Organizational commitment among physicians: A systematic literature review

Abstract

Purpose

Physicians work increasingly in larger organizations across different health care delivery systems. This systematic review examines the published empirical literature on organizational commitment among physicians within an international context.

Design

A systematic, PRISMA-guided review examining studies of organizational commitment among physicians published over time. Four article databases and a combination of appropriate search terms aided in identifying relevant articles.

Findings

Key findings include: (a) physicians, regardless of country, personal characteristics, type of job, or place of employment generally have lower levels of organizational commitment than other health care workers; (b) work- and job-related variables, particular age and job satisfaction, shape physicians’ organizational commitment; and (c) organizational commitment and the factors that shape it are similar across physicians working in different health systems.

Review implications: Organizational commitment should remain central for researchers to study in most health systems internationally. Larger samples, longitudinal research, and greater use of theory are design improvements that will strengthen the extant research. The findings imply that if healthcare organizations create workplaces that make physicians feel in control, do not overwhelm them with work, provide a supportive culture, enhance their ability to give input, and keep them job satisfied, they may gain enhanced organizational commitment.

Originality and value: To our knowledge, this is the first review of research examining organizational commitment among physicians. It is a resource for researchers and managers interested in learning more about aligning physician thinking and behavior with health care organizations.

Keywords

international context literature review organizational commitment physicians

Introduction

For professionals like physicians, the traditional thinking has been that these individuals share a common identity due to similar training backgrounds, similar experiences as practicing experts, and their membership in larger institutional structures such as professional associations that use legal, economic, and political tactics to carve out specific domains of work protected from incursion by others. ¹ This has placed a focus for decades on the concept of professional commitment, used empirically as a proxy for determining the level by which an individual professional ascribes to this shared and singular expert identity. ²

Professional commitment implies dedication to values such as autonomy, and beliefs that a given group of experts should control their sphere of work. ¹ In both research and practice, the acknowledged view for a long time was that professional commitment was mutually exclusive from and in conflict with organizational commitment, the latter suggesting a mindset typified by some acknowledgment and acceptance of organizational values, interests, and control.

This notion of a compartmentalized professional mindset that exists separate from other identities workers assume is now regarded, given the changes that continue to occur to professional work and organizations, as less accurate.^1,2 Indeed, some writers have put forth a new, dynamic, and more multi-dimensional notion of professionalism that accepts the idea of individual professionals maintaining multiple identities and values simultaneously, some which may be compete with one another at times and at others be complementary. ^1,3 In particular, Hafferty and Castellani present a “systems-based view of professionalism” (p. 289) that allows for competing and conflicting identities to co-exist; identities that the individual professional may use in a symbiotic manner to maintain internally strong altruistic and service-oriented standards for working, while at the same time functioning externally as an employee (for example) more effectively in work settings that require entrepreneurialism and some sacrifice of professional control. ³

What is appealing about such a view is that it fits realistically with the everyday lives of physicians working in many different country contexts. Physicians in particular around the world increasingly share similar sets of circumstances in their work. These circumstances include decreasing health care budgets in government-led health systems; the rise in large-organization employment; the coopting of professional knowledge through standardization and the use of information technology by hospitals and payers; and the growth of industries like health care in ways that make it difficult for physicians to want to assume partnership or ownership status. ^4–6 Modern physicians face greater uncertainty in their jobs and the need to cooperate with organizations as a result. ⁶

While the corporatization of health care has accelerated in the United States, producing large-scale integration of clinical services and greater salaried employment, health systems in the United Kingdom, Canada, and Italy, by comparison, have regularly employed physicians as employees within large organizations such as hospitals. Given this fact and the government serving as the largest source of payment for health services in these countries, the importance of studying organizational commitment internationally cannot be understated since all of these countries’ physicians find themselves beholden on a meaningful level to large-scale bureaucracy. In addition, all health systems in advanced economies have experienced rising costs and shrinking budgets for health care delivery, and in turn have depended on doctors to become more efficient in their work. This has raised the prominence of managers within physician practices and hospitals, and required doctors to cooperate with them to achieve intended organizational and system goals in this regard. ⁷

These realities internationally have made organizational commitment (OC), defined as an individual’s psychological attachment to the organization,¹ a keen focus of interest for physicians over the past couple of decades.² Understanding more fully the levels of organizational commitment among different types of doctors, for example, and the relationship of that commitment to other outcomes, is important. For example, the issue of how best to integrate physicians as employees into settings such as hospitals remains hotly debated, with no magic bullet for accomplishing the goal of true physician-organization alignment. Psychological attachments are one focus of better understanding how to achieve these goals.

