Background

Australia has a workforce shortage of general practitioners (GPs), particularly in rural and regional areas [1, 2]. This phenomenon is reflected globally, in countries including England, Canada, USA, India, Israel and South Africa [3,4,5,6,7,8]. As GPs are responsible for providing primary care services [9], any deficit in their numbers has a significant potential impact on access to basic medical services and follow-up care [10].

In areas of workforce shortages, GPs are required to work longer hours, often on their own or in a small practice, and at the extremes of their scope of practice [11]. One of the most commonly noted issues for rural and regional doctors is the difficulty in accessing locum support that is timely, affordable or of an adequate quality [11]. Additionally, access to continuing professional development (CPD), including procedural upskilling or specialising can be also difficult to obtain in areas outside major towns and cities [11]. This is a barrier to sustained interest and challenge for GPs and can, together with issues of unsustainable work demands, lead to burnout and early retirement [12]. A further issue is the ageing of the existing GP workforce. Approximately 30% of the GP population in NSW is aged over 55 years and approximately 25% Australia-wide [13], with the average age being 53 years [14]. Not only are rural and regional GPs on average older than their urban counterparts, as a population they also retire at a younger age [12].

Increasing workforce supply is inherently a multifactorial challenge, necessarily entailing both increased recruitment and training of new GPs, of which experienced GPs are an integral part, as well as strategies aimed at minimising early retirement from general practice. It is an important aspect to keep experienced GPs in practice in order to continue to provide healthcare to rural communities as well as to facilitate the training of future generations of doctors. GP recruitment, migration and retention in rural and regional areas are important national matters if shortages are to be addressed [15]. This should necessarily involve the identification of appropriate and effective incentives, as well as strategic efforts directed at addressing barriers and facilitators identified through consultation with GPs.

The work ability (WA) model has historically been used to explain and explore retirement and long-term employability. The WA model was developed in the 1980s at the Finnish Institute of Occupational Health as an instrument to predict retirement age by analysing the interactions of various factors that affect work ability [16]. The model encompasses the resources of the individual, the external factors related to their work, the environment outside of their work and how these factors relate to an individual’s workability. The model has been visually depicted as a house, with four interconnected floors, and a surrounding environment to illustrate the interactions of all of these elements (Fig. 1).

Fig. 1
figure 1

Work ability model (Finnish Institute of Occupational Health, 2014) [17]

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The work ability concept blends well with the sustainability movement. People, organisations and governments are increasingly aware that employment goes beyond having a job at one point in time, but rather that we need to think about sustainable employment [17]. Van der Klink and colleagues have defined SE as follows: ‘Sustainable employability means that, throughout their working lives, workers can achieve tangible opportunities in the form of a set of capabilities. They also enjoy the necessary conditions that allow them to make a valuable contribution through their work, now and in the future, while safeguarding their health and welfare. This requires, on the one hand, a work context that facilitates this for them and on the other, the attitude and motivation to exploit these opportunities’ [18]. While the capability approach is not synonymous with workability, it is important to note the definition here to place the SE concept into a wider context. While the WA model has historically been used to explain and explore retirement and long-term employability, this may not be the same as sustainable employability. The International Standards Organisation has recently released a guideline on Sustainable employability (SE) for organisations [19]. In this guideline, SE for the individual is defined as ‘the long-term capability to acquire, create and maintain employment, through adaptation to changing employment, economic and personal conditions throughout different life stages’. Workability can be seen as an element of sustainable employability at one point in time and can also be used as a proxy measure to measure sustainable employability [20]. In a recent study amongst 49 content experts, 97% of participants agreed that workability can be used as a proxy measure to measure sustainable employability [20]. Based on the above, we propose the following definition of sustainable employability, in order for it to be more measurable in practice: ‘Sustainable employability refers to a person’s ability to gain or maintain quality work throughout their working lives, while

  • having the motivation to conduct quality work

  • maintaining good health and wellbeing and

  • having the opportunity and the right work context

  • co-creating value on personal, organisational and community level

  • being able to transfer skills, knowledge and competencies, to another job, company or other future roles’

The WA model does not necessarily have a future component in the model itself but it may lend itself to categorising and exploring factors influencing sustainable employability. Demonstrating this in the case of general practice, it can help us explore how GPs can ‘recycle’ current knowledge, skills and abilities for use in future roles such as teaching or GP advocacy work. It can also help us understand how GPs maintain a work-life balance to sustain a busy demanding career in general practice.

