Trends in the practice environment of Chinese healthcare professionals from 2008 to 2023: an age period cohort analysis | Human Resources for Health

Our study found period effects in Chinese medical practitioners’ perceptions of their practice environment from 2008 to 2023 that closely correspond to major healthcare reform initiatives. According to recent researches, a higher job satisfaction often indicates a better practice environment [25, 26]. The decline in perceptions during 2013–2018 aligns with reforms promoting tiered healthcare delivery and diverting patients to community facilities. This indicates that medical personnel in top-ranked hospitals are experiencing a significant degree of income-orientated uncertainty and skepticism in response to disruptive systemic changes that are impacting clinical operations and patient flows [27]. However, in meantime, medical workers in county hospital are experiencing reduced job satisfaction due to surging workloads. Furthermore, they were also skeptical about the effectiveness of healthcare reforms [28]. Our study has yielded similar results to the one previously research in Turkey. Despite patients being satisfied with the reforms, healthcare professionals have consistently complained about their workload being too heavy and their pay being insufficient [6].

The nadir in perceptions in 2015 coincides with early stage reforms like the zero markup drug policy, which sought to curb over-prescription by banning hospitals from profiting on drug sales. While there is a need to rectify distorted incentive mechanisms, it is important to recognize that such corrections could potentially disrupt the revenue streams of hospitals. This, in turn, may have a significant impact on the income levels of healthcare professionals [29], resulting in a temporary deterioration of the practice environment for staff members. Simultaneously, this policy, obviously reduces doctors’ level of practice autonomy, particularly among township doctors. The declining income and limited clinical autonomy adversely affect their practice environment, and compels them to leave township hospitals and pursue opportunities for better career advancement in larger healthcare facilities [30].This is also demonstrated by the aforementioned study in Texas. Retention of nurses is influenced by the working environment, and a deteriorating working environment can cause nurses to leave. This has been suggested in a Chinese review published in 2015 [31], and since then a qualitative study abroad has reported similar results, with nurses leaving the clinic because of poor practice environments, high workloads, low pay, and limited clinical autonomy [32]. Ensuring geographic equity in healthcare human resources is important for the sustainable development of a region [33]. The subsequent improvement in perceptions after 2018 relates to a shift in reforms towards measures directly enhancing clinic environments, practice autonomy, career development pipelines, and doctor–patient relationships—addressing more immediate staff concerns.

The peak positive effect seen in 2023 correlates with major reforms in the 2020s to comprehensively transform public hospital management, operations, compensation schemes and governance—as well as new initiatives to resolve healthcare tensions through strengthened legal protections and sanctions against violence towards medical staff. In 2020, the “Basic Medical and Health Promotion Law” was introduced, emphasizing a “zero tolerance” approach towards violence against medical personnel [34]. This indicates that these transformative reforms may be achieving their aims of fundamentally improving the on-the-ground practice environment.

The COVID-19 pandemic beginning in 2020 also exerted period effects on Chinese medical practitioners’ practice environment. Foreign studies have indicated that during the peak of the COVID-19 pandemic, the prevalence of physician burnout reached 57.7% [35]. Furthermore, healthcare professionals who had direct contact with COVID-19 positive patients experienced a significant decrease in job satisfaction [36]. However, in the present study, there has been an observed improvement in healthcare professionals’ satisfaction with the medical practice environment from 2020 to 2023. This disparity in findings could potentially be attributed to divergent pandemic response policies between domestic and foreign contexts, with stricter and more organized measures being implemented domestically. Another possible reason is that, during the COVID-19 pandemic, there has been a noticeable shift in public opinion towards Chinese doctors and the doctor–patient relationship [37]. This change may be attributed to media coverage, spontaneously or under government guidance, that has highlighted cases portraying doctors in a positive light [38]. The media has referred to doctors supporting Wuhan as ‘countermarch people’, praising them for approaching the worst-hit city which others were escaping, in an effort to save more lives [39]. This indicates that in the face of unfavorable internal work factors (high work risks and pressure), enhancing external motivational factors (sense of responsibility, recognition) can also increase healthcare professionals’ satisfaction with their practice environment. Utilizing media and other promotional methods to foster positive doctor–patient relationships can inspire a sense of responsibility and recognition among healthcare professionals.

The comprehensive public hospital reforms during 2021–2022 aimed to promote standardized, transparent management and optimized allocation of healthcare resources. New policies also encouraged wider adoption of emerging technologies like artificial intelligence to enhance clinical processes [40]. Although the pandemic increased work pressures, these latest reforms signal continued policy attention to improving the on-the-ground practice environment.

