Open Access Highly Accessed Research article

High workload and job stress are associated with lower practice performance in general practice: an observational study in 239 general practices in the Netherlands

Pieter van den Hombergh1*, Beat Künzi2, Glyn Elwyn3, Jan van Doremalen1, Reinier Akkermans1, Richard Grol1 and Michel Wensing14

Author Affiliations

1 IQ Healthcare, Center for Quality of Care Research, University of Nijmegen, PO Box 9101, 6500 HB Nijmegen, the Netherlands

2 Swisspep Institute for Quality and Research in Healthcare, PO Box, CH-3073 Guemligen, Switzerland

3 Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, CF14 4YS, Wales, UK

4 Department of General Practice and Health Services Research, Heidelberg University Hospital, Germany

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BMC Health Services Research 2009, 9:118  doi:10.1186/1472-6963-9-118

Published: 15 July 2009



The impact of high physician workload and job stress on quality and outcomes of healthcare delivery is not clear. Our study explored whether high workload and job stress were associated with lower performance in general practices in the Netherlands.


Secondary analysis of data from 239 general practices, collected in practice visits between 2003 to 2006 in the Netherlands using a comprehensive set of measures of practice management. Data were collected by a practice visitor, a trained non-physician observer using patients questionnaires, doctors and staff. For this study we selected five measures of practice performance as outcomes and six measures of GP workload and job stress as predictors. A total of 79 indicators were used out of the 303 available indicators. Random coefficient regression models were applied to examine associations.

Results and discussion

Workload and job stress are associated with practice performance.

Workload: Working more hours as a GP was associated with more positive patient experiences of accessibility and availability (b = 0.16). After list size adjustment, practices with more GP-time per patient scored higher on GP care (b = 0.45). When GPs provided more than 20 hours per week per 1000 patients, patients scored over 80% on the Europep questionnaire for quality of GP care.

Job stress: High GP job stress was associated with lower accessibility and availability (b = 0.21) and insufficient practice management (b = 0.25). Higher GP commitment and more satisfaction with the job was associated with more prevention and disease management (b = 0.35).


Providing more time in the practice, and more time per patient and experiencing less job stress are all associated with perceptions by patients of better care and better practice performance. Workload and job stress should be assessed by using list size adjusted data in order to realise better quality of care. Organisational development using this kind of data feedback could benefit both patients and GP.