Background

The aging population and the growing prevalence of chronic diseases posed a great challenge to healthcare systems worldwide, especially in countries, where healthcare was fragmented [1,2,3]. To improve the quality and accessibility of healthcare while reducing the general cost, many countries initiated reforms to promote the integration of care, such as the Kaiser Healthcare Group of the United States and the YiliantiFootnote 1 of China [5,6,7,8].

Primary healthcare providers (PCPs) played an essential role in promoting the integration of care, especially concerning the continuity and coordination of healthcare [9,10,11,12,13]. The job satisfaction of PCPs is recognized as an essential pillar of healthcare systems worldwide, which is known to be associated with several factors [14]. Many factors have been well-explored by the literature including systematic reviews [14,15,16,17,18,19,20,21,22]. Along with the integrated care reform, there was a growing evidence base for the correlation between the integration of care and the job satisfaction of PCPs. On one hand, studies reported that the job satisfaction of PCPs affected the quality and coordination of healthcare by influencing their job performance, job stability, and teamwork [23,24,25,26,27]. On the other hand, a growing literature explored the influence of integrated care on the job satisfaction of PCPs but the findings were inconsistent across studies. Some studies found that the integration of care enhanced the job satisfaction of PCPs by improving their working conditions, career development, and interpersonal relationships [11, 28,29,30,31,32]. Whereas, some studies claimed that integrated care generated a negative influence on the job satisfaction of PCPs because of the extra workload and job stress [30, 33, 34]. Due to the inconsistency of findings across studies, little seems known about how the integration of care impacts the job satisfaction of PCPs. Identifying job satisfaction and associated determinants of PCPs will help address major questions regarding the job satisfaction of PCPs who work in integrated care. However, to the best of our knowledge, the influence of integrated care on the job satisfaction of PCPs has yet to be the topic of any systematic review. To facilitate the integration of care from the primary care perspective and to support evidence-based healthcare decisions, consolidating the literature to systematically explore the correlation between the integration of care and the job satisfaction of PCPs is of crucial importance. This study aimed to address this gap by answering the following question based on Herzberg’s two-factor theory: how does the integration of care influence the job satisfaction of PCPs?

Methods

Research design

This study conducted a systematic review following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement [35]. Meta-analysis was not used for the review as selected studies were considered too heterogeneous in terms of methods and analysis and thus a more descriptive approach was suitable.

Data source and searches

We searched the following databases: CNKI, WANFANG, PubMed, Web of Science, Cochrane Library, and Embase, among which CNKI and WANFANG were the commonly used databases for retrieving Chinese academic research. This study retrieved the data from inception to 19 March 2023. At the stage of identification, we used the following keywords to identify relevant studies: integrated care, primary care provider, and satisfaction. The search strategy is shown in Table 1.

Table 1 Search strategy
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Study selection

We included studies following the PRISMA statement. First, we excluded duplicate studies from the database. In the screening stage, two researchers reviewed the title and abstract of the study and excluded the studies that were irrelevant to the topic. In the eligibility stage, we carefully reviewed the whole study and excluded studies that violated the inclusion criteria. Studies excluded at this stage are listed in Table 2 with detailed justifications. To be included in the review, the study had to meet the following inclusion criteria: (1) the research background of integrated care practice, including the integration of horizontal and vertical organizational management, governance mechanisms, financing and payment, and service provision; (2) the study population was the primary healthcare providers; and (3) focusing on the satisfaction of PCPs. Articles are excluded for several reasons: (1) changes in satisfaction of PCPs were not related to integrated care practice; (2) to study the evaluation of the cognition or effect of integrated care among PCPs, excluding the influence on satisfaction; and (3) the study of PCPs was not included.

Table 2 Excluded studies and justification for excluding
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Quality assessment

Critical appraisal of the included studies was essential to a high-quality systematic review. Appraisal consisted of systematically examining studies to ensure they were trustworthy, valid, and reliable [36, 37]. Considering the varied types of the included studies (e.g., quantitative, qualitative, and mix-methods studies), we used the Mixed Methods Appraisal Tool (MMAT) version 2018 to evaluate the quality of the included studies [38]. MMAT was a quality assessment tool that could be used to evaluate five different types of studies: (a) qualitative, (b) randomized controlled, (c) non-randomized, (d) quantitative descriptive, and (e) mixed methods. Each criterion was rated as "yes", “no” or “unsure”. In this study, two researchers conducted MMAT independently. If there were any differences, they would discuss and resolve the differences. If the two evaluators could not resolve the differences, the third researcher would be invited to review the differences until a consensus was reached. Details of the quality evaluation of the included studies are shown in Table 3.

