when determining factors contributing to job satisfaction. This study was cross-sectional in nature

and confirmed previous evidence showing that work-life balance is a critical determinant of job

satisfaction (Hoff et al., 2015; Jackson et al., 2018). Leaders of organizations that strive to

improve work-life balance through strategies like reducing shift times and increasing intervals

between shifts may experience more satisfied staff and reduced rates of attrition.

Previous researchers have indicated that understanding physicians’ ideas of job

satisfaction can influence morale and retention (Brennan & Monson, 2014; Cofer et al., 2018;

Gazelle et al., 2015; Hariharan, 2014; Nantha, 2013; Plomp & Van Der Beek, 2014).

Dissatisfaction in a physician’s employment negatively influences well-being, decreases

physician retention, worsens patient care, adds to patient noncompliance, contributes to low

physician morale, and decreases organizational unity (Gazelle et al., 2015). U.S. physicians

experience more position dissatisfaction compared to other U.S. workers, increasing turnover

intentions within this profession (Tziner et al., 2015).

Incentivization does not appear to make as strong of a difference to prevent stress,

burnout, and attrition in physicians as does modifying work hours. Tsai et al. (2016) performed a

nationwide survey of 2,423 full-time physicians in Taiwan to determine the degree to which

satisfaction with pay influenced turnover intention. Tsai et al. (2016) found that approximately

15% of the sample demonstrated a strong intention to leave the current work setting, and the

average number of hours worked per week was nearly 60. Interestingly, while work hours

independently predicted turnover intention, pay satisfaction did not significantly moderate this

relationship (Tsai et al., 2016). This finding illustrates that financial incentives are not strong

predictors of turnover intentions in physicians and supports previous studies also demonstrating

this relationship (Jongbloed et al., 2017; Lu et al., 2017).

Physicians value well-being and work-life balance more highly than financial incentives,

and at the time of writing, hospital managers are misguided in their belief that increasing salaries

justifies the long work hours and demanding work environments that physicians face. Instead of

spending more to compensate physicians, hospitals may more effectively address the turnover

problem by reducing work hours and providing physicians with shorter shifts. Hospitals may also

potentially hire more staff and simultaneously increase salaries.

Increased competition for physician talent requires that care organizations have an

integrated approach focusing on physician engagement and well-being to improve retention

(Brennan & Monson, 2014; Windover et al., 2018). The results from this study may be useful for

increasing physician retention rates and reducing costs associated with continually hiring and

training new physicians. These findings may lead to reduced costs of care and a more efficient

healthcare system.

Reducing the total number of hours worked and reducing shift durations can improve

organizational outcomes, according to recent research. Grossman et al. (2018) performed a cross-

sectional and retrospective study comparing 183 physicians in 2015 and 176 physicians in 2016

to determine productivity based on part-time versus full-time work hours. The results indicated

that physicians who work part-time demonstrate equal, and oftentimes greater, productivity than

full-time physicians. The reasons for this outcome may be increased work-life balance and greater

job satisfaction, leading to higher organizational commitment and greater performance during the

shortened shift (Shanafelt & Swensen, 2017; Yeager & Nafukho, 2012). In full-time physicians,

the high level of demand and stress incurred on a daily basis likely detracted from any increased

productivity associated with longer shift durations. Reducing the number of hours worked and

allowing physicians to take part-time roles in healthcare organizations appears to be a valid way

in which to promote work-life balance and increase retention intentions within the healthcare

industry.

Cultural factors influencing job satisfaction also warrant consideration. Arima et al.

(2016) conducted a study in Japan, where the cultural perception is generally collectivistic in

nature. As a result, work-life balance may be more highly valued by the participants of this study

than what can be expected in the individualistic West. Lu et al. (2017) also found that physicians

in China valued work-life balance more highly than those in the West. Drawing on a cross-

sectional design involving nearly 4,000 Chinese physicians, these authors sought to determine the

relationship between work-family conflict, work-related stress, job satisfaction, and turnover

intentions. The authors found that turnover intention was significantly and positively correlated

with longer work hours, job dissatisfaction, work stress, and work-family conflict. The findings

showed that physicians that worked in rural areas demonstrated greater turnover intentions than

those in rural areas. These findings offer a range of predictive variables for turnover intentions

that apply to Chinese physicians, which may be useful in guiding future interventions to mitigate

stress, burnout, and turnover intention. The degree to which these findings can be generalized to

physicians in the West warrants further investigation. Research is needed to account for cultural

perceptions in determining factors that contribute to work-life balance and organizational

strategies to promote this construct.

Professionalism can influence job satisfaction, specifically in physicians. In a conceptual

and argumentative paper on the role of professional in healthcare organizations, researchers

suggested that professionalism was likely to be more highly valued in physicians than lower-level

healthcare professionals (Brennan & Monson, 2014; Lacy & Chan, 2018). The reason for this

finding may be that physicians are more involved in organizational and administrative aspects of

the facilities in which they are employed than other healthcare professionals. As a result,

physicians may find that professionalism is a strong determinant of satisfaction in their work

environments because of their need to impart leadership roles and responsibilities on other

members of the organization. Factors such as communication and interpersonal skills contribute

to perceptions of satisfaction in organizational leaders, while those in lower-level positions

typically favor transactional rewards, such as compensation and time off from work (Tsai et al.,

2016). Leaders of healthcare organizations are advised to consider the role of professionalism in

determining physicians’ satisfaction and strive to enhance this construct whenever possible.

Similar to general healthcare workers, early recruitment may be an effective strategy to

retain physicians as well. Verma et al. (2016) performed a systematic review of the literature

pertaining to recruitment and retention strategies in primary care doctors. Based on the

identification of 51 studies involving 42 interventions, these authors found that multiple strategies

had been employed to recruit and retain qualified physicians. These strategies included financial

incentives, recruiting rural graduates, recruiting internationally, undergraduate placements,

providing postgraduate training to underserved areas, focusing on well-being and social support,

marketing, mixed interventions, and continuing education strategies. The most frequently used

strategy was financial incentivization, while well-being and peer support were the least used

strategies. This trend reflects a problem within existing healthcare organizations and their

attempts to promote retention, as previous evidence suggests that personal and emotional factors

related to well-being most strongly influence turnover intentions (Filho et al., 2016; Murale et al.,

2015).

Filho et al. (2016) established that healthcare organization leaders falsely believe that

financial incentivization is sufficient to retain qualified physicians and should focus more on

promoting work-life balance and satisfaction (Filho et al., 2016). No scholars have evaluated the

efficacy of reducing hours or modifying the work schedule in improving satisfaction and

decreasing turnover attentions (Verma et al., 2016). The belief that financial incentivization is

sufficient to retain qualified physicians (Filho et al., 2016) is also contradictory to studies

showing that long work hours are the most significant predictor of stress, burnout, and attrition in

physicians (Tsai et al., 2016). Verma et al. (2016) found that studies in the review were of low

methodological quality, and no randomized controlled trials have been performed to determine

the effectiveness of different retention strategies. Verma et al. (2016) indicated that improvement

in research design and intervention focus is needed to mitigate the growing physician shortage

crisis.

Some researchers have investigated how individual factors contribute to morale and

general well-being of physicians. Tak et al. (2017) performed a cross-sectional study to determine

how intrinsic motivation contributes to physician well-being. Drawing from data from a national

physician survey of 1,289 physicians in the United States, these researchers found that the

strongest predictors of well-being included job satisfaction, high meaning, sense of calling, career

satisfaction, and life satisfaction. Burnout was strongly negatively correlated with all indicators of

well-being. Those with higher job satisfaction were significantly more likely to remain in their

positions (Tak et al., 2017). These findings align with those of previous research and offer strong

support for the role well-being and intrinsically motivating aspects of the work environment play

in determining retention versus attrition rates (Fida et al., 2018; Nantha, 2013). Striving to

maximize well-being through intrinsically rewarding factors can increase physician morale and

satisfaction and reduce undesirable rates of attrition within the industry. The rationale behind why

healthcare organizations have not yet implemented a consistent and cohesive policy or strategy to

achieve this objective is unclear. There is no comprehensive strategy to address the turnover

problem, which may be due to a lack of understanding as to how to promote well-being in

physicians and why some physicians respond to organizational factors more strongly, while others

more highly value personal factors in determining their levels of satisfaction with the work

environment.

Physician job satisfaction may also be related to the relationship between actual versus

preferred job size. Jongbloed et al. (2017) performed a cross-sectional analysis of previously

published longitudinal data pertaining to physician job satisfaction and retention. Based on a

sample of 506 participants, most physicians preferred not to work full time, and larger job sizes

were significantly and inversely correlated with job satisfaction. Twelve percent of the sample

reported wishing to increase their work hours. Physicians who preferred to increase their work

hours did so because of dissatisfaction with their professional accomplishments. Improving job

satisfaction in physicians generally requires reducing total work hours as well as shift duration.

The mediating role of perceived or actual professional accomplishments warrants further

exploration. No previous researchers have incorporated this factor into predictive models of

satisfaction and retention. Low professional accomplishments may be due to a combination of

individual and organizational factors, and the role this variable plays in retention versus attrition

offers an interesting direction for future research (Jackson et al., 2018). Jackson et al. (2018)

clearly showed that most physicians report feeling overworked and perpetually experience

undesirable levels of stress and symptoms of burnout as a result of the long hours associated with

their positions.

Strategies used by Organizations to Retain Employed Primary Care and Internal Medicine

Physicians

Previous literature reflects various strategies used as a means of retaining primary care

physicians. Willard-Grace et al. (2019) examined physician burnout as well as strategies to reduce

high turnover. The researchers examined data from 2013 and 2014 across 740 primary clinicians

and staff across San Francisco. The findings indicated that 53% of clinicians reported burnout,

and 35% reported high engagement. As a result, physicians that reported high burnout were less

likely to be employed 2 to 3 years after the initial survey period. According to the authors, a

reduction of clinician turnover rates is associated with reduced burnout and improved

engagement. Basu et al. (2020) similarly reported that to improve retention of primary care and

internal medicine physician, reduction burnout strategies must be considered. Other strategies can

include improving work-life balance and support from other staffing procedures.

