1. Aust. J. Rural Health (2005) 13, 149–155
Blackwell Science, LtdOxford, UKAJRAustralian Journal of Rural Health1038-52822005 National Rural Health Alliance Inc.June
2005133149155Original ArticlePSYCHOLOGICAL WELL-BEING AND RETENTION OF GPSM. GARDINER
Et al.
Correspondence: Maria Gardiner, School of Psychology,
Flinders University of South Australia, Bedford Park,
South Australia, 5042, Australia. Email: maria.
gardiner@flinders.edu.au
Accepted for publication November 2004.
Original Article
The role of psychological well-being in retaining rural
general practitioners
Maria Gardiner,1
Roger Sexton,2
Mitchell Durbridge1
and Kiara Garrard2
1
School of Psychology, Flinders University of South Australia, Bedford Park and 2
Rural Doctors
Workforce Agency, Wayville, South Australia, Australia
Abstract
Objective: Retention of rural GPs is an increasing area
of concern and is receiving considerable attention from
the government, medical authorities and the media. This
study aimed to examine the potential for psychological
interventions to assist in the retention of rural GPs
through targeting their psychological well-being.
Design: GPs completed a questionnaire, including ques-
tions about their level of support in rural practice, psycho-
logical health (work-related morale and distress, distress
related specifically to working in rural general practice,
quality of work life) and intentions to leave rural practice.
Setting: Rural general practices in South Australia.
Participants: One hundred and eighty-seven rural GPs.
Results: Results indicated that rural GPs who were seri-
ously considering leaving rural practice had higher
work-related distress, higher distress related specifically
to working in a rural general practice and lower quality
of work life. GPs who considered leaving rural practice
also reported having fewer colleagues with whom to
discuss professional issues.
Conclusion: Results indicated that psychological inter-
ventions (such as cognitive behavioural training), assis-
tance with stress reduction and coping mechanisms
(such as more interaction with colleagues) may be of
benefit to GPs who are considering leaving rural prac-
tice. Such training may increase the number of GPs who
ultimately stay in rural practice.
KEY WORDS: psychological well-being, quality of life,
rural general practice, rural GPs, stress.
Introduction
The maintenance of a viable rural general practice
workforce has attracted considerable attention from
government, media, medical organisations and Divi-
sions of General Practice.1
In particular, the focus has
been on retaining the relatively low number of rural
doctors and recruiting new doctors to work in rural
areas.2
Some of the more commonly reported reasons for
work dissatisfaction and/or rural GPs leaving rural gen-
eral practice include increased workload and profes-
sional isolation, family conflicts and increasing demand
from a changing rural health care system (e.g. hospital
closures and reduction in staff numbers).3–6
Other fac-
tors influencing the decision to leave rural general prac-
tice include inadequate leave from work, a lack of
suitable and affordable child care, a lack of anonymity
in rural communities, reduced employment opportuni-
ties for spouses and reduced educational opportunities
for children.1,7–9
To date, the majority of strategies and initiatives to
improve retention rates have focused on improving the
environment in which doctors work. Some of the strat-
egies suggested include increasing the number of loc-
ums available (both long- and short-term), providing
specific skills training (e.g. trauma management train-
ing) and instigating multidoctor communities. How-
ever, given their limited success and their inability to
address such issues as choice of schooling and family
problems, some rural doctor organisations are apprais-
ing the role of psychological support in the retention of
rural GPs (recent research shows that GP well-being is
amenable to improvement through evidence-based
approaches).10
An example of one such program that directly targets
psychological well-being of GPs is the Physicians Health
Program (PHP) conducted by The Foundation of the
Pennsylvania Medical Society.11
This program includes
counselling and training and asserts that ‘physicians
have to change the way they live and learn to balance
their personal needs with those of their patients’.
In South Australia, the Dr DOC program, a rural GP
health and well-being program instigated in 2000 by
the Rural Doctors Workforce Agency (RDWA, formerly
SARRMSA), has implemented a statewide approach

2. 150 M. GARDINER ET AL.
aimed at improving rural doctors’ health and well-
being. The program aims to support rural and remote
GPs and their families in maintaining their well-being
through both physical and psychological health strate-
gies, as well as providing timely support to those in
crisis.