More evidence is needed to demonstrate the effectiveness of SE interventions for ageing workers [21, 22]. The purpose of this study was to ascertain whether the WA model can provide a useful explanatory framework to understand sustainable employability amongst GPs.

Methods

The current investigation is based on a qualitative analysis of data that was previously collected as part of a larger mixed-method study, described in further detail elsewhere [11]. Participants were recruited via the Northern Rivers General Practice Network (NRGPN), which is a local body representing GPs in the region. The region is a coastal area comprising the far northeast corner of the state. The region depends economically mainly on tourism, with a large number of small towns and comprises localities classified as Small Regional to Medium Large Regional according to the Modified Monash Index [23]. GPs (N = 165) received a study package from the NRGPN containing a covering letter from the NRGPN, a participant information sheet, consent form, a reply-paid envelope and an anonymous quantitative survey about early retirement, healthy lifestyle, occupational health and work-related factors [10]. All eligible participants received two reminders 2 and 4 weeks after the initial invitation. GPs who returned a completed consent form for participation in the interview component were contacted to arrange a time and a preferred venue for the interview. Consenting GPs who were unable to participate in a face-to-face interview were interviewed by phone (n = 1).

Two interviews were conducted by an occupational health physician, while the remainder of the semi-structured interviews were conducted by Author SP, who is an experienced academic researcher, who was personally known to some of the participants due to her familiarity with the medical professional networks in this geographical area. There were no other people present at the interviews. Interviews lasted approximately 60 min and were mainly undertaken in general practice clinics. A few GPs preferred the interviews to be conducted at a café, their own home, phone or a university location. The semi-structured interview schedule was developed by the authors, and pilot tested with two GPs. Specifically, the questions were asked to explore GPs’ perceptions of the factors which hinder and encourage healthy workforce participation, reasons for choosing to work or not until and beyond traditional retirement age, and to explore current retirement pathways amongst GPs. The interviewer showed and briefly explained the WA model to the participants at the beginning of the interview. Interviews were audiotaped and transcribed verbatim and identifying information was removed.

Data analysis

NVIVO 10 was utilised to assist with the organisational aspects of the data analysis. A hybrid deductive-inductive thematic analysis approach was used, similar to that described by Fereday and Muir-Cochrane [24]. Initially, two authors independently coded three transcripts and developed a draft coding hierarchy. This was both deductively derived from the WA model [25] as well as inductively generated based on categories arising from in vivo coding. Discrepancies were discussed and the revised coding structure was applied during a first cycle coding of the full data set. This structure was further discussed, refined and expanded by all the authors throughout the coding process, allowing the development of a final coding scheme which was applied the data set during a second cycle coding. A thematic map was developed based on the coded data with the WA model as the organising framework. The alignment with this and the identification of aspects which were not explained within this model were discussed amongst the authors and formed the development of a revised model. Thematic narratives were generated.

Results

Of the 19 GPs participating, 14 (74%) were male. The average age was 57 years (standard deviation, 12 years). All participants were actively engaged in GP-related employment. Two were in solo practice.

The analyses supported the general applicability of the WA model in understanding SE amongst GPs, in finding that all the elements of the original model were strongly represented in the data. Themes aligned with the model and embodied the fluid and dynamic relationships between the various model components from a general practice perspective. However, in order to provide a more comprehensive reflection on the factors and dynamics found to underpin work ability in this group of GPs, a modification of the WA model was required which entailed the creation of additional subcategories within the model (Appendix). Additionally, new themes relevant to general practice also emerged from the data, which were not reflected in the original model. Hence, the current data set revealed a set of important, new factors and relationships that required additions and refinements to the original model, in order to fully explain sustainable employability in this GP sample. These factors included work-life balance and lifestyle, which both were found to connect to the external and internal environments, the addition of an extended social community to reflect the influence of the wider community within which a GP resides, and the impact of gender.