Improving retention in primary care physicians requires improved strategies regarding

work-life and integration-based approaches. Parlier et al. (2018) argued that strategies to improve

the retention of primary care physicians are related to the ability to address financial

incentivization, integration, and work-life balance. Particularly, physicians within rural

environments may benefit from improved incentivization to increase retention. Underdahl et al.

(2018) noted that improved physician retention is based upon engagement. Underdahl et al. noted

that factors such as resiliency and grit may potentially increase physician retention, indicating that

multiple internal and external variables are used when considering appropriate retention strategies

for physicians. However, a qualitative assessment specific to these considerations is absent in the

literature.

Various factors are related to the potential issue of reduction of retention, including

burnout and gender. Wangmo et al. (2019) reported that high burnout of physicians is one

potential factor that requires assessment to improve retention. According to the authors, reduction

of burnout within survey strategies can be effective in terms of improving the retention rate of

primary care physicians. Carr et al. (2018) identified potential differences in retention between

physicians based on gender. Data were collected from 1,273 facilities of medical schools across

17 years. The findings indicated that women were less likely than men to achieve higher

academic career advancement, which resulted in reduced retention of physicians. These findings

indicate potential differences regarding strategies based upon personal and interpersonal factors.

The physicians’ location may also mediate the optimization of retention strategies.

Asghari et al. (2019) examined the retention of physicians with a focus on rural areas. The

findings indicated that rural physicians require different supports and resources to optimize

retention strategies. Similarly, Paladine et al. (2020) explored the retention of rural physicians and

noted similar issues regarding lack of engagement, poor job satisfaction, and increased workload

because of a lack of supportive staff. The findings indicate that the physicians’ location may also

mediate the specific retention strategy employed.

Job satisfaction can also mediate retention levels and appropriate strategies. Wangmo et

al. (2019) examined the job satisfaction of physicians and identified a reduction in outcomes of

various populations. According to Wangmo et al., the attention of physicians requires addressing

job satisfaction. Higher job satisfaction, associated strategies, and resources can potentially

improve the retention of physicians. Perrigino et al. (2019) indicated that increased job

satisfaction and work-life balance, including being able to spend time with family, are important

factors that can optimize the retention of physicians.

Predicting physician retention is also mediated by the factors related to improving

outcomes of family physicians’ ability to engage with their families and spend time with their

communities. Minor et al. (2019) indicated that physician retention requires a healthy work-life

balance. Similarly, Asghari et al. (2019) indicated that improved work-life balance and

community integration can retain physicians in a long-term based assessment. The findings of

Asghari et al. (2019) and Minor et al. (2019) indicate that one such optimization strategy can

include addressing work-life balance and other associated community factors for physicians.

The reduction of stress, as identified by Burton et al. (2017), is one factor that may

improve interventions designed to improve retention strategies. According to Burton et al.,

mindfulness-based interventions can be effective to improve retention strategies as a means of

reducing stress and other emotional exhaustion faced by physicians in the workplace. Linzer et al.

(2017) argued that organizational factors also contribute to stress experienced in the workplace.

This indicates that improved approaches for optimizing retention may be based on the methods

employed specifically in the organization and the culture created within the medical facility.

Linzer et al. (2017) collected data from a cluster-randomized trial of 35 clinics in the United

States. Six months after the intervention, the researchers found that work conditions could

improve the reduction of errors and quality of care period; however, stress levels continue to

increase burnout symptoms of physicians. The findings illustrate the importance of understanding

organizational strategies optimization. These reflections also indicate a lack of focus specific to

the qualitative perceptions of physician leaders, which the current researcher addressed.

One optimization strategy to reduce retention effects among medical facilities within

primary care physicians is the reduction of burnout. Malhotra et al. (2018) and Dyrbye et al.

(2017) indicated that burnout serves as a threat to healthcare industry practitioners not only based

on physical and mental effects, but also in terms of increasing retention issues. Improving

retention rates can potentially be optimized by addressing burnout, reducing stress, and improving

work-life balance. Physicians must manage work-life balance, overloaded working hours, and

other factors that ultimately increase stress and burnout. One optimal strategy for improving

retention is to reduce burnout and stress by focusing on personal and organizational factors

(Abayasekara, 2015; Jackson et al., 2018).

Optimal strategies to reduce burnout can include professional coaching. Karakash et al.

(2019) argued that professional coaching is an appropriate model for improving self-awareness,

identifying burnout, as well as understanding compulsiveness to improve the mental and physical

wellness of physicians. Gazelle et al. (2015) argued that professional coaching can also be

effective in reducing burnout. Empirical studies specific to understanding how the reduction of

burnout through professional coaching strategies is effective for the reduction of turnover

associated with physicians are lacking within the review literature.

Other strategies appropriate for optimizing retention include improving morale. Biddison

et al. (2016) and Tziner et al. (2015) indicated that reduction of morale can ultimately decrease

job satisfaction and increase stress and burnout of physicians. Thus, improving morale can

improve organizational attitudes and may also benefit physicians’ retention rates (Rosenstein,

2017; Tziner et al., 2015).

Summary and Conclusions

I reviewed the literature pertaining to stress, burnout, and attrition in the healthcare

profession in general, followed by a specific focus on physicians. Stress is a perpetual problem

influencing healthcare professionals, including physicians. Professionals in the healthcare

industry exhibit among the highest levels of chronic stress of any occupation, and this problem

has increased over the past several decades (Burton et al., 2017). While research involving stress,

burnout, and attrition in physicians is scarce, a large body of evidence on this topic exists

regarding general healthcare practice, and many of the organizational strategies that have been

implemented to address the needs of physicians have been drawn from general healthcare

literature. The attrition problem in healthcare is significant because of the increasing demand for

healthcare services. This factor is due to a range of factors, one of which is globalization of

healthcare (Tsai et al., 2016). Researchers have begun to explore how attrition among physicians

has affected the healthcare industry based on growing evidence of the shortage and imbalance in

the supply and demand of these professionals; however, practitioners have yet to fully understand

how these constructs are experienced in healthcare professionals in general and among physicians

specifically. Only through an understanding of stress, burnout, and attrition, can morale,

satisfaction, and retention be facilitated.

I reviewed the literature pertaining to morale, satisfaction, and retention both in the

general healthcare professional population as well as in physicians. I found that working to boost

morale of healthcare workers can increase their engagement and positively influence their

attitudes toward safety and patient care (Biddison et al., 2016). Higher levels of healthcare

professional satisfaction are associated with a more patient-centered culture and greater patient

satisfaction (Cliff, 2012). Most physicians report feeling overworked and perpetually experience

undesirable levels of stress and symptoms of burnout as a result of the long hours associated with

their positions (Jongbloed et al., 2017). Retention factors may be categorized into two

dimensions: organizational factors and job-level factors (George, 2015). These findings suggest

that maximizing retention in general workers requires both organizational and job-related

strategies, although addressing each individually will also likely have a positive effect on

retention in any organization.

Transition

This concludes Section 1, in which I presented foundational materials for the current

study. This section included a discussion of the study’s background, problem statement, purpose

statement, and pertinent aspects of the study scope. The following two sections include an

overview of the project and results, respectively. Specifically, Section 2 includes the methodology

and research design that were implemented to address the purpose of this study. In Section 3, I

present the findings of the study, an overview the application of findings to professional practice

in healthcare, and recommendations for future practice and research.

Section 2: The Project

The need for and costs associated with the U.S. healthcare industry have grown

dramatically over the last 50 years (W. Y. Chen et al., 2016). The number of physicians has not

kept pace; as such, it is necessary to address physician retention. By 2025, a physician shortage of

90,000 is expected due to increases in both the average age of the population and the rate of

chronic disease (Sinsky et al., 2017). These shortages in physicians may lead to other problems,

such as decreased quality of patient care (Gazelle et al., 2015; Henry, 2015); the accumulation of

unnecessary costs (Fibuch & Ahmed, 2015); and physician burnout, which contributes to

decreased physician retention (Gazelle et al., 2015). The retention of physicians is critical for

mitigating these issues, and retention should be a hiring goal within the healthcare industry

(Petrou et al., 2014). With that in mind, I explored the strategies that healthcare organizational

leaders use to retain employed primary care and internal medicine physicians.

In this section, I present and rationalize the qualitative multiple case method that was

utilized to address the problem outlined above. This method was deemed the most appropriate

because it is used to identify phenomena as opposed to distilling correlations between individual

variables (see Roller, 2019; Williams et al., 2020a; Wu et al., 2016). I present all aspects of the

research process in this chapter, including the participants and how they were selected, the

research method and design, and the data collection and analysis instruments.

Purpose Statement

The purpose of this qualitative multiple case study was to explore the strategies that

healthcare organizational leaders use to retain employed primary care and internal medicine

physicians. I collected data through semi structured interviews with six physician leaders

regarding reasons for attrition and how to optimize retention based on their experience. The

research population included five organizational leaders from three healthcare organizations with

demonstrated success retaining primary care and internal medicine physicians serving Alexander,

Burke, Caldwell, and Catawba counties in North Carolina. Addressing this issue is socially

significant because maximizing retention for patient-centered care can lead to a generally higher

quality of service delivery and a more efficient healthcare system (Henry, 2015; Underdahl et al.,

2018).

Role of the Researcher

In the context of a qualitative multiple case study, the role of the researcher is to record

the participants’ honest experience of the case being studied. Qualitative research is a suitable

method for business problems with explorations of operational processes aiding the researcher in

understanding the significance and importance of life situations (Roy et al., 2015; Yin, 2018).

According to Degen (2017), qualitative researchers seek to obtain unseen interpretations, feelings,

emotions, understanding, and motivations from participants. Qualitative research is the result of

knowledge acquired from the understandings and significances of those involved in a

phenomenon under study, with an attempt to understand the experiences of study participant

(Merriam & Tisdell, 2015). Qualitative inquiry depends on engaging research practice, with the

researcher understanding the role and process of objective observation and negating biases (Roger

et al., 2018). For this reason, I took precautions to ensure that participant responses were not

influenced by researcher bias. To mitigate researcher bias, the researcher may prioritize the first-

hand experiences of participants (Roy et al., 2015; Yin, 2018). A qualitative case study method is

associated with the assumption that individuals know the most about their own lives; therefore,

the researcher trusts that what participants say is the truth (Merriam & Tisdell, 2015). Within this

context, the researcher is an observer whose role is to listen and record, but not to influence.

