Work-Family Conflict (WFC)
Work-Family Conflict (WFC) has been commonly defined as a "form of interrole conflict in which the role pressures from work and family are mutually incompatible in some respect" [1, 2]. Its theoretical background is a scarcity hypothesis, which describes that individuals have a certain, limited amount of energy. When involved in multiple roles, these roles tend to drain them and cause stress or interrole conflict [3, 4] (in ). As conflicts may arise not only between work and family some authors extended the view on other obligations in personal life [6, 7].
Individuals identify themselves through social roles. For many people, work and family roles are the most important and self-relevant life roles. As demands and expectations within the family and work domains are not always compatible, conflicts between family and work life can arise. This conflict between work and family is bidirectional in nature; there is work interfering with family (WIF) and family interfering with work (FIW) . WIF occurs when demands and obligations of the work role are deleterious to family life. FIW describes the conflict arising from family obligations that disturb one's work. Family and work as social roles have different grades of permeability: family roles tend to be less structured and more permeable than job roles . This may explain the higher reported frequency of WIF compared to FIW [10, 11].
The relationship between work and family life has been investigated over the past years. Different aspects of Work-Family Conflict, its antecedents and consequences as well as gender differences have been examined by various measures and in different samples. As the number of dual-career and single-parent families in Germany has increased over the last decades , Work-Family Conflict as a phenomenon in the workforce gains more and more attention.
In the medical sector, Germany currently experiences a situation of major physician attrition which has been attributed to the exit or non-entrance into medical care of young physicians in particular . The introduction of the DRG-based financing system in 2004 has led to major changes in work organisation and condensation of workload for physicians. Additionally in the clinical sector, the number of viable and employed physicians diminished drastically over the last few years . So in 2003, already 21.7% of physicians were without medical occupation . This was mainly due to decrease in medical students and graduates, increased attrition of medical students during their studies and loss of physicians to public health systems of other countries as well as into non-clinical occupations, e.g., health management, pharmaceutical industry, occupational health and safety, research, consulting, or journalism [15, 16, 14]. In 2004, the German Ministry for Health and Social Security sponsored a study on major reasons for the German physicians' exit from curative medical occupation . 44,4% of the physicians in non-clinical occupations would theoretically like to continue working in hospitals. Major barriers for their return were the following: overwork (52% of male, 54% of female physicians), incompatibility of family and work obligations (37% of male, 54% of female physicians) and insufficient income (51% of male, 24% of female physicians). 82% of physicians working abroad would not like to return to Germany; major reasons for not coming back were good adaptation to the foreign country (70% of male, 72% of female physicians), professional perspectives (69% of male, 65% of female physicians), compatibility between work and family (51% of male, 64% of female physicians) and income (64% of male, 53% of female physicians). Antecedents and sources of Work-Family Conflict among physicians were not investigated in .
Already 92,2% of the German medical students expect the conflict between job and family demands to be very high, especially for female physicians . J URKAT ET AL. described the highest expected strains on personal life to be related to childcare and finding time for other activities.
As the ratio of female medical graduates has increased to over 50% in the last 20 years in Germany, Work-Family Conflict could have serious impact on future doctor shortage in Germany leading to a serious threat of the overall quality of medical care [13, 14]. Not only in Germany but in most Western countries, the share of female physicians has increased, so that some researchers are talking of a future "pink-collar medicine" . To prevent extreme physician attrition by improving working conditions in particular for women, gender differences of WFC have to be investigated intensively in future.
Physicians hold a profession that is traditionally connected to very high work commitment. Residency, the time of medical specialisation, has been described as the most strenuous and work demanding period during a career as a physician . In this period, physicians mostly experience high work demands with low job control, which may by itself contribute to high job stress . At the same time, residency as a career stage directly follows graduation from medical school, and often coincides with the family-founding life stage of young physicians. Young physicians are more likely to have young children and consequently experience high family or parenting demands, and hence might experience high levels of Work-Family Conflict. On the other hand, female and male physicians who endured the hardship of the time of medical education and residency training  may have already given precedence to work over personal activities  (in ). Data examining the Work-Family Conflict within medical professions is rare in general. Some research has been conducted concerning WFC among nurses [22, 23]. Data on WFC among physicians and gender difference in particular is very sparse in general, although D UMELOW observed higher dissatisfaction with work-life balance among female physicians . Physicians' health is underinvestigated in Germany . We are not aware of previous research on details of WFC among German hospital physicians. Our study tries to contribute to a more detailed knowledge of different aspects on WFC.
From the occupational health point of view, in our study we will only examine work interfering with family conflict (WIF) thus focussing on a parameter which may possibly be modified by changes of work-related strains, e.g., work organisation.
Key Question I a : What is the prevalence of work interfering with family conflict (WIF) among German hospital physicians?
Key Question I b: Does the prevalence of WIF among German hospital physicians differ from that of the general German population?
Key Question I c: Which sociodemographic covariates (e.g., age) significantly predict WIF?