There is, however, a distinct lack of data on rural GP
psychological well-being as well as empirical evidence
to guide or support these types of initiatives.12
In an
effort to add to the empirical literature, the current
study aimed to provide a snapshot of South Australian
rural GP psychological well-being, and to begin to look
for possible interventions that could improve well-being
and ultimately increase retention rates, thereby provid-
ing a baseline measure with which to compare the effi-
cacy of the Dr DOC Program as an interventional
strategy.
Method
Participants and survey distribution
Participants in the survey were 187 GPs working in
rural practice in South Australia, as identified by the
RDWA. The questionnaire was mailed out twice to 336
valid participants, resulting in a 56% response rate. All
information was coded for anonymity. Ethics approval
was obtained from the Social and Behavioural Research
Ethics Committee at Flinders University of South
Australia.
Survey instrument
The questionnaire comprised the following five sections:
1. Demographic data were collected by asking ques-
tions regarding age, gender, marital status, number
of children, years in general practice and practice
information.
2. Support in rural general practice was assessed by
asking questions about the following areas: use of
crisis support services, continuing medical educa-
tion (CME) activities and social support.
3. Four psychological health measures were used to
assess the psychological well-being of rural GPs.
They are: work-related distress, work-related
morale, quality of work life and rural doctor dis-
tress. Work-related distress and work-related
morale are orthogonal measures each consisting of
seven items and quality of work life consists of six
items.13
GPs were asked to rate the frequency of
their feelings whilst at work over the previous
month, and also their perceptions of their work life
on a 7-point scale (higher scores indicating higher
morale, distress or quality of work life). Internal
reliability was high for distress (Cronbach’s
alpha = 0.89), morale and quality of work life (both
Cronbach’s alpha = 0.91). In line with Gardiner
et al. to determine clinical significance a cut-off
score representing the bottom one-third of respon-
dents was used, with a score of 26 and above indi-
cating a high level of distress, 29 and below
indicating poor morale and 22 and below indicating
poor quality of work life.10
Rural doctor distress is
a customised 10-item scale, designed to measure
distress that respondents attributed specifically to
being a rural GP. Respondents were asked to indi-
cate on a 7-point scale how much they agreed with
each of the statements (1 = not at all and 7 = very
much so). Internal reliability was high for this scale
(Cronbach’s alpha = 0.88). However, the results
have been reported for each question separately, as
well as for the scale. The measure agreed well with
the other psychological health measures, correlating
0.629 with work-related distress, -0.439 with
work-related morale and -0.439 with quality of
work life (all P > 0.0001).
What is already known on this
subject: Increasing the number and retention of
doctors in rural general practice is both a
government and community priority. To date
mostly only structural interventions (such as
increasing the number of locums) have been
tried. There are a number of fledgling GP well-
being programs in operation that aim to
improve GP well-being and ultimately GP
retention rates. However, none of these
programs have been evaluated.
What this study adds: This present study aims
to provide a snapshot of rural GP psychological
well-being as well as baseline measurement for
a South Australian well-being program (the Dr
DOC program). This survey study found that
GPs who seriously considered leaving rural
general practice have higher stress and lower
morale and quality of work life than those not
considering leaving. In addition, GPs, when
asked, requested more personal management
skills than medical skills to assist them in their
work life. These results indicate that providing
self-management skills such as stress and time
management may well increase rural GP
retention rates.

3. PSYCHOLOGICAL WELL-BEING AND RETENTION OF GPS 151
4. GPs were asked whether in the last two years they
had seriously considered leaving rural general
practice.
5. GPs were asked to make any general comments that
they felt were relevant and important to them and
that related to their personal and professional life
as a rural GP.
Results
Demographic data
Demographic data revealed that the majority of GPs in
the survey were male, with two-thirds aged between 30
and 50 years. Over 80% of the GPs had been in rural
general practice for more than five years. Only 5.9%
had been in rural general practice for less than a year.
Most GPs (87.2%) also reported having a partner living
at home. The majority of GPs (78.5%) reported working
more than seven sessions per week and nearly two-thirds
(63.2%) worked in a practice with four or more GPs.