Keeping an ongoing log of the researcher’s own thoughts and interpretations throughout

the research process can provide a check for the researcher that enables them to analyze the

validity of their understanding of the data (Conroy, 2003). This type of ongoing analysis also adds

greater transparency to the research process, which is helpful in identifying and accounting for

any potential influence over results that the researcher may have (Levitt et al., 2018). As the

interviews occurred, I continuously analyzed these notes with the intention to ensure that the

results reflected the participants’ true experiences. The participants for this study included six

physician leaders recruited from Alexander, Burke, Caldwell, and Catawba counties in North

Carolina. As I am a doctoral candidate within the business school at Walden University, there

were no existing conflicts of interest relating to prior work relationships or power dynamics.

Aside from the roles and responsibilities of the researcher mentioned above, upholding

the three elements of the Belmont Report (1979) is also an important role of the researcher. The

Belmont Report requires that researchers address the following: (a) respect for persons; (b)

beneficence and (c) justice (Brothers et al., 2019). To ensure respect for the persons was upheld in

the study, I maintained participants’ confidentiality through pseudonyms. I also completed an

informed consent process and eliminated any forceful acts to encourage participation to show

respect for persons. To ensure that the study upheld the value of beneficence, I minimized risks to

participants during the recruitment and data collection. To uphold the value of justice, I kept all

procedures reasonable and nonexploitative. All actions and scope of participation were explained

to the participants prior to them deciding whether they agreed to be part of the study.

Participants

The participants for this study included six physician leaders recruited from Alexander,

Burke, Caldwell, and Catawba counties in North Carolina. To gain access to participants, I

contacted potential participants through the hospitals that employed eligible individuals for this

study. First, I contacted the administrative officials in the human resources department of

hospitals in the area, who disseminated information about this study to their staff via email and

fliers. A sample size of six physician leaders has been identified as an appropriate and

manageable number. If during this first step I could not identify six physician leaders willing to

participate in the current study, I would have adopted a secondary plan. The secondary plan for

recruiting and selecting study participants would be the snowball sampling technique, where

additional participants would be acquired by asking participants in the primary plan to share

recruitment materials with other potential participants. I expected that if the first step did not lead

to the recruitment of six required participants, the second step would help to achieve that goal.

To be eligible for the study, physician leaders were required to have been employed by

their current institution for a minimum of 2 years. This minimum length of employment was

included as a qualifying attribute because I aimed to focus on the long-term retention of physician

leaders. Any individual who has not worked at the same institution for at least 2 years would not

be able to provide the same insight into long term plans or burnout. Further, the physician leaders

were required to be able to understand and speak English fluently. The interviews were conducted

in English, and participants must be able to succinctly understand the questions provided in

English to answer them adequately. Furthermore, the responses were required to be in fluent

English for me to be able to understand and analyze them.

Because researchers conducting qualitative multiple case studies are concerned with

understanding a very specific phenomena within a real-life context that only affects a small group

of people, the sample size for studies in which this method is used can be quite small (Converse,

2012). Of more importance than data saturation is the ability for the data collected from

participants to adequately reflect the case under study. It should also be noted that a large sample

size may be hard to manage in multiple case studies because the interviews with each participant

are extensive and complicated. For these reasons, I identified a sample size of six physician

leaders as an appropriate and manageable number.

Research Method and Design

The research method for this study was qualitative. I deemed this approach to be the most

appropriate approach because the findings from this study may illuminate the strategies that

healthcare organizational leaders use to retain employed primary care and internal medicine

physicians. I selected a multiple case study as the design because the semi structured interviews

used for data collection in this method resulted in nuanced and personal accounts of the

relationships between variables.

Research Method

I used a qualitative research methodology to guide the current study, desired was to

identify and describe the experiences of physician leaders regarding reasons for attrition and how

to optimize retention (see Smith, 2015). I did not select a quantitative approach because I did not

intend to quantify aspects of participants’ experiences in any way. Further, I selected a multiple

case study design to explore and describe a phenomenon within the specific context in which it

exists and to identify optimal strategies to enhance retention within that context (see Yin, 2018). I

did not consider mixed-methods as appropriate because this methodology does not result in rich

insight into a phenomenon specifically within the context in which it exists and to provide

practical solutions to a pervading problem. Other qualitative designs, such as grounded theory,

ethnography, and phenomenology, were not selected because such designs do not allow for the

same level of focus on a particular case as a multiple case study. I conducted semi structured

interviews with six physician leaders regarding reasons for attrition and how to optimize retention

through in-depth insights from experts in the field.

The method for the current study was qualitative. Qualitative studies are appropriate

when the researcher wishes to collect emerging data and data that account for individual

experience (Roller, 2019; Williams et al., 2020a; Wu et al., 2016). Qualitative researchers focus

on the complex and nuanced aspects of phenomena (Ormston et al., 2013). Researchers use this

approach to distill themes within phenomena, as opposed to quantitative research, in which the

investigators draw conclusions about the relationships between specific variables (Roller, 2019;

Williams et al., 2020a; Wu et al., 2016). Qualitative research can be used to discern themes within

specific phenomena, rendering it integral in the initial process of naming and relating variables

that have not previously been statistically correlated. For this reason, qualitative research is often

used as way of understanding the topics about which little is known (Levitt et al., 2018).

Previous researchers have established the links between morale, satisfaction, and

retention of healthcare professionals (see Ellenbecker, 2004; Filho et al., 2016; Murale et al.,

2015; Tsai et al., 2016). There have been limited investigations into the factors that increase

satisfaction and morale in physicians (Roller, 2019; Williams et al., 2020a; Wu et al., 2016).

Qualitative investigations into this topic are, therefore, needed to distill what personal,

interpersonal, and environmental factors increase the satisfaction and morale of physicians. I used

qualitative methods to gain deeper insight into the connections that individual physicians perceive

between their workplace satisfaction and morale as well as their intention to stay at their job.

These insights may inform the design of both programs for increasing physician retention and

quantitative hypotheses in future studies of healthcare employees’ satisfaction, morale, and

retention rates.

Research Design

I chose a qualitative, multiple case study design because my goal was to describe the

strategies that healthcare organizational leaders use to retain employed primary care and internal

medicine physicians in a real-life context. Yin (2018) defined the case study research method as

an empirical inquiry that is used to investigate a contemporary phenomenon within its real-life

context, when the boundaries between phenomena and their context are not clearly evident, and in

which multiple sources of evidence are used. The interviews are then analyzed extensively for

themes. Researchers use this technique to develop new patterns and connections between

variables and within phenomena (Roller, 2019; Williams et al., 2020a; Wu et al., 2016).

In multiple case studies, the ability to derive understanding from participant experiences

is only possible because the information provided by participants within a real-life context is

assumed to be true and valid (Moustakas, 1994). An assumption exists that the information given

by participants is true because individuals are the inherent authorities of their own lives (Merriam

& Tisdell, 2015). Using a multiple case study method, I was able to pinpoint what personal,

interpersonal, and environmental factors influence the satisfaction and morale of physicians at

work. Furthermore, the findings may provide insight into the strategies that healthcare

organizational leaders use to retain employed primary care and internal medicine physicians.

Population and Sampling

Sampling techniques within multiple case studies are different than those used within

other types of qualitative research in that they typically encompass a small sample size and are

less generalizable (Converse, 2012). Although a small sample size would be undesirable within

other types of research, it is acceptable within the context of a multiple case study because the

concepts and trends under investigation are so specific. A small sample size is, therefore,

appropriate for investigating a phenomenon within the small group of individuals to whom it is

applicable (Khan, 2014).

Most multiple case study researchers use a purposeful sampling technique, which entails

gathering participants who have some sort of experience or expertise relevant to the phenomena

under investigation (Converse, 2012). There are three types of purposeful sampling: (a)

judgement sampling, which involves the selection of participants who have answers to specific

research questions; (b) quota sampling, which involves selecting quotas of participants who

match different aspects of the research phenomena; and (c) snowball sampling, which involves

the selection of participants solely based on their applicability to the phenomena under

investigation (Khan, 2014). Because snowball sampling is a method for selecting participants that

can provide rich insight into the phenomena under investigation (Khan, 2014), I selected this

method as the sampling procedure for the current study.

I contacted potential participants for this study directly or through the hospitals in which

they are employed. I obtained contact information by contacting each hospital directly via each

institution’s publicly available contact information. Recruitment occurred directly or via HR or

administrative officials, who distributed knowledge of this study to their staff via e-mail and

fliers. Potential participants responded directly or via e-mail, at which point they were screened

for eligibility. Those who did not meet the eligibility requirements were informed that they could

not participate, while those who did were asked to choose a time for the face-to-face interview.

This recruitment process continued until I recruited six participants. All participation in this study

was voluntary.

Ethical Research

Before beginning their interview, every participant was required to read, sign, and date a

consent form that detailed how the data for this research would be collected, stored, and used.

Participants were required to return the consent form prior to participating in any part of the

study. This information included an overview of the ways in which the findings of this study

could possibly contribute to the larger field. Participants who were not willing to take part in this

informed consent process were not able to continue with their interview.

Although participants’ names were attached to their interview, only I had access to this

information. Both the audio and Microsoft Word files that contain the interviews were housed in

encrypted locations. I removed participants’ names from any information pertaining to

participants that was not contained within an encrypted location.

For the purposes of protecting participants, the data collected from each interview were

completely anonymous. Protecting the identities of participants in this study was important

because these physician leaders may disclose information regarding intentions of employment

management. Knowledge of intentions of employee management or an employee’s intention to

leave could negatively affect the employer/employee relationship. Furthermore, discovering

management plans regarding employed staff could change relationships with patients. It was

important that participants in this study remained anonymous.