Work-life balance and lifestyle

A desire for work-life balance or to pursue a particular lifestyle was a significant influence on where many GPs chose to reside and work. Intrinsically linked to this theme was family. These themes were dynamically interactive and uniquely functioned as a connection between the external environment and the interior of the WA house and all of its floors. Personality and personal characteristics (first floor) determined the GPs desire to pursue a particular lifestyle, and the ability to work in a particular manner drove their education and upskilling (second floor). A balance between lifestyle and work meant improved physical and mental health (first floor) and consequently improved their attitude to work and the perception of intrinsic benefits such as personal fulfilment (third floor). The influence of lifestyle and work-life balance also affected workload (fourth floor):

…we’ve tried to make the job fit the lifestyle rather than the other way ‘round. (GP1)

Distance and travelling

GPs identified that pursuing the lifestyle or work-life balance they desired had a significant impact on the time they were required to spend travelling to work, education or social events. GPs described living close to schools for families, near the beach, on a farm, or in a different town to maintain anonymity, which often lead to increased distance and consequent time spent travelling:

When I stopped working at [a clinic], it was because I was spending two hours driving there. (GP13)

As with the theme of work-life balance, this sub-theme interweaved all of the floors of the WA house, as too much travel was found to negatively impact mental and physical health (first floor), and access to education (second floor) in some cases. Prolonged travel times impacted the workplace due to its influence on time management (fourth floor).

Extended social community

The community in which GPs lived had a direct impact on their work. GPs are recognised members of the community. This was found to have either a positive impact on their work experience, with intrinsic rewards (first floor, third floor):

…I contribute to the community here, and that’s where I’m sort of trying to make my mark (GP2)

or a negative impact as community expectations exerted an external pressure to work in a certain fashion (fourth floor):

If you’re in private practice you are basically a slave for your community. (GP14)

Of consideration for many GPs was the lack of anonymity in a small community, the experience of which was mediated by their personality and personal characteristics (first floor):

…I run into patients around and about…that would become a bit of an issue. (GP9)

Finally, the structure of the community itself can influence the type of work a GP is undertaking (fourth floor):

…there’s a lot of people with depression in our community and that’s a major part of their presentation. (GP8)

Gender

Gender was a complex theme that emerged throughout the interviews. It appeared to have a multilayered impact on the individual, evidenced by gender’s influence on the various floors of the WA model, and also on the GPs’ interaction with their external environment and family. Gender also appeared to exert either an amplification or moderation of the influence of family on the WA model.

Female GPs attracted different presenting problems in their practice with more complex and emotionally loaded problems leading to a higher emotional burden for the GP and longer consultations, which impacted work content (fourth floor) and mental health (first floor):

They might have longer visits. Like [GP name] … she doesn’t see the volume of patients that a few of us see. (GP8)

Some female GPs found that the emotional load from these different presenting problems also necessitated more time for recharge and recuperation, in order to maintain what is perceived as a sufficient level of compassion (first and third floors):

But people tell me as a female GP you get all the tears and smears, and it’s the tears that really drain you at the end of the day. (GP9)

The very specific work content that female GPs often encountered meant varying their education and upskilling (second floor) to match the needs of their patient demographic (fourth floor and external environment). Commitments to family (operational environment) also impacted their access to and time for continued education:

My general practice isn’t really general practice; it’s women’s health, which started when I first came here…I never really ever got to do general practice once I had children because the population came for 1001 Pap smears and other things pertaining to women’s health. (GP13)

In some cases, male GPs avoided a certain kind of work or patient determined entirely by gender:

‘Cause there’s female doctors in the practice, I do less Pap smears… (GP6)

Female GPs also described using different methods to manage their practice (and work within a practice) to their male counterparts, as they defined themselves differently from men. It appeared that women’s identity was still largely tied to their role as a mother and wife:

…but as a woman GP, I was not valued—this is a terrible thing to say—I was not valued in my own practice. And the culture in my own practice, which was an interesting practice, was you’re playing at general practice. You’re a mom; you’re playing at general practice. You’re not a real GP. (GP13)

Hence, it appeared that women’s work ability was more strongly impacted by family than men. Some women felt that they were perceived as less committed than their male counterparts (third floor) due to their apparent prioritising of family commitments and the consequential reduction in (paid) work (fourth floor).