Table 3 Quality appraisal of the included studies
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Data synthesis

This study used the integrative review method to extract and synthesize the data [39]. At the stage of data extraction, the key information extracted from each of the included studies were as follows: title, author(s), publication year, country(s), research method(s), integration types (horizontal/vertical), and measurement dimensions of satisfaction, which are summarized in Table 4. Horizontal integration refers to the integration between different types of healthcare services, such as medical services, social services, and other care, which is often in the form of multidisciplinary teams and/or care networks to take care of specific groups of patients. Vertical integration refers to the collaboration among primary, secondary, and tertiary medical institutions which aimed to increase the continuity of healthcare services [40, 41]. At the stage of data synthesis, we coded and divided the extracted information into categories and themes based on Herzberg’s two-factor theory. Two-factor theory is one of the most commonly used theoretical frameworks for exploring job satisfaction among health professionals [42, 43]. It hypothesizes two separate sets of mutually exclusive factors that either cause job satisfaction or dissatisfaction. Factors that primarily contributed to satisfaction alone called motivation factors, while the other factors that primarily contributed to dissatisfaction alone called hygiene factors. Herzberg also described motivation factors as intrinsic to the job and hygiene factors as extrinsic to the job [44]. Inspired by Herzberg’s analysis, we divided the dimensions of job satisfaction into intrinsic and extrinsic categories and used the notions of intrinsic and extrinsic factors to keep consistency. In this study, extrinsic factors were mainly related to working conditions, such as salaries and benefits, interpersonal relationships, and work environment. Intrinsic factors were mainly related to intrinsic work motivation, such as achievement and recognition, autonomy, and promotion opportunities. During the process of data synthesis, we found that some key information under certain themes needed to be specified. Therefore, we generated several sub-themes from coding. In the end, we formed a comprehensive picture of the analysis framework of influencing factors of PCP’s job satisfaction, as described in Fig. 1.

Table 4 Data extraction of the included articles
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Fig. 1
figure 1

Analysis framework of influencing factors of PCP’s job satisfaction

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Results

Search results

The PRISMA flow chart in Fig. 2 illustrates the search process for this review. First, a total of 805 articles were retrieved through databases, among which 57 duplicate articles were removed. Second, after reviewing the title and abstract of the remaining 748 articles, we excluded 689 articles that did not match the inclusion criteria previously mentioned. Third, after the initial review, 59 full texts were examined carefully and 33 articles were excluded due to being irrelevant to integrated care, not associated with PCPs satisfaction, and PCPs were not study subjects. Fourth, 3 articles were added based on a reference review. In the end, we included 29 articles in this study.

Fig. 2
figure 2

PRISMA flow diagram of study selection

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Description of the included studies

Of the 29 studies included in this review, there were 14 quantitative studies (4 longitudinal studies and 10 cross-sectional studies), 3 qualitative studies, and 12 mixed-method studies. The selected articles covered diverse countries including China, the United States, Canada, Ethiopia, Kenya, the Netherlands, and the United Kingdom. Concerning the integration type, there were 16 vertical integration studies and 13 horizontal integration studies. A summary of the above-described characteristics of the included studies is shown in Table 5.

Table 5 Characteristics of included studies
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Of the 16 vertical integration studies, 14 focused on the Yilianti of China, 1 focused on the urban medical groups in China, and 1 focused on the integration of care in a rural area of the USA. Of the 13 horizontal integration studies, 9 studies reported the integration of primary care and other kinds of healthcare, including public healthcare [9], mental healthcare [11, 45,46,47,48], pain care [12], and pharmaceutical care [10]. There were also 3 studies focusing on providing integrated care for vulnerable individuals, such as children [28, 49] and the elderly [50]. Besides the mode of “primary care + X”, there was also a study reporting the integration of HIV care and mental healthcare [30]. In addition, studies also explored the integration of care through the collaboration of healthcare professionals [51].

The included studies assessed the impact of integrated care on PCPs’ satisfaction through different methodologies and tools. Of the 14 quantitative studies, only 1 study used a scale named Job Satisfaction Questionnaire [52], and the other 13 studies used self-developed questionnaires to assess the satisfaction of PCPs. Of the 12 mix-method studies, semi-structured interview was the most used method for collecting qualitative data, while the quantitative data were mainly collected through self-developed questionnaires and only 1 study used the Perceived Organizational Support Scale [53].