Meyer and Allen’s⁸three-factor model of OC, which consists of normative, continuance, and affective attachments to the organization, has become the norm through which we view organizational commitment. Normative commitment involves obligatory attachment based on alignment of values and beliefs with the employing organization; continuance commitment rests on instrumental attachment (e.g. the costs of leaving); and affective commitment is emotional attachment. All three forms of attachment may work simultaneously and independently on the individual’s psyche, making for a complex mix of identification between employer and worker. Each form of commitment presumably leads to different outcomes and behaviors among professionals like doctors.

Work on organizational commitment and its outcomes supports the importance of this concept in terms of its impact on key work outcomes. For example, “dual commitment” in the form of worker attachment to both team and organization enhances citizenship behaviors on the part of the worker. ⁹ Employees possessing higher levels of affective commitment also have stronger organizational citizenship behaviors, and produce a higher level of task performance. ¹⁰ Meyer et al. also found that affective commitment in particular was positively related to multiple measures of job performance.¹¹ We examine in this study if higher levels of organizational commitment are associated with better job performance, improved quality of care, and higher levels of satisfaction both for themselves and patients.

The present review examines the cumulative empirical findings across an international context related to organizational commitment among physicians. To our knowledge, no similar review has been published. Several goals guide the review: (a) to better understand commitment levels over time and across different employers, and health systems; (b) to identify if and how organizational commitment shapes other outcomes for the doctor and organization; (c) to provide cross-country comparisons of organizational attachments among doctors; and (d) to assess the methodologies used in the empirical literature, and identify areas for improvement.

Methods

Search strategy

The authors used a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guided approach to conduct the present review. See Figure 1 for the complete PRISMA flow diagram.

Figure 1.

PRISMA flow-diagram.

First, the three coauthors collectively agreed upon a search strategy. PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, Business Source Complete, and PsychINFO were identified as the databases most likely to contain research relevant to the present review. PubMed is an extensive database of health, medical, and science journals that is updated daily, and is the de facto health-related publication database in use. Currently, PubMed is comprised of approximately 6000 journals and over 30 million citations including fields such as biomedicine, life sciences and behavioral sciences. With over 750 health journals indexed, CINAHL is a good source of primary studies for qualitative evidence, emphasizing nursing and interdisciplinary practices. Business Source Complete includes 3712 number of journals, as of July 2019. With its focus on administration, human resources and management, this database was included for its insight into organizational behavior and potential likelihood to contain studies of organizational commitment. Lastly, PsycINFO indexes more than 2,500 journals with nearly 4 million bibliographic records. Its collection of research was reviewed to locate relevant commitment findings across a host of disciplines such as behavioral and social science, health and business. We were able to identify a number of duplicate articles across these four major article databases, lending additional confidence that we were identifying the full range of organizational commitment studies for physicians.

Seven commitment terms were used: “organizational” AND “commitment,” “organisational” AND “commitment,” “organizational commitment,” “organisational commitment,” “affective commitment,” “normative commitment,” or “continuance commitment.” Each commitment term was combined using AND with either “doctor(s)” or “physician(s)” and searched for in the abstract. One of the coauthors performed these 14 individual searches of all article abstracts in each of the chosen databases in September of 2018. A second coauthor replicated the search to ensure the accuracy of the results. These searches yielded 1,154 initial results. We did not bind the review to a specific timeframe and included any article the search terms identified, regardless of the year published. This was to capture studies that used physician data at different time periods of health care system change across various countries. We also included any study regardless of the country in which the physician sample derived, as one of our goals was to provide an international comparison. Endnote 8.0 software was used to compile these articles for further sorting.