Support in rural general practice
Use of crisis support services
Responses indicated that although 19% of GPs needed
a crisis support service in the past year, just over two-
thirds of these GPs did not actually use one. The reasons
for not using services seemed unrelated to a lack of
knowledge about their availability, but more to a reluc-
tance or unwillingness to access the services, with
respondents stating that they preferred to resolve the
issue themselves (34.8%), lacked confidence in the abil-
ity of crisis support services to help (26.1%), felt a
general reluctance to be helped (21.7%), or cited prac-
tical reasons such as lack of time (8.7%).
Continuing medical education
Tables 1 and 2 show that there was a wide variety of
CME activities judged to be most useful in general prac-
tice, with little consensus over which activities were
most useful. However, of most note is that although the
most frequently attended activities relate to patient care,
the skills GPs would most like to acquire relate to per-
sonal issues such as stress management and time man-
agement.
Social support
Table 3 shows that the majority of respondents
reported having at least some contact with other GPs.
However, the opportunity to discuss personal issues
with other GPs was less evident, as was the opportu-
nity to discuss these issues with people other than GPs
or partners.
Psychological health of rural GPs
Rural GP distress (rural general practice-specific
influences on psychological well-being)
The results in Table 4 show that approximately 10% of
respondents reported feeling elements of rural GP dis-
tress ‘quite a lot’. One-third (34.7%) of participants felt
quite strongly that they should take better care of their
health, while 16% felt a strong degree of personal iso-
lation. More generally it is estimated that at least one-
third to one-half of GPs indicated that they had either
‘some degree’ or ‘quite a lot’ of distress directly related
to rural general practice.
Quality of work life, work-related morale and
work-related distress
Overall, participants reported a moderate (scale
median) quality of work life, with approximately one-
third (31.4%) reporting high quality. Very few respon-
TABLE 1: Continuing medical education (CME) activities
attended in the last 12 months that were most frequently
reported as being most useful in respondents’ general practice
(n = 142)
Activity
Number of
respondents Percentage
Cardiology 11 7.7
Anaesthetic refresher 11 7.7
Practice management seminar 8 5.6
Obstetrics 8 5.6
TABLE 2: Most frequently mentioned skills identified by
respondents that would make rural general practice better
(n = 148)
Skill Number of respondents Percentage
Personal skills† 31 20.9
Time management 28 18.9
Practice management 18 12.2
Surgery skills 16 10.8
Computer skills 15 10.1
Counselling skills 14 9.5
Mental health skills 14 9.5
Respondents were asked to nominate two skills.
†Personal skills include relaxation, balancing career/family,
stress management, communication skills, spare time.

4. 152 M. GARDINER ET AL.
dents (5.4%) reported a low quality of work life. This
same pattern also held for work-related morale, with
most (75.7%) reporting moderate levels, and very few
(2.7%) reporting low levels. Similarly, for work-related
distress most respondents (65.9%) reported moderate
levels of work-related distress, with few reporting high
levels (3.8%).
Intentions to leave rural general practice
Approximately half of the respondents (52.7%, n = 96)
reported that in the last two years they had seriously
considered leaving rural general practice.
Further analyses
GPs who seriously considered leaving rural
general practice in the last two years
GPs who seriously considered leaving rural general
practice in the last two years were approximately twice
as likely to have poor levels of work-related distress,
morale and quality of work life (Table 5). There was
also a small effect of social support, with GPs who
seriously considered leaving rural general practice also
having fewer other GPs with whom to discuss profes-
sional issues (a measure of support).
The relationship between social support and
psychological health
There were small but significant positive relationships
between the levels of reported psychological health
(work-related morale, rural GP distress and quality of
work life) and having other GPs available with whom
to discuss issues. Those GPs reporting higher levels of
support also reported lower rural GP distress (r = 0.21;
95% CI, 0.06–0.34) and higher work-related morale
(r = -0.32; 95% CI, 0.18–0.44) and quality of work life
(r = 0.25; 95% CI, ·
0.11–0.38; all P < 0.01).
Comments made by GPs
Overall, GPs’ comments tended to be polarised, with
many stressing the negative aspects and difficulties of
being a rural GP, and nearly as many reporting the
positive and enjoyable experiences associated with rural
practice.