If participants wished to withdraw from the study, they were required to inform me no

more than 2 weeks after the completion of their interview. Participants were not required to

provide any reasoning for their decision to withdraw. At that time, all interviews and other

information pertaining to that participant would be deleted or shredded. Information on the

withdrawal process was included within the informed consent paperwork.

Data Collection Instruments

The central research question that guided this study is as follows: What retention

strategies do hospital administrators and physician leaders use to retain primary care and internal

medicine physicians? The data for this study were collected through face-to-face open-ended

interviews. This is the standard form of data collection for multiple case study research designs

(Petty et al., 2012). The questions that were included in these interviews are as follows:

1. What is your role for retaining primary care and internal medicine physicians?

2. What retention strategies do you use to maintain physician staffing in your system of

primary care and internal medicine physicians, and how have these strategies contributed

to your organization?

3. What approaches have you taken to overcome impediments or barriers to

implementation of your retention strategies?

4. What are the internal factors that have aided or hampered retention of primary care and

internal medicine physicians?

5. What are the external factors that have aided or hampered recruitment and retention of

primary care and internal medicine physicians?

6. How have governmental entities or programs played in your retention efforts?

7. What measures do you use to monitor, update, or change retention strategies to ensure

ongoing staffing of primary care and internal medicine physicians?

8. What else can you share about strategies that contribute to successful physician

retention?

9. Would you like to share any other relevant information that we have not already

discussed?

I carefully designed and analyzed these questions to answer the research question, What

retention strategies do hospital administrators and physician leaders use to retain primary care and

internal medicine physicians? All participants were presented with definitions for the terms job

satisfaction and retention before beginning their interview. This ensured that the participants and I

were speaking about the same concepts throughout the interview.

Data Collection Technique

The participants for this study included six employed physician leaders recruited from

Alexander, Burke, Caldwell, and Catawba counties in North Carolina. To gain access to

participants, I contacted potential participants through the hospitals that employ eligible

individuals for this study. First, I contacted the administrative officials in the human resources

department of hospitals in the area, who disseminated information about this study to their staff

via e-mail and fliers. A sample size of six physician leaders was identified as an appropriate and

manageable number. If during this first step I could not identify six physician leaders willing to

participate in the current study, the secondary plan would have entailed recruiting and selecting

study participants via the snowball sampling technique, where additional participants would be

acquired by asking participants in the primary plan to share recruitment materials with other

potential participants. I expected that if the first step did not lead to the recruitment of the six

required participants, the second step would help to achieve this goal.

Prior to any data collection taking place, several permissions and approvals were required

to be obtained. Prior to any data collection taking place, I obtained IRB approval, which was

expected to be granted based on the initial proposal presented to the IRB. Each of the participants

were also required to have completed and returned the consent form provided during participant

selection. Because Zoom was utilized to interview participants, I did not expect to need site

permission to interview participants onsite.

The instrument for data collection was a semi structured interview protocol that was

developed to align with the research questions and the theoretical framework. The semistructured

format was selected because this creates consistency from one interview to the next, as each

participant answers the same set of core questions (Qu & Dumay, 2011). However, there was

flexibility to ask probe questions between core questions, which lead to greater depth and variety

of responses (Stuckey, 2013). Prior to the start of each interview, I ensured that each participant

had completed the informed consent form. I also explained to all participants that their

participation was voluntary, and they may withdraw from the study at any point in time if they

wish. The interview took place via Zoom. I used Zoom to ensure that interviews could take place

wherever and whenever the participant was comfortable. Each interviewee was also required to

have the Zoom application. Recorded meetings on Zoom were used to generate interview

transcriptions. These recordings and transcriptions were utilized during the data analysis process.

After the meetings were transcribed, I also asked participants if they would be willing to

participate in member checking, which entailed the participants reviewing their interview

transcript to verify the accuracy of the information therein (Petty et al., 2012).

During the interview, I asked the participants a particular set of questions that were

aligned to the research questions (Creswell, 2013). I expected that each interview would take

between 30 and 45 minutes to complete. Digital audio versions of the entire interview were

recorded via Zoom so that a transcript of the interview could be generated to ensure that I could

refer to the interview details later in the research process if needed. After the completion of the

interview, each participant was provided with my contact information so that they could ask any

further questions.

Data Organization Technique

The data for this study were organized as both mp3 files and Microsoft Word documents.

All files were hosted in an encrypted folder, to which only the primary researcher had the

password. The files were organized in the order of their assigned letter/number sequence followed

by the word “interview,” starting with “P1_interview.”

Throughout the analysis process, I reorganized the data into groupings that reflected

themes. To distill the themes, I listened to the audio and readings of the transcriptions multiple

times. I took separate notes on each interview and organized these notes in Word documents with

identifying titles (e.g., “P1_notes,” “P2_notes”). After the interviews were sufficiently analyzed,

all emergent themes were categorized within a Microsoft Excel spreadsheet. Important

information was included with each theme, including the number of participants who mentioned

it, the total number of times it was mentioned, and relevant quotes that helped to explain the

theme.

To ensure that the data collected for the study were secured, I kept all physical data and

information sheets in a locked cabinet in their private office. All electronic data were kept in a

password-protected hard drive that was placed inside the same cabinet where the datasheets were

stored. All files will be kept for 5 years from the completion of the study. After 5 years, all data

will be destroyed, and all physical documents will be burnt. All electronic files will be deleted,

and all devices will be formatted to ensure no remnants of data remain.

Data Analysis

I completed data analysis using the methods of interpretive multiple case analysis and

thematic analysis. Interpretive multiple case analysis is a way of analyzing interview data that

allows the researcher to study both the meaning that participants give to their circumstances as

well as the meaning given within the larger context of the phenomena being studied (Austin &

Sutton, 2015). When using this method to analyze interviews, it is recommended that researchers

remain fluid in their interpretation, allowing new insight from the data to change how it is

perceived (Callary et al., 2015). According to Smith (2011), all studies that use interpretive

multiple case analysis must include the following in their analysis:

• A defined focus that contributes insight into the nuances of a very specific topic.

• Both descriptive and interpretive analysis that incorporates convergence and divergence

of themes must be included.

• The above must be included in the final write up of the analysis. (Smith, 2011)

Interpretive multiple case analysis was a useful analysis tool within the current study, as it

facilitated deep investigation into the personal perceptions of the participants. This part of the

analysis also helped me to distill the larger trends that influence the relationships between

physician job satisfaction and morale and their intention to remain at their job.

I also used thematic analysis, which is a process of finding patterns in qualitative data

through text analysis (Maguire & Delahunt, 2017), to analyze the emergent themes within the

data. This type of data analysis provides the researcher with flexibility in terms of what they want

to concentrate on. It is possible to perform thematic analysis on the entire dataset or on a specific

area of the data, offering opportunities for insight on both a macro and micro level (Braun &

Clarke, 2012). Furthermore, this aspect of the analysis provided a more concrete interpretation of

the data, which provided greater insight into the findings of the interpretive multiple case

analysis.

Thematic analysis is a popular method for analyzing qualitative studies. Consequently,

many methods for conducting this type of analysis have been proposed, resulting in

misperceptions in terms of how thematic analysis should be conducted (Maguire & Delahunt,

2017). I loaded all data into the NVivo software, which was the tool used to aid in data

organization and analysis. I used the six-step method of thematic analyses as laid out by Braun

and Clarke (2012) in the current study. The steps involved in this process are as follows: (a)

become familiar with the data, (b) create initial codes, (c) search for themes, (d) review themes,

(e) define themes, and (f) write the report.

Becoming Familiar with the Data

According to Degen (2017), qualitative researchers seek to obtain unseen interpretations,

feelings, emotions, understanding, and motivations from participants. The data for this study were

collected through face-to-face open-ended interviews. As the interviews occurred, I continuously

analyzed these data with the intention to ensure that the results reflected the participants’ true

experiences. I became familiar with the data by continuous review of the information and

identifying possible codes and themes.

Generating Coding Categories

According to Braun and Clarke (2006), it is possible to perform analysis on an entire

dataset or on a specific area of the data that offers potential insight on both a macro and micro

level. Coding data allows the researcher to identify characteristics of the information.

Furthermore, researchers can use coded data to arrive at themes. I uploaded all of the data into the

NVivo software, which was the tool used to aid in data organization and analysis.

Generating Themes

Computer assisted qualitative data software is a useful tool to increase the efficiency and

help with interpretation. I uploaded all of the data into the NVivo software, which was the tool

used to aid in data organization and analysis. I used thematic analysis, which is a process of

finding patterns in qualitative data through text analysis (Maguire & Delahunt, 2017), to analyze

the emergent themes within the data. I used the six-step method of thematic analyses as laid out

by Braun and Clarke (2012) in the current study. The steps involved in this process are as follows:

(a) become familiar with the data, (b) create initial codes, (c) search for themes, (d) review

themes, (e) define themes, and (f) write the report.

Reviewing Themes

I applied Braun and Clarke’s (2012) thematic analysis approach to analyze the interviews.

Along with the thematic analysis approach, I also applied IPA to determine and discover the

participants’ most common but meaningful perceptions and experiences regarding the retention

strategies for primary care and internal medicine physicians. I incorporated thematic categories to

maximize the interviews and address the main research question as wholly and thoroughly as

possible.

Defining and Naming Themes

I used the six-step method of thematic analyses as laid out by Braun and Clarke (2012) in

the current study. The fifth step is to define and name themes that are the essential information

about the research question. Major themes and minor themes are the parent themes of the study,

where the major themes represent more significant meanings than the minor themes. The major

themes include the most crucial findings with the most references from the participants.

Meanwhile, minor themes followed and are considered important but with fewer references than

the major themes. Lastly, I also included subthemes to provide examples and details about the

parent themes shared by the participants. Numerous themes were generated in response to the

study’s research question allowing for a final results report that supports the themes described

(Braun & Clarke, 2006).

Reliability and Validity

Although ensuring reliability and validity within qualitative research is different than

doing the same for quantitative methods, it is just as important (Noble & Smith, 2015). These

concepts are also related to the trustworthiness of a qualitative study, which refers to the measure

of the credibility, dependability, confirmability, and transferability of the data within a study

(Connelly, 2016). The actual strategies for ensuring reliability and validity within qualitative

research act as checks of authenticity and bias throughout the research process (Noble & Smith,

2015). Researchers use these strategies to reasonably confirm that all results truly reflect the

phenomena under investigation.