Duplicate articles were removed using Endnote’s “Find Duplicates” tool. Articles were then manually screened by two of the coauthors to detect any duplicates that were not removed by the tool and articles not originally published in English. This stage of the sorting process left 532 unique, English-language articles for further screening. The remaining articles were sorted into “empirical” and “non-empirical” based on whether they were presented research, regardless of whether or not it was commitment-specific. One author led this part of the sorting process and it the other two co-authors reviewed it. This stage of the sorting process left 280 empirical articles for further review.

The empirical articles were assessed for their relevance to the present review based on close reading of the articles’ abstracts and, in a several cases, the full article. Articles retained at this stage presented empirical findings related to organizational commitment (or affective, normative, or continuance commitment) in physicians as either a dependent variable, independent variable, or descriptive variable (e.g. mean levels of commitment expressed). In short, any findings related to physicians as the specific sample and organizational commitment were included in the review. Two co-authors completed the abstract review, and the third co-author audited their results. This stage of the sorting process left 51 relevant articles for full-text review.

Upon full-text review, articles had to report findings regarding levels of organizational commitment in physician subjects and/or relationships between organizational commitment and other dependent or independent variables. Articles not reporting discrete (i.e. physician findings not mixed in with other samples like nurses in ways impossible to disentangle) findings for the physician sample in the results section were also removed at this stage (n = 18). This final stage of the screening and sorting process left 33 articles for inclusion in the final qualitative synthesis and literature review.

Data extraction and analysis

A standardized data abstraction form was used to extract pertinent information from the included studies. This type of form has been used by the authors in previous studies. The form contained categories of interest for which study data were abstracted. These categories included the research setting (e.g. hospital, doctor’s office); geographic location of settings (including country); research design (e.g. cross-sectional, multivariate); types of methods (e.g. interviews, survey); whether theory was used; types of statistical analyses performed; physician sample size; time period of the data collection; the type(s) and reliability of organizational commitment measure(s) used; and the commitment findings for each study. These categories were included in the abstracting process given the intent of the review, which was to both examine individual organizational commitment findings and critique design and methods aspects of this empirical literature.

The three co-authors reviewed each article individually, completed separate abstraction forms, and then met to compare the forms and resolve any discrepancies. Between-author discrepancies occurred in 2.5 percent of the abstracted data (33 data abstraction forms X 11 data cells per abstraction form = 363 total cells, with nine total cell disagreements, resulting in 9/363 or 2.5% disagreement). All nine discrepancies were discussed and resolved as a team. Once the data abstraction process was complete, information from the forms was transcribed into a spreadsheet for further analysis. Frequency counts were performed across all abstraction categories using Excel 2016. Qualitative synthesis of both the quantified and open-ended study findings was performed collaboratively by the three co-authors. The results compiled include commitment-related descriptive findings for individual studies and the study sample as a whole, as well as patterns in findings that emerged across the 33 studies.

Review limitations

Several limitations of the present review are worth noting. First, there is the possibility we may have missed studies examining organizational commitment among physicians. However, we used a series of search terms, and major health and business literature databases that could capture the relevant literature in a reliable way. Second, while the variable organizational commitment is a major proxy for understanding the alignment between doctors and their employing organizations, it is not the only one. Thus, this review is not a fully comprehensive statement on what the research tells us about physician alignment or identity. Finally, it would be interesting to compare the results of this review to one done on professional commitment (PC) among doctors. This was beyond the scope of the present review, but examining both the levels of PC and OC over time, and comparing various predictors of each, would have benefits.

Results

Research settings and designs

Twelve of the 33 included studies took place in the United States, but the majority (21/33, 63%) took place in health systems in other countries. The most common non-U.S. research sites were India (n = 7), China (n = 3), and Turkey (n = 3). Publication dates of the 33 included studies ranging from 1985–2018, with 26 studies published after 2000. Studies were relatively evenly distributed across that timeframe. The majority (10/13) of the studies published in the first half of that timeframe (1985–2002) are from the U.S. (the remaining three took place in India) while the majority (18/20) published in the latter half (2003–2018) are from outside of the U.S. The reported time periods of data collection across the studies range from 1982–2014. However, 18 of 33 studies (55%) did not report the time period in which data was collected. All seven U.S. studies that reported a time period of data collection used data from before 2000, whereas all nine non-U.S. studies that reported a time period took place post-2000.