Effects of integrated care on the job satisfaction of PCPs

Due to different research aims, the effects of integrated care on the job satisfaction of PCPs were reported differently by the included studies in this review. We coded and divided the discussed effects into categories, themes, and sub-themes based on Herzberg’s two-factor theory, as presented in Table 6.

Table 6 Diverse influence of integrated care on the job satisfaction of PCPs
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Intrinsic job satisfaction

Intrinsic job satisfaction referred to the internal factors of a job that were relevant to job satisfaction which included 4 themes: responsibilities, opportunities for advancement, recognition, and a sense of personal achievements and growth.

Responsibilities

In this review, responsibilities are related to the work autonomy of PCPs. Studies reported that the integration of care affected the job satisfaction of PCPs by influencing their work responsibilities [29, 54, 55]. However, there was no consensus on whether the effects were positive or negative. For instance, a study focused on integrating multiple public healthcare, such as individual preventive services and population health interventions, into primary care claimed that the integration generated negative effects on PCPs’ work autonomy. Providing public healthcare imposed fixed work procedures and stringent requirements on PCPs, especially the increased paperwork and frequent evaluations generated by the bureaucratic structure of public health [9]. On the contrary, 2 studies reported that the job satisfaction of PCPs was increased along with their improved work autonomy due to the integration of care [13, 29].

Recognition

The theme “recognition” included 2 sub-themes: “patient feedback” and “service effect”. The recognition from patients or providers themselves was an important driving force behind the job satisfaction of healthcare providers [56, 57]. In this review, 5 studies showed that the integration of care significantly increased the accessibility of high-quality healthcare which benefited patients. The better health outcomes of patients increased the self-esteem and confidence of PCPs which positively influenced their job satisfaction [10, 28, 47,48,49]. 2 studies directly reported that integrated care increased the job recognition of PCPs, because they got more positive feedback from patients, especially from those with multi-morbidity [30, 48]. Besides the integration of care, a study showed that collaboration and cooperation among health professionals would increase the job recognition of PCPs by cultivating a teamwork culture [49]. Furthermore, about 77% of the surveyed PCPs expressed their recognition of integrated care and believed that a well-structured care team with a clear division of responsibilities would also be beneficial to the quality of primary care services [12].

A sense of personal achievements and growth

“Knowledge and skills improvement”, “work achievement/meaning”, “learning and training opportunities” and “self-efficacy” were classified into the theme “a sense of personal achievements and growth”. Studies found that PCPs held a higher self-expectation under integrated care, because the integration of care provided them with more opportunities to participate in teamwork and to get trained in a wide range of different clinical settings [12, 30, 49, 53, 58]. Besides the benefits of teamwork and training opportunities, the integration of care helped PCPs to gain more practical experiences from diagnosing and treating patients with complicated conditions [13, 30, 45, 48, 59, 60]. The increased knowledge and the improved skills could also help PCPs to build confidence to work towards their career goals and ultimately enhanced their job satisfaction [11, 12, 28, 45]. Despite those substantial benefits, the integration of care would also increase the perceived work value of PCPs and thereby enhanced their job satisfaction [29].

Promotion opportunities

Studies indicated that there was a close relationship between job satisfaction and the promotion opportunities of PCPs who worked in integrated care [32, 61, 62]. Studies showed that the current promotion evaluation system of PCPs over-emphasized their scientific research achievements. However, the majority of primary healthcare institutions (PHIs) were underdeveloped and lacked the necessary facilities and patient cases to support PCPs to conduct research. As a consequence, most of the PCPs complained about the hardship of getting promoted. The lack of promotion opportunities has brought down the job satisfaction of PCPs [34, 63].

Extrinsic job satisfaction

Extrinsic job satisfaction referred to the external factors of a job that influenced job satisfaction. In this review, extrinsic job satisfaction was divided into 5 themes which included salaries and benefits, organization policy and administration, interpersonal relationships, working conditions, and work status.

Salaries and benefits

Some studies claimed that integrated care can affect the job satisfaction of PCPs who worked in integrated care through salaries and benefits levels [32, 60, 62]. 7 studies included in this review reported that PCPs had the lowest satisfaction with salaries and bonuses [13, 31, 32, 59, 61, 64, 65]. Studies also reported the imbalance between the increased workload and the relatively low income of PCPs who worked in integrated care, which also brought down the job satisfaction of PCPs [9, 30, 31, 33, 59, 61]. Furthermore, a study of Tianchang Yigongti specifically pointed out that 94.5% of PCPs were unsatisfied with Yigongti reform and the main reason for their dissatisfaction was related to low salaries [66].