Reliability

Reliability refers to the consistency of participant answers throughout the study as well as

the means by which a researcher works to minimize their influence on the study. The recognition

of bias is an important aspect in the data analytical process that increases reliability (Noble &

Smith, 2015). This process is known as bracketing, which is an exercise that allows researchers to

set aside the preconceived notions they have based on who they are. Researchers are then better

able to fully comprehend the experiences of participants (Callary et al., 2015), which allows them

to produce, comprehend, and analyze data in a more reliable way. To improve reliability, I

performed member checking of the transcripts and the initial interpretations. Member checking is

an effective means of improving the credibility of a qualitative research (Candela, 2019). I asked

the participants to review the transcript and my initial interpretations of their interviews to

provide feedback about the correctness and accuracy of the information found in the document. I

conducted member checking prior to processing the data through thematic analysis.

Validity

The process of defining researcher bias is also important for ensuring validity, which

refers to how well aligned the results are with the data (Noble & Smith, 2015). Furthermore, the

validity of this study was critiqued through thorough record keeping, the inclusion of quotes

within the final manuscript, and engagement with other researchers and the participants in terms

of their perceptions of the study (Noble & Smith, 2015). This final strategy was utilized with

bracketing to ensure that my own biases were acknowledged and kept in check.

To ensure validity of the study, I also transcribed each interview and wrote an initial

interpretation of the interview data collected. After transcription, I performed member checking,

wherein feedback regarding the accuracy of initial interpretations was obtained from the

participants (Lincoln & Guba, 1985). I sent the initial interpretations of an interview to its

respective participant. The participant had 7 days to review the accuracy of these initial

interpretations. For any misinterpreted interviews, the participant sent the details of the

misinterpreted information and corrected the wrong information within the given period. After 7

days from sending the document, no changes were made.

Transition and Summary

The qualitative multiple case study research method and design outlined in this section

was appropriate for the study of physician leaders’ perceptions of job satisfaction, morale, and

intent to remain in their job, as the connections between these variables have not been adequately

investigated in the pre-existing literature (Roller, 2019; Williams et al., 2020a; Wu et al., 2016).

Qualitative multiple case study methods are appropriate as a means of defining connections

between concepts when none have previously been pinpointed, as this design prioritizes the

subjective realities of participants above all else (Roller, 2019; Williams et al., 2020a; Wu et al.,

2016). Although there has been a large amount of research conducted on the connections between

the relevant variables in the healthcare context (Ellenbecker, 2004; Filho et al., 2016; Murale et

al., 2015; Tsai et al., 2016), little research has addressed the factors that help support job

satisfaction and morale in physicians as well as how they perceive the factors affecting their

intention to stay in their current job. I sought to fill this gap using the qualitative methodology

outlined in this section. In Section 3, I provide an overview of how this research applies to

professional practice in healthcare and suggests the changes that it may be able to foster in both

practice and research.

Section 3: Application to Professional Practice and Implications for Change

The general business problem is that a shortage of physicians negatively affects practice

viability and patient care (Lu et al., 2017). The specific business problem is that some healthcare

leaders lack strategies to maximize physician retention. The purpose of this qualitative multiple

case study was to explore the strategies that healthcare organizational leaders use to retain

employed primary care and internal medicine physicians. I used the theory of Ellenbecker’s

(2004) job retention model as the theoretical framework for this study. The following central

research question was addressed in this study: What retention strategies do hospital administrators

and physician leaders use to retain primary care and internal medicine physicians?

I performed a qualitative multiple case study with six physician leaders in order to

explore the phenomenon of interest. I recruited the sample using both purposeful and snowball

sampling methods. The six participants were from Alexander, Burke, Caldwell, and Catawba

Counties in North Carolina. I interviewed four female and two male participants. The roles or

positions of the physician leaders who participated in the study varied, including managers,

executive officers, department directors, a vice president, and an administrator.

The source of data for this study was open-ended semi structured interviews via Zoom. I

used Zoom to ensure that the interviews took place with the convenience and comfort of the

participants in mind. I analyzed the data from the interviews using Braun and Clarke’s (2006) six-

step thematic analysis method. I also applied IPA to ensure that I could determine and discover

the participants’ most common but meaningful perceptions and experiences regarding the

retention strategies for primary care and internal medicine physicians. I provide the

interpretations and implications of the study to practice and social change along with

recommendations based on the findings.

Demographics

I recruited and interviewed six participants for the current study. These six participants

were physician leaders recruited from Alexander, Burke, Caldwell, and Catawba Counties in

North Carolina. Of the six participants, four were female and two were male. These participants

held different roles and positions in the healthcare industry but had wide and varying experiences

concerning the retention strategies of physicians in their respective institutions. Table 2 contains

the breakdown of the participants’ backgrounds.

Table 2

Breakdown of the Participants’ Demographics

Participant number

Gender

Role/ Position

Participant 1

Female

Financial Operations Manager

Participant 2

Male

CEO of Health Council

Participant 3

Female

Director of Human Resources

Participant 4

Male

Chief Ambulatory Officer and

Vice President of a Medical

Group

Participant 5

Female

Executive Director of a

Medical Group

Participant 6

Female

Administrator of Psychiatry

Services

Analysis

I applied Braun and Clarke’s (2006) thematic analysis approach to analyze the interviews

with the six participants. Along with the thematic analysis approach, I also applied IPA to

determine and discover the participants’ most common but meaningful perceptions and

experiences regarding the retention strategies for primary care and internal medicine physicians. I

incorporated thematic categories to maximize the interviews and address the main research

question as wholly and thoroughly as possible. Furthermore, major themes and minor themes are

the parent themes of the study, where the major themes represent more significant meanings than

the minor themes. The major themes include the most crucial findings with the most references

from the participants. Minor themes followed and are considered important but with fewer

references than the major themes. Lastly, I also included subthemes to provide examples and

details about the parent themes shared by the participants. As seen in Table, a total of 15 themes

were generated in response to the study’s main research question.

Table 3

Breakdown of the Total Number of Themes

Thematic

category

Number of major

themes

Number of minor

themes

Number of

subthemes

Total

TC1

TC2

Total

Presentation of Findings

In this section, I discuss the themes that emerged from the thematic analysis and IPA of

the interviews with the six participants. The main research question that guided the study was as

follows: What retention strategies do hospital administrators and physician leaders use to retain

primary care and internal medicine physicians? I uncovered two key themes or perceptions in

response to the phenomenon after completing the analysis process. According to the three

participants, the primary challenge faced by healthcare and physician leaders was the need to

sustain the financial needs of physicians, given the low patient population in some areas. Five

participants reported that the most effective retention strategy for them is to demonstrate and give

value to the needs of providers by collaborating and communicating with them. In particular,

three practices helped them immensely: practicing flexibility and concession when dealing with

physicians’ needs and requests, understanding the personalized needs of providers, and having a

physician leadership structure in place. Table 4 contains the complete breakdown of study themes.

In this section, I only discuss the themes with references from at least 35% of the participants.

Minor themes with limited participant references or only one participant reference are found in

their respective tables. These themes may require further research to improve their

trustworthiness.

Table 4

Breakdown of the Complete Study Themes

Thematic category

Themes

Number of

references

Number of

participants

TC1. Challenges

faced in retaining

primary care and IM

physicians

Needing to sustain the financial needs

of physicians

* Not reaching the average number of

patients being served

Having constant rotations in manpower

Competing with healthcare institutions

with larger funds and more significant

resources

Addressing workload and time

management issues

TC2. Retention

Strategies in Place

Giving value to the needs of providers

by collaborating and communicating

with them

*Practicing flexibility and concession

when dealing with physicians' needs

and request

*Understanding the personalized needs

of providers

*Having a physician leadership

structure in place

Offering tuition, training, and

certification reimbursements

Offering life insurance and other

insurance benefits

Promoting work-life balance

Offering other financial incentives and

bonuses based on performance

Offering a stipend instead of an

insurance policy

Highlighting the value and mission of

their work

Thematic Category 1. Challenges Faced in Retaining Primary Care and IM

Physicians

The first thematic category includes the challenges faced by healthcare and physician

leaders in retaining primary care and IM physicians. From the thematic analysis and IPA of the

six interviews, three participants reported the barrier to sustaining the financial needs of

physicians. For them, it has become increasingly challenging to ensure the financial stability of

the physicians in their respective institutions given the many internal and external factors present.

The three other minor themes are presented in Table 5 and may need further research given the

limited participant references recorded under them.

Table 5

Breakdown of the Themes Addressing Thematic Category 1

Thematic category

Themes

Number of

references

Number of

participants

TC1. Challenges

faced in retaining

primary care and IM

physicians

Needing to sustain the financial needs

of physicians

*Not reaching the average number of

patients being served

Having constant rotations in manpower

Competing with healthcare institutions

with larger funds and more significant

resources

Addressing workload and time

management issues

Major Theme 1: Needing to Sustain the Financial Needs of Physicians

The first major theme falls under the first thematic category of challenges faced in

retaining primary care and IM physicians. For this theme, it was found that the major challenge

for retention was the need to sustain the financial needs of physicians. Participants highlighted

that being a physician is a job. Several participants expressed the problems encountered about

sustaining salaries and addressing other financial issues in order to retain physicians.

Furthermore, physician leaders expressed that the shift from perceiving the role of a physician as

a mission or calling to being just a job has affected the financial needs and demands of

physicians.

This finding from the data contrasts several studies included in the literature review in

Section 1. For example, Tsai et al. (2016) claimed that physicians’ satisfaction with the pay they

received does not significantly predict turnover intentions. Other studies included in the literature

review also corroborated Tsai et al. (2016) by claiming that financial incentives are not strong

predictors of turnover intentions in physicians (see Jongbloed et al., 2017; Lu et al., 2017).