Twenty-two of 33 studies examined the organizational commitment of the physicians within one hospital or multiple hospitals in a system, network, or region. The remaining 11 studies used mixed physician samples, i.e. from a variety of different practice settings, organizations, and specialties. ^12–15 These mixed physician samples allowed for multivariate comparisons of organizational commitment levels across different physician specialties and employment locations. Physician sample sizes ranged from 18 to 2,635, with a third of studies having sample sizes under 100 physicians.^15,16

The vast majority, 25 of 33 studies (76%), used a cross-sectional research design and performed multivariate statistical analyses. Seven studies used a cross-sectional design with only univariate or bivariate analyses and one study used a longitudinal design with multivariate analyses. Twenty-three of the 25 studies that conducted some form of multivariate analysis (i.e. linear or logistic regression, ANOVA, structural equation modeling) used some measure of organizational commitment (OC) as the dependent variable for comparison with a wide variety of independent, predictor variables. The two remaining studies used OC as an independent or mediating variable only, using “patient safety culture”, “structural empowerment”, “counter-productive work behaviors”, and “dark triad personality” as dependent variables. ^17,18

Commitment theory and measures used

Eight of the included studies used social exchange theory (SET) as a basis for relating the demographic and workplace variables they studied to organizational commitment.¹⁹ For purposes of commitment studies, SET would imply that physicians psychologically attach to their employing organization when there is something intrinsically or extrinsically to be gained for themselves. Three studies framed their research with the idea of psychological contracts between the employee and the organization. Eleven studies did not provide any theoretical framework.

Thirty-one of the 33 included studies (94%) utilized primary data. Fifteen of the included studies (46%) used some or all of Meyer and Allen’s original three-dimension scale to measure organizational commitment. Eighteen of 33 studies examined affective commitment, making it the most widely studied dimension of organizational commitment. Six studies used adapted versions of Mowday et al.’s²⁰ organizational commitment questionnaire (OCQ). Twenty-five of the included studies provided reliability coefficients for the commitment measures they used in the form of a Cronbach’s alpha. The reliability of the measures used ranged from 0.6–0.96. Only one study did not define the type of commitment measure used. ¹²

Mean levels of commitment

Twenty-six of 33 studies (79%) reported the mean levels of commitment among their physician cohort, while the remaining seven studies analyzed differences in mean commitment levels without overtly reporting them. There were no meaningful differences found between mean levels across commitment categories (i.e., organizational, affective, normative, or continuance) or within any commitment category when compared across years of publication or country of origin. See Figure 2 for a comparison of all mean levels by country and year. Just over half the studies measured levels of affective commitment (AC) (18/33, 55%), making it the most widely used measure of commitment across the included studies, with ten studies (30%) measuring only AC as their “organizational commitment” variable. One study measured only normative commitment (NC).²¹ Three studies measured only AC and continuance commitment (CC) and five studies used a three-factor model (including AC, NC, CC).

Figure 2.

Mean commitment levels by country and publication year. Note: Mean commitment in each category in each country in reverse chronological order by publication year.

Comparisons across healthcare professionals

Twenty-four of the 33 articles studied only physicians, while the remaining nine articles used a physician sample along with a sample of other healthcare employees. These mixed professional samples allowed for multivariate comparisons of organizational commitment across occupational groups possessing different levels of education and varying job demands and responsibilities. One study of physicians and nurses did not compare mean levels of organizational commitment between the two occupational groups. Instead, it found that awareness of the external environment predicts organizational commitment among physicians whereas awareness of the internal (to the organization) environment predicts the OC of nurses.¹⁶

The remaining eight studies using mixed samples compared mean commitment levels in physicians to commitment levels in other healthcare professionals. The differences in mean levels across professional groups were statistically tested in six of these studies. The most common comparisons made were physicians vs. nurses (n = 6), physicians vs. administrators (n = 6), and physicians vs. other hospital staff (n = 2). One study found physicians having slightly higher affective commitment than nurses (2.8 vs. 2.7 out of 4, respectively), but this difference was not statistically tested.²² Another study found no significant difference in mean affective commitment levels among physicians, nurses, and medical therapists, but medical technicians had significantly higher levels of mean affective commitment than physicians (3.92 vs. 3.51 out of 5, respectively, p = 0.01).²³