Organizational policy and administration

Organizational policies mainly referred to the performance evaluation system of integrated care for PCPs in this review. Studies showed that the current performance evaluation system was unable to effectively reflect the work value of PCPs and, as a consequence, affected their job satisfaction [32, 34, 60, 61, 63]. A study of Yilianti in China reported that integrated care reform concentrated on integrating medical resources while paying less attention to improving institutional structures. As a consequence, Yilianti fell short of a fair payment distribution and promotion system which negatively influenced the job satisfaction of PCPs [63].

Interpersonal relationships

The theme “interpersonal relationships” included “relationships between colleagues”, “relationships with leaders”, and “teamwork”. In this review, 5 studies pointed out that integrated care prevented unfair competition by creating a friendly and supportive environment for teamwork [28, 45, 47,48,49]. Furthermore, a study compared the experience of PCPs who worked in integrated care and those who worked in standard care and found that PCPs who worked in integrated care were more satisfied with inter-professional collaborations [46]. In addition, 3 studies claimed that integrated care increased the mutual support between employees and employers which strengthened the professional identity and organizational belonging of PCPs and, as a consequence, improved their job satisfaction [13, 34, 65].

Working conditions

Studies reported that more positive perceptions of the environment and working conditions of medical staff brought higher job satisfaction [67, 68]. Concerning integrated care, studies also reported that it created a supportive working environment for PCPs [69, 70], thereby improving the work efficiency, service quality, and job satisfaction of PCPs. Similarly, studies that investigated the impact of Yilianti on the satisfaction of PCPs showed that vertical integration expanded the accessibility of high-quality medical resources, optimized the infrastructure and management level of PHIs, created a good working environment for PCPs, and improved their job satisfaction [13, 31, 32, 62,63,64, 71]. However, studies pointed out that many PCPs, especially those from less developed countries, complained about the organizational structure and poor facilities of PHIs [30, 34, 60]. Furthermore, a study that explored the experiences of providers who participated in the integration of HIV and reproductive health in Kenya pointed out that the infrastructure of health facilities urgently needed to improve [30].

Work status

In this review, the theme “work status” was associated with “workload”, “work stress”, and “burnout”. 12 of the included studies investigated the work stress of PCPs who worked in integrated care, but yielded inconsistent results. Among these studies, 3 studies reported that PCPs complained more often or easier to feel burnout when he or she experienced a heavier workload caused by the integration of care [9, 29, 33]. For instance, the underdeveloped integration of care would generate adverse effects on the continuity of care which turned out to be another source of work stress for PCPs [49]. Besides, 4 studies of Yilianti in China showed that the development of integrated care guided more patients to pay their first visits to PHIs which directly increased the workload of PCPs and burdened them with more work stress. However, the increasing workload of PCPs did not increase their income which negatively affected their job satisfaction [31, 33, 59, 63]. Whereas, two studies reported adverse results. They argued that integrated care (e.g., integrating mental healthcare into primary care) expanded the availability of healthcare providers with different backgrounds which released the work stress of PCPs and reduced their chances of burnout [10, 12].

Discussion

This systematic review aimed to explore the influence of the integration of care on the job satisfaction of PCPs. To the best of our knowledge, this study is the first systematic review to explore the influence of integrated care on the job satisfaction of PCPs based on Herzberg’s two-factor theory. By synthesizing evidence from the included 29 studies, we summarized the measurement methods of job satisfaction and found that the integration of care affected different dimensions of the job satisfaction of PCPs. To help with clarification, we identified and classified the discussed effects into three levels (i.e., categories, themes, and sub-themes) based on Herzberg’s two-factor theory. Finally, we identified 2 categories (i.e., intrinsic and extrinsic), and 9 themes (i.e., responsibilities, promotion opportunities, recognition, a sense of personal achievements and growth, salaries and benefits, organizational policy and administration, interpersonal relationships, working conditions, and work status). Besides, we also identified 14 sub-themes to specify some key information.

Under the category of intrinsic job satisfaction, this review found both positive and negative effects of integrated care on PCPs’ satisfaction. Positive effects were mainly reflected by the theme of “recognition” and “personal accomplishment”, while negative effects were mainly reflected by the theme of “work autonomy” and “promotion opportunities”. The perception of work autonomy was identified as an important endogenous incentive factor for PCPs [72].

