Perceived fulfillment of multilevel psychological contract responsibilities, job burnout, and turnover intention among primary care physicians: a structural equation modeling analysis

Background and objectives Primary care physicians face substantial occupational mental health challenges, including job burnout and turnover intention. Psychological contract theory conceptualizes employment relationships in terms of perceived reciprocal obligations, while the Job Demands–Resources (JD-R) model provides a complementary framework for understanding how work-related conditions may be associated with burnout. This study examined the structural associations among perceived fulfillment of multilevel psychological contract responsibilities, job burnout dimensions, and turnover intention among primary care physicians. Methods A cross-sectional survey was conducted among 486 family doctors from primary healthcare institutions in Shandong Province using multi-stage random sampling. Perceived psychological contract fulfillment was assessed across three responsibility domains: institutional responsibility, physicians’ responsibility, and governmental/societal responsibility. Structural equation modeling (SEM) and bootstrap analysis with 5,000 resamples were used to examine direct and indirect associations among responsibility fulfillment, burnout dimensions, and turnover intention. Results Perceived fulfillment of the three psychological contract responsibility domains showed differentiated associations with burnout dimensions and turnover intention. Institutional responsibility demonstrated a significant negative direct association with turnover intention ( β = −0.231, p < 0.01) as well as significant indirect associations through emotional exhaustion and cynicism. Governmental/societal responsibility was indirectly associated with lower turnover intention primarily through cynicism ( β = −0.141, p < 0.01) and secondarily through emotional exhaustion ( β = −0.036, p < 0.05). Physicians’ responsibility showed no significant total association with turnover intention but demonstrated a significant specific indirect association through reduced personal accomplishment ( β = −0.025, p < 0.01). Conclusion Perceived fulfillment of different psychological contract responsibility domains was differentially associated with burnout dimensions and turnover intention among primary care physicians. Institutional and governmental/societal responsibility fulfillment showed associations primarily involving emotional exhaustion and cynicism, whereas physicians’ responsibility was specifically associated with the pathway involving reduced personal accomplishment. These cross-sectional findings should be interpreted as statistical associations, and longitudinal studies are needed to clarify their temporal and causal relationships.