Moreover, other authors claimed that physicians value well-being and work-life balance more

than financial incentives (Windover et al., 2018). Many healthcare professionals develop stress

and burnout largely due to the demanding schedules and long shifts, which can have unavoidable

negative cognitive consequences (Neumann et al., 2018; Sander et al., 2015). Based on some of

the literature reviewed, reducing work hours and avoiding a demanding work environment are

more effective means of retaining physicians than increasing salaries. In another study, Parlier et

al. (2018) claimed that work-life balance and financial incentives or salaries all have positive

influences on improving the retention rate of primary care physicians.

A contradicting study was included in the literature reviewed in Section 1. Filho et al.

(2016) found that healthcare organization leaders falsely believe that financial incentives are

sufficient to retain qualified physicians. This claim offers indirect support for the first major

theme. Similarly, other scholars claimed that the inability to address the wage growth needs of

physicians has reduced healthcare professionals’ job satisfaction (Kaufman, 2011; Satiani &

Prakash, 2017). The participants of the study are physician leaders who commonly claimed that

physicians place high value on their salary or incentives more than other components of their

profession, such as the mission to serve the people and treat those who are sick.

The existing literature revealed contradicting claims regarding the importance of financial

incentives and salaries on the retention of physicians. Some studies support the claims under the

first major theme that sustaining the financial needs of physicians is important, as physicians may

quit their job if their financial needs are not met. However, some researchers agree with the first

major theme that leaders perceive the salary of physicians as a strong determinant of retention. In

this manner, more data or explanations may be needed in order to fully understand the importance

of financial needs of physicians in relation to retention and turnover.

According to three participants, although physicians have an noble mission of serving

and saving patients’ lives, it is also crucial to acknowledge that being a physician is a job. In this

regard, it has become challenging to manage and sustain physicians’ salaries when other factors

affect the management’s ability to provide for the physicians financially. As Participant 1 narrated

during the interview, recently, physicians have had a shift in their mindset. At the same time, with

the physicians’ refusal to serve the number of patients assigned to them, financial issues emerge

as well. The participants stated the following:

After a while, that did not work. Therefore, they go back to the hospitals and become

employees again. So now you have this pendulum that is going back and forth. And what,

in essence, happened, which I think is a very critical point leading you up to retention, is

in the beginning it was an vocation, it was a calling, and now it's a vocation. It is a job

and that is the big switch.

Yes. In addition, that takes the whole mindset to, "I just work here. It is not my ship to

steer; it is not my burden to carry. I'm just here to punch a clock and leave." In addition,

that has led to the challenges now that management has on what more can we do, but

what can we sustain? That is my role in it, is you can promise this, but if I cannot sustain

it monetarily for the next few years, you are in trouble.

Therefore, again, I would want to fall back on base salary plus commission. I would think

if you had the right kind of personality, they would see that, as the sky is the limit.

Moreover, "Boy, I'm going to get in there and see some patients this week. Put them on

my schedule." In addition, I do not want it to sound like a machine, but currently, if I

have a provider who is seeing six patients a day that is not covering the salary. That

moves that person from being an asset to a liability. And that is what is happening. We are

asking our providers to see 13 a day and they are balking.

Participant 2 shared the same perception and experience. For this participant, there would always

be revenue and financial constraints. However, these are heightened when physicians are unable

to reach the target number of patients to be served. Participant 2 shared,

It is always being constrained by revenue and finances. So, what can I afford? Yet, I have

to be somewhat, again, flexible with current employees and potential candidates, about

what I can use them for or how I can use them… So, they are not going to be able to see

18 to 20 patients a day. At best, during their tenure here, which is going to be about three

to four years before they decide to move on... they have that experience now, and they go

to the hospital for more money because they have that experience now, they are seeing

averaging 10 to 12 patients a day, as opposed to 15 to 16 patients a day.

Lastly, Participant 6 commented on the direct impact and influence of the COVID-19 pandemic

on the financial stability of the healthcare institution and their ability to retain their financial

obligations to physicians. The participant stated, “And again, I'm speaking recently, the COVID

pandemic that drastically hit. Financially, the organization had a hit. We had to revisit salaries,

contracts, and some negotiations occurred.”

Thematic Category 2. Retention Strategies in Place

The second thematic category of the study was the retention strategies already in place

that have been deemed effective by the participants. Five of the six participants reported the

strategy of giving value to the needs of providers by collaborating and communicating with them.

Three participants noted the effectiveness of offering tuition, training, certification

reimbursements, life insurance, and other insurance benefits. Two participants also added the

importance of work-life balance and the availability of other financial incentives and bonuses

based on performance. I uncovered two other minor themes or strategies of highlighting the value

and mission of their work and offering a stipend instead of an insurance policy. These minor

themes were referenced by only a few participants and may require further research to develop

their trustworthiness. Table 5 displays the themes in response to the second thematic category of

the research study.

Table 6

Breakdown of the Themes Addressing Thematic Category 2

Thematic category

Themes

Number of

references

Number of

participants

TC2. Retention

Strategies in Place

Giving value to the needs of providers

by collaborating and communicating

with them

*Practicing flexibility and concession

when dealing with physicians' needs

and request

*Understanding the personalized needs

of providers

*Having a physician leadership

structure in place

Offering tuition, training, and

certification reimbursements

Offering life insurance and other

insurance benefits

Promoting work-life balance

Offering other financial incentives and

bonuses based on performance

Offering a stipend instead of an

insurance policy

Highlighting the value and mission of

their work

Major Theme 2: Giving Value to the Needs of Providers by Collaborating and

Communicating With Them

The second major theme falls under the second thematic category of effective retention

strategies that are already in place. Collaborating and communicating with physicians may be

effective in promoting retention. From the data, I found that collaborating and communicating

between leaders and physicians is an effective strategy to promote retention, as this shows that the

leaders value the needs of these healthcare professionals.

The importance of having leaders that value the needs of physicians is supported in the

literature reviewed in Section 1. For example, a lack of consideration of needs, specifically

regarding wage growth, was found to reduce job satisfaction among healthcare professionals

(Kaufman, 2011; Satiani & Prakash, 2017). Other scholars have also highlighted the importance

of addressing the psychological and emotional needs of physicians to maximize retention (Filho

et al., 2016; Jackson et al., 2018; Rotenstein et al., 2017). For example, Jackson et al. (2018)

highlighted the importance of leaders satisfying the personal needs of physicians in order to

maximize the physicians’ retention.

In terms of collaboration and communication, the data that led to the emergence of this

aspect of the second major theme were indirectly supported in the literature reviewed in Section

1. Tsai et al. (2016) expressed that leaders’ communication and interpersonal skills contribute to

their followers’ perceptions of satisfaction. Anandarajah et al. (2018) highlighted the importance

of collaboration between and among physicians to mitigate any negative concerns about how

adding new staff members will influence existing healthcare organizations. These studies focused

on the role of communication and collaboration but did not explicitly claim the influence of

communication and collaboration to the retention of physicians.

The need for leaders to show that they value the needs of physicians in order to maximize

retention has been supported in the existing literature reviewed in Section 1. However, there is a

lack research that supports the claim that physicians need proper communication and

collaboration in order to maximize their retention intention. Overall, there may be a need to

further explore existing research to further understand the concepts involved in the second major

theme. There is also a need to collect more data in order to fully understand how physician

leaders value the needs of their physician subordinates as shown through communication and

collaboration.

The major theme was discussed by five of the six interviewed physician leaders.

According to Participant 2, “But primarily, just working with the providers to see what their

needs, again, professional and personal needs are and their fit within WC Health Council, how we

meet that.” Participant 3 highlighted the culture that they have created within their healthcare

institution and how they have tried to become as inclusive as they can for their physicians.

Furthermore, Participant 3 added the importance of communicating closely with the physicians to

ensure that the physicians are aware that they are heard and valued at all times. Participant 3 said,

And in addition to that, I just feel that the culture that we have within our organization is

so important. We strive to be one of inclusive. We want to include our employees, so we

have good communication. And we twice a year have company-wide events. In the

summertime, we have an employee development day outside in the park where we take

the afternoon and we have fun and we also have education. And then at holiday time, we

also... and we give bonuses. So, merit raises, increases, things like that. Is that helpful?

Well, I will tell you what, it has been a struggle. Culture is something that we

have really... its part of our strategic plan, right. We are doing a better job now. Just in the

last year, we seem to have improved in developing a culture where we want our

employees to feel like they are valued. And then how do we do that, right? We

communicate with them. We include them in... we let them know about decisions. We

value their opinion, we hear them. We show them that we hear them. If they make a

recommendation and we can implement that, we do that, right? But it is tough, it is tough.

COVID and trying to recruit, it has been difficult. Everybody has their own idea these

days of what their workday and their work week and their paycheck should look like. It is

hard. Recruitment is hard, it truly is. Especially if you are a specialist like a pediatrician,

they are difficult to come by. Very difficult.

Based on Participant 4’s experience, an inclusive and conducive environment for physicians to

perform at their best abilities is crucial. Physician leaders must ensure that physicians feel

recognized and valued for their work. The participant narrated the following:

So, I think the big thing and the thing that I have talked with my team about over the

years both from the operator side of things, as well as from the physician recruitment and

retention side of things, is we have to create an environment that physicians enjoy

practicing medicine. Now, again, just like burnout, everything is different for every

physician, so you have to have that relationship with them. The physicians that we

brought in 15 years ago under an acquisition of a practice that they had built over the last

20 years, how we retain those folks is different than how we retain the new physician

coming out of residency and what they're wanting to see in terms of a great place to

practice medicine.

You have to know your physicians. My leadership team knows that the

requirement I have is 80/20, 80% you are rounding, and 20% you are sitting at your desk

answering emails. If you are out there and you are talking to those physicians, you are

building the relationships with them; they are going to tell you when there are things that

make them unhappy. And then it is up to leadership at that point to make those

adjustments. And again, just like the word burnout is different for everybody, retention is

different for everybody. And you have to be flexible and know that what retains Physician

X in McDowell is not going to retain physician Y at Table Rock.

For Participant 5, feedback through close communication is an effective retention strategy.