Discussion

The thematic analysis revealed that much of the data could be broadly categorised according to the WA model, suggesting that the work ability model can be used to explain elements of sustainable employability amongst ageing GPs. Our findings aligned with previous research [26, 27] which identified that the areas of particular relevance to rural and regional GPs were workforce support, rural and regional training opportunities, access to continuing professional development, flexibility in practice ownership, family support, and recognition and remuneration. However, in order to provide a more comprehensive reflection on the factors and dynamics found to underpin work ability in this group of GPs required the creation of specific subcategories within the WA model (Appendix). Quantitative analyses [28, 29] using the work ability index have previously pointed to health and functional capacity (first floor) presenting the highest explanation rate for continued work ability in older workers, followed by work factors (fourth floor). The current thematic analysis supported these findings for GPs.

In addition to the specific subcategories, which emerged from the data, entirely new factors were identified: work-life balance and lifestyle, extended social community, and gender. Hence, a modified WA model is proposed to more accurately reflect the components of work ability which forms the basis for sustainable employability in GPs. (Fig. 2).

Fig. 2
figure 2

Modified work ability model (modifications marked in red and based on themes identifed in qualitative analyses)

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Work-life balance and lifestyle provided important and previously unidentified connections between the WA House and the external environment. Where and how a GP chose to live impacted the various elements of their work ability and vice versa. This finding supported previous research which has alluded to the importance of work-life balance for GPs [11, 30, 31].

The data also revealed that rural GPs experienced the added dimension of an extended social community not previously included in the WA model. The community in which the GP lived had a direct impact on their work. They felt to be recognised (and ‘public’) members of the community, which for some had a positive effect on their work experience (intrinsic rewards), while others experienced a negative impact with increased work demands and lack of anonymity. Further research would be beneficial to ascertain whether the significance of the extended social community could be extrapolated to other (health) professional groups.

Gender was the third emergent theme that could be added as an element to the original WA model to explain GPs’ sustainable employability. Previous research into the impact of gender on work ability has alluded to women professing greater intolerance to some work challenges earlier than men, especially with regard to physical requirements, but demonstrated greater tolerance for jobs requiring a high cognitive demand compared to men [32]. Women have also been found to be exposed to more unfavourable work conditions than men even when they carry out the same work [32], which corroborates the findings of this study.

Gender impacted every floor of the WA ‘House’ and had a moderating or amplifying effect on the influence of family. Women GPs were predisposed by their roles as mothers and caregivers to be more likely to modify their work hours to accommodate family commitments compared to their male counterparts. These findings suggest there may be merit in developing gender-specific sustainable employability frameworks.

Strengths and limitations

While care should be taken in generalising the current findings to other GP or professional populations, a major strength of this study was the inclusion of a cross section of GPs within a well-defined geographical area of New South Wales. Additionally, the achievement of data saturation and alignment of the current results with previous research lend support to the validity of the findings. Studies of larger GP populations from a variety of regions/communities would provide further empirical validation of this modified model. This study would also be strengthened by the inclusion of GPs not currently engaged in practice, as this may have provided a more accurate picture of the factors contributing to early exit. This should ideally be a focus of further research.

Impact of research outcomes

This study has revealed the importance of new factors influencing work ability in GPs. It has provided a more comprehensive model for effectively explaining elements of sustainable employability for GPs in the Northern Rivers region of New South Wales. The model can ideally be utilised as a basis for addressing workforce planning issues and to assist in the design of programmes to promote sustainable employability amongst GPs. For example, the WA model can be used as a conversation tool to raise awareness and teach individuals, such as GPs, which factors relate to their own workability and how these factors may influence their own sustainable employability [33].

Conclusions

This is the first study that has empirically tested the WA model in a general practice population using qualitative methodologies. In our study, we tested whether the WA model may lend itself to categorising and exploring factors, which influence sustainable employability. The WA model can be utilised to understand elements of sustainable employability amongst GPs. However, work-life balance and lifestyle, extended social community and gender were aspects of work ability pertinent to GPs which did not form part of the original model and required inclusion to more accurately reflect the components contributing to sustainable employability amongst GPs.