The remaining six studies comparing commitment levels across different groups found physicians to have the lowest levels of organizational commitment among the healthcare professionals studied. Five of the six studies found these differences to be statistically significant and one study did not perform statistical testing. Four studies found physicians had significantly lower levels of commitment than nurses did, four studies found physicians had significantly lower levels of commitment than administrators did and two studies found physicians had significantly lower levels of commitment than other hospital staff. One study also found physician executives had significantly lower mean organizational commitment levels than non-physician executives (5.22 vs. 5.72 respectively, p < 0.01).²⁴

Organizational commitment as the dependent variable

The majority of the studies analyzing organizational commitment using multivariate statistical models examined organizational commitment (OC) as a dependent variable (23/25, 92%). Generally, OC was predicted by a variety of different types of variables that were explored across the different studies (Tables 1 and 2). Two major sets of variables were studied most: demographic variables and job or workplace variables. However, few studies examined the same types of predictors, making cross-study comparisons difficult. In addition, there were a number of independent variables examined only once in relation to OC across the sample, with several of these seemingly important to better understand such as psychological contract violation, employment status (e.g. part vs. full-time), social support, work climate, and specialization.

Table 1.

Effects of most common independent variables on organizational commitment.

Job/Workplace Variables, n=8
Job satisfaction, n = 5
US, n = 2	+	SS
	+	SS
Non-US, n = 3	+	SS
	+	SS
	+	SS
Citations (top to bottom):Kim et al., 1996²⁵; Mercer and Bilson, 1985²⁶; Kim, 2015²⁷; Mishra and Srivastava, 2001²⁸; Mishra and Srivastava, 1999²⁹
Job control, n = 3
US, n = 1	+	SS
Non-US, n = 2	+	SS
	+	SS
Freeborn, 2001¹²; Heponiemi et al., 2011¹⁴; Kuusio et al., 2010¹⁵
Job demand, n = 2
US, n = 1	−	SS
Non-US, n = 1	−	SS
Freeborn, 2001¹²; Kuusio et al., 2010¹⁵
Organizational justice, n = 2
Non-US, n = 2	+	SS
	+	SS
Trybou et al., 2016³⁰; Heponiemi et al., 2011¹⁴
Conflict, n = 2
US, n = 1	−	SS
Non-US, n = 1	−	SS
Kim et al., 1996²⁵; Demir et al., 2009³¹
Perceived organizational support, n = 2
US, n = 1	+	SS
Non-US, n = 1	+	SS
Mercer and Bilson, 1985²⁶; Malik et al., 2016³²
Leader-member exchange, n = 2
Non-US, n = 2	+	SS
	+	SS
Trybou et al., 2016³⁰; Trybou et al., 2017³³
Organizational culture, n = 2
Non-US, n = 2	−	NS
	+	SS
Gokce et al., 2014³⁴; Shannawaz and Hazarika, 2004³⁵

Demographic variables, n = 5
Age, n = 6
US, n = 3	+	SS
	+	SS
	+	SS
Non-US, n = 3	+	SS
	+	SS
	+	SS
Freeborn, 2001¹²; Burns et al., 2001³⁸; Kim et al., 1996²⁵; Heponiemi et al., 2011¹⁴; Kuusio et al., 2010¹⁵; Hwang and Chang, 2008 ³⁶
Professional commitment, n = 2
US, n = 1	+	SS
Non-US, n = 1	+	SS
Hoff, 2001¹³; Demir et al., 2009³¹
Primary care/family practice, n = 3
US, n = 2	+	SS
	+	SS
Non-US, n = 1	−	NS
Freeborn, 2001¹²; Alexander et al., 2001²¹; Kuusio et al., 2010¹⁵
Private practice, n = 2
Non-US, n = 2	−	SS
	+	SS
Malik et al., 2016³²; Heponiemi et al., 2011¹⁴
Years in profession, n = 2
US, n = 1	−/+^*	NS
Non-US, n = 1	+	SS
Thompson and Van de Ven, 2002³⁷; Hwang and Chang, 2008³⁶. ^*Predicted lower commitment in 1996, but higher commitment in 1997, both findings NS

Note: SS = statistically significant at p < .05 or less; NS = not statistically significant finding; + = Positive relationship between independent variable and organizational commitment; − = Negative or inverse relationship between independent variable and organizational commitment.