We also found age effects in perceptions, with a peak in early career that began declining from that peak, producing a negative effect starting at age 24, reaching a nadir in the early 30 s, before recovering again in later career stages. There are several potential factors may contribute to this effect. First, empathy is regarded as a significant motivating factor for individuals pursuing a career in medicine [41]. Students opt for medical school due to their inherent empathy, and this empathetic inclination generally remains stable throughout their educational journey [42]. Consequently, newly qualified doctors often exhibit a higher level of enthusiasm and engagement in their professional duties. However, their proficiency in professional knowledge, skills, and business competencies remains limited, leading to various challenges in handling job tasks. These difficulties can easily give rise to feelings of frustration, despondency, and negative emotions, potentially even leading to a loss of confidence [43]. They are confronted with increasing responsibilities and pressures, and without appropriate support and protection, they may risk experiencing burnout and disillusionment in the mid-career phase of their professional journey [44]. To address this issue, it is suggested that reasonable remuneration workload and night shift be provided to those doctors, to improve the expectations of the profession. Hospital managers or senior doctors may be able to provide suitable support for work-related challenges, such as offering regular training [45]. It is recommended that opportunities for continuous professional development and training programs be made available to middle-aged doctors, to enhance their expertise, skills, and professional competence. For example, they could be offered the opportunity to study at higher level hospitals, attend academic conferences, and participate in continuing education courses [46]. These measures have the potential to improve their work performance and increase their confidence in their career prospects. Possible career changes, such as hospital management or research positions, could be made available to those middle-aged [47]. It is important to consider the needs of married doctors, especially female doctors, and provide reasonable time off for marriage and childbearing [26]. It is recommended that pregnancy and childbirth not have a significant impact on their career. A study conducted in Jiangsu, China, revealed a positive association between the duration of medical practice and doctors’ remuneration and promotional prospects. Doctors who have accumulated significant practice experience tend to enjoy higher social standing and exhibit greater confidence in their future career growth. Consequently, older doctors typically demonstrate a more optimistic professional mindset compared to their middle-aged counterparts. This positive outlook is so pronounced that it even leads to some medical workers expressing reluctance to retire [48]. For example, subset of retired nurses in the United States choose to resume their careers to reap the following benefits: affirmation of personal value, positive mindset, opportunities for altruistic service, and mitigation of social isolation [49].

According to cohort effects, individuals born after 1995 have consistently demonstrated more favorable perspectives, these findings align with certain research conducted abroad. Internationally, the individuals in question are referred to as “Generation Z” and are considered to possess more open-minded and inclusive perspectives, as well as a greater willingness to embrace novelty. These characteristics are expected to have a positive impact on the medical community [50]. In China, doctors belonging to Generation Z exhibit a more favorable perception of healthcare reform compared to older generations, potentially because they entered the labor market in 2013, after the previous healthcare reform had been implemented. Consequently, they were not directly exposed to the challenges associated with the previous reform and were not negatively affected by it. In contrast, earlier cohorts like the 1970s-1980s exposed to those difficulties exhibited lower perceptions, highlighting how early experiences shape generational outlooks [51]. Our study confirms Mannheim’s hypothesis [52] that the socioeconomic and historical events experienced by members of a birth cohort can significantly shape their value orientations. Individuals born in the 1970s and 1980s, also known to researchers as the “social reform generation,” are perceived as more pragmatic, more likely to pursue economic success, and more conservative in their political views [20]. Consequently, this generation may have a negative perception of government healthcare reform policies that result in reduced income. Millennials, those born after the 1980s, have faced increased economic pressure due to the one-child policy, which is because that they have to support both parents and children [53]. Negative perceptions are more likely to be shown when their incomes are lower due to healthcare reform. Individuals born in the 1960s hold more positive perceptions of policy. This difference may be attributed to the perception that individuals from the 60 s are more idealistic and collectivist, and have greater confidence in the government [20]. Additionally, those born in the 1960s tended to hold senior positions in the medical field at the time of the survey, with higher incomes and greater respect. As a result, they did not perceive the policy-induced decrease in pay as significantly as others. To enhance perception of the professional environment across different generational cohorts, a multifaceted approach is recommended. For the Generation Z cohort, initiatives should focus on nurturing their innovative mindsets and embracing inclusivity through specialized training programs. Establishing feedback mechanisms to amplify their voices is crucial. Addressing the pragmatic concerns of the social reform generation necessitates safeguarding reasonable income levels, offering professional development and retraining avenues. The economic pressures faced by millennials, exacerbated by the one-child policy, should be alleviated through measures such as housing and child education support, enhanced compensation packages, and work-life balance policies.

Controlling for covariates revealed that female practitioners as well as those in obstetrics and emergency medicine had more positive perceptions of the practice environment. Higher job satisfaction and more harmonious doctor–patient relationships are also associated with more favorable perceptions. A similar result was shown by Hou et al. [54]. Compared to physicians, nurses, technicians and administrators also had more positive perceptions. This study is comparable to research conducted in Israel, where female nurses and working in emergency reported higher levels of job satisfaction [55]. Furthermore, as stated in the Norwegian study, even among professionals in the same field, midwives who do not perform managerial duties have a less-favorable evaluation of their work environment than those who do [17]. The alignment between income and efforts also played a crucial role. When income matched efforts, it positively impacted perceptions of the practice environment compared to situations where income lagged behind efforts. However, this positive impact diminished when income exceeded efforts, suggesting that overly high compensation may not necessarily translate to improved perceptions. This finding is noteworthy, as it aligns with a previous study on the relationship between income and happiness that reached a similar conclusion [56]. Furthermore, perceptions of promotion fairness were linked to more positive views of the practice environment, while more severe physical fatigue and anxiety negatively affected these perceptions. This statement is consistent with the findings of a qualitative study conducted in Iran [57]. To enhance healthcare providers’ perceptions of the practice environment, an approach targeting various interrelated factors may be beneficial.