Studies in this review reported that PCPs from different PHIs which were in the process of integrated care reform demonstrated varied levels of work autonomy. This might be because PHIs were in the different stages of integrated care reform, such as the integration of services and the collaboration between different medical institutions were varied at different levels. Herzberg emphasized the importance of promotion opportunities as a motivating factor for employees [73]. However, this review found that compared with other countries, PCPs in China were less satisfied with promotion opportunities. This might be because of a higher threshold for promotion at the grass-roots level for PCPs. This review also suggested that increased levels of professional skills proved valuable to job satisfaction [30, 74]. According to Maslow’s hierarchy of needs theory, providing more career development opportunities could satisfy the self-actualization needs of PCPs, which is an effective way to improve the satisfaction of PCPs [75]. Another important aspect of intrinsic satisfaction was "recognition". This review found that self-affirmation of intrinsic value and recognition of extrinsic achievements could meet the needs of self-esteem, and thus had a positive impact on the job satisfaction of PCPs.

Under the category of extrinsic job satisfaction, studies included in this review also reported both negative and positive effects of integrated care on PCPs’ satisfaction. Negative effects were mainly reflected in “work status”, “work conditions”, “salaries and benefits”, and “organizational policy and administration”, while positive effects were mainly reflected in “interpersonal relationships”, “work status”, and “work conditions”.

Some studies in this review reported that integrated care increased the workload and work stress of PCPs [30, 31]. Whereas, some studies claimed that the integration of care helped to release the work stress of PCPs because of the improved cooperation and collaboration among medical institutions and health professionals [12, 76]. Those adverse effects of integrated care on the job satisfaction of PCPs might be due to the different types of integrating. Furthermore, studies in this review reported that “salaries and benefits” were a prominent factor that might generate job dissatisfaction. Due to the current unfair performance appraisal system, there existed an imbalance between income and workload which led to dissatisfaction and burnout of PCPs [9, 29]. This might be well-explained by the pay-return imbalance model: when more energy and effort was put into the work than the return, it could cause employees to have a sense of psychological imbalance, which could lead to negative emotions and dissatisfaction [77]. Moreover, studies in this review also demonstrated that working conditions were a commonly discussed extrinsic factor influencing job satisfaction. Previous studies of job satisfaction among PCPs explored the diverse influence of work conditions on PCPs and their work, such as the quality of medical services, occupation development, quality of life, and the turnover perception of PCPs [71, 78]. Taking the integration of care as a context, this review explored and collected specific findings about the working conditions of PCPs under the integrated care reform and the resulting job satisfaction. According to the studies included in this review, some countries did not pay enough attention to optimizing working conditions for PCPs [30, 34]. In addition, studies in this review also addressed the importance of mutual support among PCPs and emotional support from their supervisors to their job satisfaction under integrated care [79, 80]. Stable and secure emotional bonding would contribute to the working efficiency of PCPs [56].

Limitations

This systematic review has several limitations. First, the studies included in this review vary considerably in the methods and tools used to measure the job satisfaction of PCPs. Therefore, it is difficult to standardize the results for satisfaction, limiting the comparability of the results. Second, most of the studies included in this review were cross-sectional studies, and differences in job satisfaction measurement tools may affect the generalizations of the findings. In addition, based on the results of the quality assessment of the articles, some of the studies included in this review did not fully meet the quality criteria and lacked information on sampling strategy, target group representation, and response rates. Finally, different populations, sample sizes, backgrounds, ethnic cultures, healthcare systems, types of integration, and institutions may have influenced the study results.

Implications for future studies

Given that the included studies of this review were mainly cross-sectional studies with only 4 longitudinal studies, future studies on exploring the impacts of integrated care on PCPs were recommended to employ longitudinal study design. Given that the majority of the included studies used self-developed questionnaires to measure the impact of integrated care on the job satisfaction of PCPs with only 2 studies used valid scales, there was a need of developing a comprehensive and effective measurement tool to measure the effects of integrated care on the job satisfaction of PCPs. Given the important role of motivation in improving PCPs’ performance and achieving desired health system outcomes, future studies on integrated care should consider expanding their analysis to include the impact of changes in motivation on PCPs’ performance and other broader health system outcomes.

Conclusion

This review synthesized the included 29 articles and explored the effects of the integration of care on the job satisfaction of PCPs. Based on Herzberg’s two-factor theory, this review identified 2 categories, 9 themes, and 14 sub-themes from the included studies. Findings suggested that the integration of care had both negative and positive effects on the job satisfaction of PCPs and the effects were different depending on the types of integration. Since PCPs played a vital role in the successful integration of care, their job satisfaction was an important issue that should be carefully considered when implementing the integration of care.