Table 2.

Additional independent variables used only once across studies.

US, n = 13
Demographic variables
Pediatric specialty	+	SS	Freeborn, 2001¹²
Education	−	SS	Kim et al., 1996 ²⁵
Job/workplace variables
Enablement	+	SS	Thompson and Van de Ven, 2002³⁷
Work climate	+	SS	Hoff, 2001¹³
Physician group cohesion	+	SS	Hoff, 2001¹³
Amount of resources	+	SS	Freeborn, 2001¹²
Social support	+	SS	Freeborn, 2001¹²
Years in system	−/+*	SS	Burns et al., 2001³⁸
Salary/Stipend	+	SS	Burns et al., 2001³⁸
Group size	−	SS	Alexander et al., 2001²¹
Productivity compensation	−	SS	Alexander et al., 2001²¹
Intent to stay	+	SS	Kim et al., 1996²⁵
Involvement	+	SS	Mercer and Bilson, 1985²⁶
^* Predicts lower affective commitment, but higher continuance commitment, both findings SS
Non-US, n = 8
Demographic variables
Part-time employment	−	SS	Heponiemi et al., 2011¹⁴
Specialization	+	SS	Heponiemi et al., 2011¹⁴
Personal incentives	+	SS	Demir et al., 2009³¹
Job/workplace variables
Administrative breach	−	SS	Trybou et al., 2016³⁰
Professional breach	−	SS	Trybou et al., 2016³⁰
Leadership behavior	+	SS	Gokce et al., 2014³⁴
Participation in decision-making	+	SS	Liu et al., 2014³⁹
Empowerment	+	SS	Liu et al., 2014³⁹

Age (six studies) and job satisfaction (five studies) were the most frequent predictor variables examined. Both of these variables had a significant, positive effect on OC across all 11 studies in which they were examined, both within and outside the U.S. (see Table 1). Likewise, job control (three studies), perceived organizational support (two studies), and professional commitment (two studies) all exerted a significant, positive effect on organizational commitment regardless of study setting. Conflict (two studies) and job demand (two studies) both had significant, negative effects on organizational commitment when studied cross-nationally.

Differences in the directional effects of predictor variables between U.S. and non-U.S. studies were found for the demographic variables primary care/family practice and tenure in the profession. Specializing in primary care/family practice had a significant, positive effect on commitment in 2 U.S. studies ^12,21 and a non-significant, negative effect on commitment in one non-U.S. study. ¹⁵ However, Kuusio’s et al.’s¹⁵ finding that physicians working primary care were significantly less organizationally committed than physicians practicing in other care delivery sectors after adjustment for age, gender, graduation year, full-time employment status, and on-call status (p < 0.001) became nonsignificant in a subsequent regression model after adjusting for workplace psychosocial factors (job demands, job control, and colleague consultation).

Years of experience in the profession had a significant, positive effect on organizational commitment (OC) in one non-U.S. study. ³⁶ However, its effects on OC differed in a U.S. study that examined the variable. ³⁷ Thompson and Van de Ven,³⁷ the only study to use a longitudinal research design that surveyed the same group of physicians over time, found tenure in the medical profession to negatively predict OC in 1996 and positively predict it in 1997, but neither effect was significant. Tenure in the organization was examined by one U.S. study,³⁸ which found tenure having a significant, negative effect on affective commitment, but a significant, positive effect on continuance commitment (p < 0.01, both).

Organizational commitment as an independent variable

Four studies examined organizational commitment (OC) as an independent variable. None of these studies examined the same dependent variables in relation to OC. Liu et al.³⁹ found that physicians’ affective commitment (AC) positively predicted both patient satisfaction and care quality (p < 0.01, both). In addition, Liu et al. also found that AC partially mediates the relationship between personal feelings of empowerment and patient care quality. Horwitz and Horwitz¹⁷ found that AC significantly predicts patient safety culture (p < 0.05). Ying and Cohen¹⁸ found that affective commitment was inversely related to counterproductive work behaviors (p < 0.01), and that OC partially mediated the relationship between components of the “dark triad” personality and counterproductive work behaviors (p < 0.01). Volpe⁴⁰ found that all three components of organizational commitment (AC, NC, and CC) predict any or all of the three components of organizational cynicism they examined (trait, global, and/or local) (p < 0.001, all).