Participant 5 explained that communicating with the physicians demonstrates that they are heard

and cared for. The participant shared,

We truly use provider feedback. Our providers are going to tell us what they are seeing in

the practices. They are going to tell us how they are feeling. One of the strategies and

measures we are using right now and really trying to figure out is panel size. So, what can

a physician adequately see, still provide the care they want to give and still see patients?

So, we have providers, for example, that are seeing in a panel size of over 2000.

I mean, the biggest thing that I have learned over the past year with retention is

communication with your current providers and knowing what they need, knowing where

the gaps are, following up with your newly hired physicians. I mean, building that trust. I

mean, if they have trust with administration and trust with their other providers, that

retention's going to be much easier. They are going to feel that loyalty that you need him

to feel to stick with you

Lastly, Participant 6 also took note of the importance of creating the right environment for their

physicians. This participant stated that an environment that promotes respect, collaboration, and

positive values has been crucial for them.

And so, we have those that a retention strategy. And then we have of course our culture

here, there is a lot of collegiality and collaboration because they are employed providers.

If you have a lot of providers that are not employed, it is hard to get them to do the things

you need them to do education wise, talk to each other. But when they are employed, you

set standards and set a culture in place. And there is a lot of collegiality here. They

respect each other even among the different disciplines though.

Subtheme 1: Practicing Flexibility and Concession When Dealing With

Physicians' Needs and Request. In light of giving value to the needs and preferences of the

physicians, a subtheme that emerged under the second major theme was the need to be open and

flexible to the requests raised by the physicians. For Participant 2, giving value to physicians can

be described through the practices and acts of flexibility and concession. This participant shared

specific examples of how these are applied in their institution and how these have helped them

recruit and retain physicians:

So, flexibility. I think now more than ever, I have had to try to adjust to a C word that I

can hardly roll it off the end of my tongue there. I think it is called concession.

Concession, there it is. I can get it out there every once in a while… But understanding

that if I want to keep this individual, can I make a concession in order to keep that

individual? Can I make a concession to get that individual, that I would not really have

entertained doing eight or 10 years ago, simply because I didn't have to? So, making

those concessions, flexibility. Again, looking at the environment within Caldwell and

surrounding counties, understanding that I do not have the financial wherewithal that

UNC Healthcare has.

I guess a case in point is, how many days a week are they going to work? They

want one day off a week. Before I'd say, "Well, sorry, but I need somebody five days a

week," or "We need to be open on Saturdays, and I need you to work half a day on

Saturday, but in compensation for that, I'll let you have all day Monday off." So, making

those types of concessions that used to be somewhat foreign, but now are common

practice with the competition. So, you have to adapt and adopt some of those same

flexible work schedules and expectations that your employees have, that you may not

always agree with, but it's keeping the doors open. That's ultimately what the goal is, to

keep the doors open, because without it, there's no access. Without access, there are no

patients. And without patients, there's no revenue.

Subtheme 2: Understanding the Personalized Needs of Providers. Another

subtheme was acknowledging that physicians have different needs and preferences. Participant 5

shared how they identify and address the needs of the different physicians, saying,

So, we're looking at, what do cardiologists need? What do urologists need? What do

pulmonologists need? Because that may be different than what primary care is going

through right now. So being one group, those strategies have to, we have to move them as

the providers need them moved.

Participant 6 shared the process that they follow when hiring their physicians. In this process, the

participant demonstrated the value of getting to know the physicians and gathering their thoughts,

feedback, and feelings about their work and employment, which are all crucial for long-term

employment, and sustaining the relationship. The participant noted the following:

When I hire providers, I ask questions regarding what is important to them. And things

that I've asked them is things like ... So, I employ a provider that would be in the

inpatient location and outpatient location. So, I have to find out are they particularly

interested in what the call schedule looks like? Do they like leaving early each day?

Because if you're working in outpatient clinic, that might not be necessarily something

they can do.

So, I have to find out what drives them, so on-call scheduling, money, RVUs?

What's important to them? Is it important, like I said, mostly in the hospital or the

outpatient setting. Some would prefer to be in an office setting. Some want a mixture.

Some would rather be in the hospital. Do they like having partners in a group? Some do.

Some like to have resources to lean on. And then just things like that, the workload, if

they like having advanced practice providers like NPs and PAs and things like that. So

that's how the rest, I think when they do interviews and hire, those are the questions that

providers ask.

Subtheme 3: Having a Physician Leadership Structure in Place. Lastly, a

subtheme that emerged was giving value to the physicians by assigning a leadership structure to

ensure that physicians are being heard and provided with the best possible support system.

Participant 4 shared how the creation of a formal and actual support team has helped them

manage and retain their physicians. Participant 4 provided examples, stating,

I think the big thing here that we did; one of the big things that I think really helps with

retention is having a physician leadership structure. One, so that physicians feel they have

another physician to talk to that has the right ear of me and my operations team. Because,

let's be honest, a lot of times the rub between employed physicians is the operators. The

operators are saying, "Well, you have to do it this way, not the way that you want to do

it," kind of thing. And so having a strong physician leadership structure in place I think

really helps because, one, you have a physician that can speak to other physicians to say,

"Look, this is the why behind it. I know it's different from how we want to practice, but

here's the why behind us practicing this way." And two, it is a person then who is on our

leadership team that can think like a physician, because none of us are physicians at the

end of the day.

Participant 5 noted how close communication and the assignment of a support team have made

their physicians much happier and more satisfied. The participant explained the following during

the interview:

And we've seen, even with providers that we've not had the best relationships with in the

past, they've become our support system of, "Hey, this is what we need. How do we get

there?" And I think, from what I'm seeing, it's definitely made our physicians happier and

feel like they have a voice, which I think helps with retention.

Minor Theme 1: Offering Tuition, Training, and Certification Reimbursements. The

first minor theme that emerged was the strategy of offering tuition and other professional

development reimbursements. The theme was shared by three of the six participants. As

Participant 1 stated, “And also, I would think that those tuition reimbursements are probably

through those federal resources or governmental programs too.” Furthermore, Participant 3

explained how the tuition and loan reimbursements have been valuable to the physicians and have

also been critical in retaining them:

So as a federally qualified health center, our providers coming in, if you are a licensed

provider, you can apply for tuition or loan reimbursement from the National Health

Service Corps. So we do have that as a benefit as well. And that has been very, very

helpful. We have probably 12 providers who are taking advantage of the National Health

Service Corps loan repayment.

So, I think that one of the most important benefits that we offer our providers

coming in is the tuition reimbursement, National Health Service Corps. We do have 12

providers who are taking advantage of that. And a lot of our recruiting efforts when we're

recruiting medical providers and dental providers, that's one of the questions that comes

up, "Do you offer tuition reimbursement or loan repayment with the National Health

Service Corps?" So, I think that's key as an FQHC.

Finally, Participant 6 provided several examples of how the reimbursements of the professional

needs and development opportunities and programs have helped them retain their physicians.

Participant 6 narrated the following:

And then reimbursement for professional expenses like license, which can be costly,

certifications, the professional memberships, subscriptions. Because not only do they

have their license, you know you've done pharmacy stuff, but they have to have their

medical license, but they also have to have a DEA license and things they have to

maintain, so that can get costly. So, we do that. We do provider recognition. So pre

COVID times, now they're starting to get back to some more things. But pre COVID, we

had banquets for providers where they can bring their wives [inaudible] nice outing for

them. And then we have advanced practice providers, which is a huge thing. So, the APPs

or the nurse practitioners and the PAs, they help do physical assessments. They help do

that rounding piece because the providers can't see everybody. So, when they can't see

everybody every day, those APPs fill in the gaps. So, they help with a lot of that. Or when

they have urgent consults, they've got to get to, if the APP can help with some of the

stuff, they help with that.

Yeah, an underserved area, and I can't remember the program it's under. But

because of that, the government offers grants or whatever the program is, to provide

school loan reimbursement.

Minor Theme 2: Offering Life Insurance and Other Insurance Benefits. The second

minor theme was the availability of life insurance and other types of insurance benefits to the

physicians. The minor theme was discussed by three of the six participants. According to

Participant 1, physicians also value different insurance benefits, such as life, dental, and family

coverage.

Now, see, we offer free life insurance, we offer free dental coverage. If you want family

coverage, you'd pay the remaining balance. And now we're going to be offering, for a

nominal amount, Blue Cross Blue Shield coverage. Of course, again, if you want family

coverage, you would pay that portion, but your portion is going to be free.

Participant 3 was proud to share their benefit package and how this has significantly aided in the

retention of their physicians. Participant 3 narrated,

The one thing that I believe that High Country Community Health does very well is we

do offer a good benefit package. We have medical, we have dental, we have vision, we

have short-term and long-term disability, and a life insurance policy is a company paid

benefit. It costs our employees nothing. We spend a significant amount of money. We

have 176 employees, and so we spend a significant amount of money on an annual basis

toward our benefit package. In addition, we have paid time off, we have paid holidays.

We offer an incentive, kind of like a production incentive. We set the quota. If they meet

that quota on a monthly basis, there is additional monies that go to providers.

Minor Theme 3: Promoting Work-Life Balance. The third minor theme of the study was

the value of work-life balance, as shared by two of the six participants. For Participant 1, work-

life balance has become increasingly important to physicians:

Currently, we do offer quite a bit of time off from day one. We put that X number hours

in a bucket, and maybe you've only worked here two days, but if you say, "I'm going to

be gone for the next three weeks," well, you're gone. Doesn't help us, but we're in a

position where we feel we have to give more. Unfortunately, I don't think we're getting

more. And so, there's your quagmire… Work-life balance.

Participant 4 provided examples of how work-life balance has affected the recruitment and

retention of their facility. Participant 4 stated,

If you want inner city and a ton of money, you don't need to come to Morganton, but if

you want to make a decent wage, have some work-life balance, which is a thing that we

pride our physicians have a little bit more work-life balance than the folks down in

Charlotte do, this is the place for you. You're not going to make a gazillion dollars, but

you're going to be able to raise your family, you're going to be here, you're going to take

care of a population that really needs you, and is grateful for you to take care of them.