The main stresses and pressures that emerged in the
general comments related to:
TABLE 3: Level of social support reported by respondents
Contact 1 (none) 2 3 (some) 4 5 (a lot)
How much contact do you have with other GPs? 5.9% 9.2% 24.9% 21% 38.9%
Do you have other GPs with whom you can discuss professional issues? 2.7% 6.5% 24.3% 27% 39.5%
Do you have other GPs with whom you can discuss personal issues? 24.2% 29.6% 31.7% 9.7% 4.8%
Do you have other people (other than your spouse/partner) with whom
you can discuss professional or personal issues?
16.2% 28.6% 30.8% 15.2% 9.2%
TABLE 4: Responses to rural GP distress questions
Rural GP distress questions (scored on a 7-point Likert scale)
Not at all
(1–2)
Somewhat
(3–5)
Quite a lot
(6–7)
In the last month I have felt:
Professionally isolated 57.8% 34.7% 7.5%
Personally isolated or alone 48.7% 35.3% 16%
Like I have no one to go to for support when work or life gets hard 48.4% 40.9% 10.7%
In crisis with no help available 69.5% 26.8% 3.8%
In crisis but don’t want to ask for help 69.5% 23% 7.4%
My physical health is suffering as a result of being a rural GP 40.9% 45.1% 14%
My mental health is suffering as a result of being a rural GP 36.9% 49.2% 13.9%
I should take better care of my health 19.4% 45.9% 34.7%
I don’t have all the skills that are expected of a rural GP 49.7% 40.2% 10.1%
Like life in rural general practice is just too hard 49.5% 40.4% 10.1%

5. PSYCHOLOGICAL WELL-BEING AND RETENTION OF GPS 153
• Lack of support services (including treating doctors)
available for rural GPs
• Workload
• Finding time to balance work and family life
• Need for more doctors
• Children’s education
• Practice management (skills training)
• Issues related to being an overseas trained doctor.
Qualitative analyses of GPs’ comments indicated
while many mentioned system-related factors as con-
tributing to their intentions to leave rural practice, more
indicated that it was the difficulty in coping personally
with these stressors that influenced intentions to leave.
In summary, it is clear from their comments that most
rural GPs get much satisfaction from their work and the
survey results reflect the reasonably good level of morale
and quality of work life. However, it is equally clear that
the difficulties are multiple and sustained, and even the
most resilient rural GP has to find ways to cope with
the demands of the job. This is perhaps best summed
up by the GP who wrote:
I enjoy the content of my work (and) the company and
respect of my colleagues. (The) only problem is too
much work, too many patients (and) not enough free
time so that my family suffers.
Discussion
The findings in this study clearly reflect the nature of
current rural general practice with its mix of satisfying
clinical work juxtaposed with workload pressures, iso-
lation and work/family balance issues.
With regard to support in rural general practice, the
responses indicate that a significant proportion of GPs
(19%) have considered themselves in personal crisis
over the last year yet two-thirds of these have not used
a crisis support service, which may suggest these types
of support are unsuitable to them and different
approaches to supporting GPs are needed. In relation to
CME, it is noteworthy that when rural GPs were asked
which skills they would most like to acquire to assist
them as a rural GP, nearly 40% of the responses related
to the need for personal coping skills rather than clinical
skills. Divisions in particular might play a crucial role
in addressing this need.
In relation to psychological well-being, the majority
of rural GPs reported moderately good levels of quality
of work life and work-related morale and moderately
low levels of work-related distress. From the customised
measure of rural GP distress it is clear rural general
practice is impacting adversely upon the psychological
well-being of some GPs with approximately 10% (and
it could be as high as 15%) appearing to be suffering a
high degree of distress related specifically to rural gen-
eral practice. However, many more than this acknowl-
edge that rural general practice contributes to a
significant level of distress.