Discussion

To our knowledge, this is the first review of the empirical literature examining organizational commitment (OC) among physicians. The focus on OC is especially important across health systems at the present time, given forces that are aligning the physician and health care organization more closely together. These forces include shrinking budgets for health care services; greater use of standardization and information technology to control physician work; widespread physician shortages; and increased organizational integration leading to more bureaucratic workplaces for doctors. Organizational commitment is now something many physicians experience given dynamics such as greater employee status. Thus, it is a psychological state that must be better understood, both in terms of what promotes it and how to increase it in physicians, to achieve goals such as professional-organization integration, and improved psychological states like reduced burnout. ⁷ Given that organizational commitment involves psychological attachment to one’s employer, it can also inform issues related to how best to motivate doctors to work in partnership with their employing organizations.

Implications of the key review findings

The key empirical findings of the review are that: (a) physicians, regardless of country, personal characteristics, type of job, or place of employment generally have lower levels of OC than other health care workers; (b) a variety of work and job related variables, particularly age and job satisfaction, shape physicians’ OC; (c) both the levels of OC and the types of factors that shape OC are similar across physicians working in different health systems internationally; and (d) there are fewer studies examining the outcomes of OC for physicians, but the available studies indicate it favorably predicts outcomes like care quality. These findings are supplemented by additional ones such as two-thirds of the studies being based in non U.S. work settings; few studies examining the same predictors of OC with the exception of studies that look at physician age and job satisfaction; and affective commitment shaping workplace thinking and behavior.

The lower levels of OC among doctors generally, and compared to other workers, is not all that surprising, if one buys into the notion that physicians are trained and socialized to commit primarily to their profession and its interests.⁴¹ The reality of strong attachments to their employing organization is a relatively new phenomenon among doctors, and one might expect over time, as most physicians find themselves embedded in organizational settings as salaried employees, for OC to increase.⁷ But a consistent finding of lower levels of organizational commitment across different countries demonstrates that it remains challenging to get doctors to identify with their employers or the organizations in which they work. The reality that physicians do not easily psychologically identify with their employers makes the issue of better understanding the factors that might enhance physicians’ organizational commitment a key research and managerial goal.

Add to this the finding that physicians at later career stages may be more organizationally committed, perhaps due either to greater risk aversion (e.g. because of their age) for moving to another employer or because they have received benefits over time from their existing employer (e.g. promotion opportunities, retirement benefits) that produce stronger levels of attachment, and the issue becomes more complex. What would make younger doctors feel more organizationally committed? This is a key question for future research. Certainly some physicians at very early career stages, e.g. during their training experiences, may experience lower organizational commitment given their desire to move around to different employers in advancing their careers. But over time, if young doctors cannot be convinced to identify meaningfully with organizations, issues such as increased turnover, reduced job satisfaction, and greater burnout among this cohort may result because these professionals will be less able to feel positively towards them, especially when circumstances become challenging.

That said, only one study examined the effect of organizational tenure on commitment³⁸ and the findings were mixed. The literature also supports the notion that favorable conditions in the workplace and job predict stronger OC among doctors, particularly the affective kind that is rooted in emotional loyalties. Thus, workplaces that make physicians feel in control of their job, do not overwhelm them with work, provide a supportive and fair culture, enhance their ability to give input, and keep them job satisfied are likely to gain enhanced OC. This observation should resonate with health care organizations, as it identifies many of the same features integral to enhancing the psychological attachments and well-being for non-physician health care workers.⁴² The strategies and tactics organizations use for doctors to create such workplaces may differ slightly, but the overall aims remain the same across workers in those settings.

Finally, the review identified only four studies that examined the linkage between OC and various work outcomes for physicians. But these four studies were consistent in finding that higher levels of OC among physicians were linked to favorable outcomes like improved care quality, productive work behaviors, and lower cynicism. These findings among physicians are encouraging, because they imply that OC may be an important psychological state for organizations to pay attention to with respect to doctors. That said it appears from the limited findings that affective commitment looms perhaps as the key state to address, which means for physicians that it is the emotionally positive feelings and attachment they have towards their employers, rather than a desire to stay with the same organization (continuance commitment) or a deep identification with organizational values (normative commitment), that matters most in promoting. Unfortunately, levels of affective commitment among doctors, particularly in European countries and the United States, remains on the lower side (see Figure 1).