Minor Theme 4: Offering Other Financial Incentives and Bonuses Based on

Performance. The fourth minor theme of the study was the strategy of offering other financial

incentives and bonuses based on the physicians’ performance. This minor theme was discussed by

two of the six participants. For Participant 6, many other benefits and incentives encourage and

motivate physicians to stay in their institution. Some of the examples provided by Participant 6

include the following:

I wrote some of this too and I did touch on it just a little bit, but not all of it. So, I'll tell

you what I had thought through this. But we have to balance what they want to ensure a

level of fairness. It has to be equitable among all of them. Contracts are structured. Some

standard items are in there in regards to the liability insurances, structured, paid time off,

that doesn't waiver much. The paid time off is consistent among the providers and the

CME days that they get for CME. Offering the liability insurance is a retention factor,

and I already talked about that, can be very costly in the private practice. Creative

scheduling has been offered in some areas. And then some other retention strategies

include competitive salary with ongoing benchmark efforts.

Alignment with Conceptual Framework

I used Ellenbecker’s (2004) job retention theory as this study’s theoretical framework.

According to this theory, job retention is predicted by a range of individual and universal

antecedents, which could be categorized as intrinsically and extrinsically rewarding (Ellenbecker,

2004). Job retention and intent to stay are predicted by a combination of the factors that a

professional finds personally rewarding (Ellenbecker, 2004).

Intrinsically rewarding factors that increase job retention vary according to personal

values but generally include job satisfaction, meaning associated with the work, and peer

relationships (Ellenbecker, 2004). I found that intrinsic rewards, such as giving value to

physicians’ need for collaboration and communication with their leaders, may improve retention.

Therefore, the second major theme is aligned with the concept of intrinsic reward as a promoter

of retention based on the job retention theory.

Work-life balance was found to be associated with physician retention. Participants

revealed that work-life balance was paramount in their lives. A strategy reported to enhance

retention through work-life balance was offering off days to physicians so that they could have

time off work. Since an individual’s values and priorities influence their perception regarding

work-life balance, this falls under meaning associated with work in the Ellenbecker’s job

satisfaction theory (Ellenbecker, 2004), classifying work-life balance as an intrinsic rewarding

factor.

Extrinsically rewarding factors that can increase retention include financial incentives,

recognition at work, and prestige associated with the position (Ellenbecker, 2004). I found that

extrinsic rewards, such as appropriate wages or support for financial needs of physicians from

their leaders, are important in maximizing retention. Therefore, aspects of job retention theory are

aligned or exhibited in the first major theme for this study.

Tuition and loan reimbursements were found to be valuable in physician retention. This

includes tuition and loan reimbursements for developmental programs, certification courses and

professional expenses such as licenses and professional memberships. Offering insurance to

physicians has also been described as a strategy to retain physicians. These insurances include life

insurance and health insurance such as vision, dental, and long-term insurance. Since the above

strategies fall under financial incentives, according to Ellenbecker’s job retention theory

(Ellenbecker, 2014), they are categorized as extrinsic rewarding factor.

Applications to Professional Practice

The two main findings from this study are reflected in the two major themes that emerged

from the data. The first major theme revealed that satisfying the financial needs of physicians is

one of the most prominent problem that hinders retention of physicians. The results of the first

major theme diverged from those of previous literature. Previous literature highlighted that

sustaining the financial needs of physicians was not a strong predictor of physician retention

(Jongbloed et al., 2017; Lu et al., 2017; Tsai et al., 2016). The current study revealed that meeting

the financial needs of physicians such as salaries and bonuses based on performance plays a

crucial role in their retention. The divergence in these results highlights the importance of

conducting further research on the impact of the financial needs of physicians in relation to their

retention and turnover.

The second major theme revealed that giving value to the needs of physicians by

collaborating and communicating with them promotes retention. Findings revealed that

collaboration and effective communication between leaders and physicians could be an effective

tool in promoting the retention of physicians. This is because collaboration and communication

meant that the leaders valued the needs of healthcare professionals. This finding converged with

those of previous literature that highlighted that failure to consider needs, specifically regarding

wage growth, reduced job satisfaction among healthcare professionals (Kaufman, 2011; Satiani &

Prakash, 2017). A decrease in job satisfaction levels could be a reason for turnover among

healthcare professionals decreasing their retention. This was supported by Jackson et al., (2018)

who revealed that satisfaction of physician needs by their leaders maximized physician retention.

The above findings have implications. In this subsection, I discuss the implications of

these findings to professional practice. This includes the impact of these implications on the

society and healthcare industry.

Implications for Social Change

High rates of physician turnover have negative implications to the field of healthcare and

to society as a whole. The direct implications of high turnover of physicians to the healthcare

industry include high costs for recruitment of replacements and lower productivity and revenue

for healthcare institutions (Abayasekara, 2015; Fisher, 2016; Salles et al., 2019). As for society in

general, high turnover rates of physicians may lead to fewer available attending physicians, which

may translate to poorer access to patient care services. Healthcare institutions may be unable to

provide care for a substantial portion of the population (e.g., low socioeconomic groups,

minorities, undocumented immigrants), which increases health risks for the entire country

(Abayasekara, 2015; Fisher, 2016; Salles et al., 2019).

The results of the study may be used to improve policies and practices in the field of

healthcare to mitigate turnover of physicians and improve retention rates of these professionals.

By improving these performance measures, the availability of healthcare service may be

maintained and improved. Therefore, society in general could benefit from having enough

physicians to attend to the needs of patients in the country.

Recommendations for Action

The following recommendations for action are based on the implications to practice that I

identified in the previous subsection. The findings revealed the importance of supporting and

sustaining the financial needs of physicians. Therefore, I recommend that physicians receive a

base salary and additional commission for every extra patient they attend to. This

recommendation is based on the suggestion of one participant who presented this idea during data

collection. In this manner, physicians would be encouraged to attend to patients instead of being

disheartened to attend to as many patients as possible because of the perceived inappropriate

salary levels.

Another recommendation for action is for physicians to have a target number of patients

to attend to per day. By having this target, leader physicians would reach sufficient levels of

revenue to satisfy the financial needs of the physicians. However, these implications have yet to

be tested for effectiveness in achieving improved retention of physicians, as a possible negative

effect of these recommendations would be increased stress levels or possible burnout.

I also recommend that physician leaders be more mindful of communicating and

collaborating with physician subordinates. Leadership should conduct regularly scheduled

interactions with physician subordinates in a setting and manner that allows for open an honest

communication. Communication and collaboration leads followers to perceive that their leaders

look out for their well-being and needs. These perceptions could cultivate positive emotions and

outlook towards work among physicians. Therefore, stakeholders of the healthcare industry (e.g.,

physicians, leaders, and patients) could realize the benefits of these interactions and relationships

between leaders and subordinates.

Recommendations for Future Research

Recommendations for future research are based on the limitations and delimitations of

the study. A limitation was that I included only four counties (Alexander, Burke, Caldwell, and

Catawba Counties in North Carolina) in the study. Therefore, it is recommended that future

researchers expand the geographical scope of the study beyond these counties. In expanding the

scope of the study, future research may improve the transferability of the study to other settings.

Another limitation of the study is the lack of outside stakeholder participation, such as

patients and vendors, who could potentially provide valuable perspectives on job satisfaction and

morale. Therefore, researchers should include other stakeholders of the healthcare sector to study

the phenomenon of interest in the future. This recommendation may advance knowledge in the

field of healthcare by exploring topics where literature may be scarce. Further, the study was

delimited to a small and specific sample. The sample included only six physician leaders

specializing in family or internal medicine and employed for at least 2 years in their current

institution. Therefore, I recommend increasing this sample size in future studies.

Reflections

The topic of physician turnover has been interesting to me because of its pressing and

large-scale implication to society. As a doctoral candidate within the business school at Walden

University, I have been interested in determining how to improve businesses and establish

favorable impacts to the healthcare industry. I believe that every entity has its specific challenges

and strong points. In this study, by identifying the challenges or weak points of primary care and

internal medicine, I was able to target a specific issue that required a solution. Through the

findings of this study, modifications to policies and practices in the field of healthcare may be

informed. Moreover, I have realized that through this research, I am able to help in improving not

only the professional practice of medicine, but also the ability of patients to have easy access to

physicians instead of experiencing difficulty in accessing healthcare treatments due to a shortage

of physicians.

Conclusion

The purpose of this qualitative multiple case study was to explore the strategies that

healthcare organizational leaders use to retain employed primary care and internal medicine

physicians. The general business problem is that a shortage of physicians negatively affects

practice viability and patient care (Lu et al., 2017). High turnover rates of physicians have been a

pressing issue in the field of healthcare (Malhotra et al., 2018). The specific business problem is

some healthcare leaders lack strategies to maximize physician retention. The shortage of

physicians has been the basis for the pressing need of determining effective physician retention

strategies to minimize unnecessary costs of hiring, training, and lost productivity (Fibuch &

Ahmed, 2015; Goode et al., 2019; Kirch & Petelle, 2017). Therefore, the following central

research question was addressed in this study: What retention strategies do hospital administrators

and physician leaders use to retain primary care and internal medicine physicians?

I addressed the research problem through the implementation of a qualitative multiple

case study. I interviewed six physician leaders from Alexander, Burke, Caldwell, and Catawba

Counties in North Carolina to collect relevant data to answer the central research question of the

study. The results of the interviews and thematic analysis revealed two thematic categories: (a)

challenges faces in retaining primary care and IM physicians and (b) retention strategies in place.

Under each category, I found one major theme. The first major theme under the first thematic

category was physician leaders’ primary challenge of sustaining the financial needs of physicians

given the low patient population in some areas. The second major theme under the second

thematic category was that the most effective retention strategy involved demonstrating and

giving value to the needs of providers through proper collaboration and communication. These

findings implied the need for policies and programs to ensure the ability of the healthcare facility

to generate revenue that could cover the financial needs of physicians while managing the

expectations that physicians have from their leaders and vice versa. Collaboration and

communication must be embedded into the processes and programs of healthcare institutions to

support the needs of physicians. With these recommendations for practice, the healthcare sector

and its stakeholders (e.g., leaders, physicians, and patients) could realize the benefits of

addressing the shortage of physicians and problems of retaining these medical professionals.

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