These findings suggest that this group of GPs (conser-
vatively estimated at 30% of all GPs) is at risk of
increased psychological distress. However, the more
contact GPs have with each other (i.e. the more support
they receive), the better their work-related morale and
quality of work life, and the lower the level of their
distress. Although weak, this relationship holds across
all three measures indicating a definite advantage (in
TABLE 5: Psychological well-being for GPs who considered leaving rural general practice compared to those who did not
consider leaving
Variable
Did consider leaving
Mean value, n = 96
(95% confidence intervals)
Did not consider leaving
Mean value, n = 86
(95% confidence intervals) t-value Significance level
Rural doctor distress 3.4
(3.12–3.61)
2.6
(2.36–2.82)
4.548 0.000
Work-related distress 3.5
(3.28–3.75)
49.5% ‘poor’
3.0
(2.81–3.24)
30.6% ‘poor’
3.06 0.003
Work-related morale 4.5
(4.25–4.61)
40.0% ‘poor’
4.9
(4.72–5.02)
23.5% ‘poor’
–·
3.193 0.002
Quality of work life 4.1
(3.98–4.33)
42.7% ‘poor’
4.7
(4.43–4.92)
20.9% ‘poor’
–·
3.507 0.001
Other GPs with whom to
discuss professional issues
3.8
(3.62–4.07)
4.1
(3.93–4.37)
–·
1.955 0.052

6. 154 M. GARDINER ET AL.
terms of psychological health) for increased contact
between GPs, such as that which occurs through Rural
Divisions and networks of colleagues. Furthermore, it
seems that stress such as isolation, family/business issues
and lack of personal coping skills are more important
in determining well-being than are issues related directly
to practising medicine.
The impact of the psychological well-being of rural
GPs should not be understated, with GPs who seri-
ously considered leaving rural general practice in the
last two years having higher levels of rural GP dis-
tress and work-related distress and lower levels of
work-related morale and quality of work life. They
also had fewer other GPs with whom to discuss pro-
fessional issues. It remains to be seen whether greater
availability of personal and professional support for
these GPs would influence their decisions to leave
rural practice.
Psychological well-being is most likely to be improved
by providing better support structures and evidence-
based coping and personal skills. A significant number
(40%) of rural GPs themselves are asking for these
skills. Specifically, these skills should target new behav-
iours and attitudes such as recognising limits, saying
‘no’ and perfectionism, areas known to prove difficult
for doctors as a profession. While teaching doctors to
recognise and set personal limits (thereby possibly
reducing the number of hours they work) may reduce
services and hours worked in rural communities, it may
allow doctors to continue to practise effectively rather
than cease work altogether.
In summary, the results of this study indicate that:
1. Given that approximately 10% of GPs are highly
stressed and that some in need are not using
available services, it is essential that existing crisis
support services are promoted and maintained and
new acceptable choices are established.
2. There are benefits for rural GPs in having contact
with each other. As such, gains in well-being might
be achieved by increasing opportunities for GPs to
network with each other, particularly isolated GPs
such as solo practitioners.
3. There are many GPs who need support, but who
are not in crisis. Preventative support services
targeted at the majority of GPs who fall into this
category are highly likely to reduce the number
of those who progress to the crisis category.
Considering that GPs who have seriously
considered leaving rural general practice in the last
two years have higher stress levels, preventative
support services are also likely to increase the
retention rate of rural GPs.
4. Preventative measures through CME or other
activities should be targeted at personal coping
skills for rural GPs. Improved evidence-based
coping skills for GPs should help to improve well-
being, prevent burnout and increase retention rates.
In conclusion, although continuing to provide practi-
cal resources is important (e.g. locums or patient-related
CME skills training), the findings from this study sug-
gest that other types of support that may improve the
psychological well-being of rural GPs and possibly
improve retention rates, need to be developed. This
study was designed as a baseline evaluation for the
RDWA’s Dr DOC Program, which aims to provide such
support in a number of ways. Further empirical evalu-
ation will be needed to determine the efficacy of the
range of initiatives offered by such a program.
Acknowledgements
This research was funded by the Rural Doctors Work-
force Agency. Maria Gardiner, a Flinders University
researcher, retained independent control of all aspects
of the study and its submission for publication. Ethics
approval was granted by the Flinders Social and Behav-
ioural Research Ethics Committee. The authors wish to
thank Ms Susan Arthure for extensive editorial advice
and support.
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