Improving the study of organizational commitment among physicians

The extant literature has several key limitations that affect its usefulness in better understanding the organizational commitment of physicians. These limitations can be addressed in future OC research. First, the time period of U.S. data stops before the year 2000, making it challenging to draw real-time comparisons between U.S. and non-U.S. study findings. Why the newer OC literature is more international, and the older OC literature U.S. specific is open to speculation. One possible reason is that a number of the external forces discussed at the outset accelerated quicker in the U.S. during the latter part of the twentieth century, consistent with the managed care push of that time.⁴³ As a result, there was great interest at that time in studying if and how U.S. physicians could be aligned better with health care organizations.

That said there is no reason organizational commitment should not remain a central variable for researchers to be examining over time in most health systems internationally. If the results here have merit, then we can expect job and work variables like control, social support, job demand, job satisfaction, organizational support, and conflict to remain front-and-center with respect to physicians working in a number of international country contexts. All of these contexts are experiencing meaningful change with respect to how physician work is organized even if they are not experiencing all of the same changes simultaneously.^5,6

In the U.S. case, for example, the current health care climate of value-based care delivery, metric-driven quality improvement, and increased consolidation of health organizations into larger entities wielding greater influence makes looking at physician identity and commitment important to understand better issues such as collaborative potential between physicians and employers, and other physician states such as burnout. For other countries such as Canada, the United Kingdom, and Italy, reduced government budgets for health care and physician shortages also make studying commitment important for issues related to job recruitment, retention, and turnover. Thus, there should be a renewed period of OC research among physicians that includes these types of variables extensively in their designs.⁴⁴

To this end, while cross-sectional research designs are normal for this type of attitudinal research, longitudinal designs that illuminate whether OC modulates over time and in response to changes in the local work environment would have practical value in helping health care managers best determine how to effect changes that would produce higher levels of physician OC consistently. We know less than we should about the stability of OC among physicians. Studies moving forward should achieve greater consistency by examining similar variables as prior research, in part to build on the knowledge learned and increase the validity of overall findings.

Future research on physician OC should also focus more on ambulatory care work settings, particularly in primary care where physicians across health systems are now mostly employed as salaried workers. It is critical, given the importance of prevention and primary care services for both quality and efficiency outcomes. This greater focus on ambulatory settings would introduce new variables to study in relation to physician OC such as care continuity and doctor-patient relationship quality that are prime features of the kinds of care given in these settings. Variables that reflect today’s key external forces should also be introduced into this research stream. Examples include the percentage of doctor pay contingent on financial incentives, health care team-related dynamics like psychological safety and cohesion, perception of time spent with patients, and use of quality metrics and information technology.

In addition, and to better interpret the results in this research stream, it would be ideal to use specific theoretical frameworks and ideas to explain why OC levels, for example, tend to be lower among doctors, or why certain job-related features do impact OC, but others do not. The extant OC literature is weaker when it comes to explaining its results. The embedding of doctors within organizations implies a complex relationship between the two that require a deeper, multi-faceted understanding of how they get along. There are theories on identity, motivation, leadership, and social networks that offer insights potentially helpful in this regard. In addition, research must be expanded using OC as a predictor variable in models that examine important health care outcomes like care quality, patient satisfaction, costs of care, team effectiveness, and care delivery efficiency. Otherwise, the importance of OC for physicians, health care organizations, and patients remains less convincing that it might otherwise be in reality.

Supplemental Material

sj-pdf-1-hsm-10.1177_0951484820952307 - Supplemental material for Organizational commitment among physicians: A systematic literature review

Supplemental material, sj-pdf-1-hsm-10.1177_0951484820952307 for Organizational commitment among physicians: A systematic literature review by Timothy Hoff, Do Rim Lee and Kathryn Prout in Health Services Management Research

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Timothy Hoff

Supplemental material

Supplemental material for this article is available online.

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