According to gender role theory, women are more likely to see their family role as part of their social identity than men do [26, 27]. Consequently, WIF is threatening a central social role (and self-identity) in particular for women. Overall Europe, women's roles in the workplace have increased over the last years [12, 28], but at the same time expectations within their family roles have not diminished: working mothers still invest more time in family than working men do [29, 21, 30]. Also in the medical profession this pattern is to be found [31, 32] (in ). Nevertheless, the situation of women in medicine is somewhat peculiar: for female physicians, it is possible to combine a medical career with child rearing, via the availability of part-time working and the ability to afford high-quality child care [33, 34] (in ). It still remains unclear if female physicians would report higher levels of WIF. With our study, we want to fill this gap in literature.
Findings of previous research concerning gender difference in WIF and FIW are inconsistent: some studies report higher WIF among women compared to men [29, 10, 35]. On the other hand, WIF and FIW were found to be similar for men and women by several researchers [26, 9, 36, 3, 11, 27].
Our study addresses the issue of gender difference in order to bring greater clarity to WIF among German hospital physicians. Details on the prevalence, sources, and outcomes of WIF for female and male physicians carry important implications and high potential for future interventions.
Sources of WFC
Various causes for WFC were identified in previous research. These can be assigned to three main sources: the general demands of a role, time devoted to a role, and strains arising from a role .
Time-based conflicts occur when "time devoted to requirements of one role make it difficult to fulfill requirements of another" . Time-based sources of WFC within the work domain are for example number of hours worked [29, 5, 10, 11, 27], amount and frequency of overtime, work schedule inflexibility [5, 35], and presence or irregularity of shiftwork. Time-based family obligations might be marriage or cohabitation with a partner, responsibility for young children, child care hours , and spouse employment . F RONE identified time commitment as a proximal, direct predictor for WFC. More explicitly, the author states that work time commitment is positively related to WIF, whereas family time commitment is positively related to FIW .
Strain-based conflicts occur when "strain from one role makes it difficult to fulfill requirements of another" . Strains arising from the work field are, among others, role conflict, role ambiguity , low task autonomy and variety , low leader support [2, 29], low work group support , lack of supportive organisational culture , job pressures , and physical and mental work demands. Strain-based sources of WFC within the family domain can be low spouse support , parental commitment and demands , and family conflict  such as husband-wife disagreement about family roles. Among others, F RONE described role-related dissatisfaction or distress as one of the proximal predictors for WFC: work-related emotional distress leads to increased WIF, whereas family-related emotional distress leads to increased FIW . This has been confirmed by several researchers [3, 37, 38]. Furthermore, he identified role overload as a direct predictor for WFC; this predictor acts via psychological preoccupation, time commitment, emotional distress, and/or physical and psychological fatigue. In detail, work overload is positively related to WIF, whereas family overload is positively related to FIW . More generally, F RONE identified that job stress increased work-to-family conflict, whereas family stress increased family-to-work conflict .
One of the most recognised theoretical models concerning stress factors and consequences of perceived stress in work sciences is the "demand-control-support model" [39, 40] (in ). This model assumes working situations to have negative psychological or physical consequences in particular when high demands coincide with limited decision latitude and low social support at the workplace. According to this model, physicians working in hospitals are likely to perceive high work stress . As described above, the findings by F RONE [8, 9] support this assumption. In our study, we investigated different aspects of work demands, control, and support, focussing on hospital-specific working conditions.
To our knowledge, research on physicians' psychosocial and organisational work environment and the consequences on the employees' well-being is rare in Germany. In our study, we want to focus on sources and predictors for WIF, predominantly found within the psychosocial and organisational work environment. The different working conditions inquired in our study touch general work demands as well as time- and strain-based conditions. Most of the variables are captured by one standardised instrument, the German version of the Copenhagen Psychosocial Questionnaire (COPSOQ), whereas hospital-specific issues are measured by specific items.
Key Question II a: What are the psychosocial and organisational sources for WIF within the work domain of physicians?
Key Question II b: Do male and female physicians differ in these predictors for WIF?
Key Question II c: Do German hospital physicians differ from the general German population regarding psychosocial and organisational working conditions?
Consequences of WIF
If the job role is a threat to the family role, one of a subject's self-relevant roles is endangered. This is the case when work is interfering with family (WIF). It is likely that attitudes towards work are altered due to its impact on family role and therefore a negative appraisal towards the threat occurs [26, 42]. In contrast, FIW is more likely to alter attitudes towards the family .
Much research has focused on relationships between Work-Family Conflict and several job outcomes. WFC was negatively related to job satisfaction [26, 38, 42–44], job performance [45, 5], and positively related to job stress [22, 46] and the intention to leave the job [45, 47, 42, 44, 5, 46].
WIF can be a source of distress which may have physical and mental consequences, such as higher emotional exhaustion . Abusive alcohol consumption has also been described as an indirect consequence of WFC .
Relationships between WFC and indicators of general well-being and quality of life have also been examined. A RYEE described moderate prediction of life satisfaction and marital satisfaction by WFC . Several researchers described the negative relationship between WFC and life satisfaction [38, 42, 44]. Gender differences in the relationship between WFC and the above described outcomes have been observed. For example, G RANDEY stated that WIF was predictive for women's job satisfaction, but not for men's . In addition, the author suggested that it is likely that women respond with stronger negative attitudes towards their job than men do . Y AVAS reports a stronger relationship between WIF and job performance for men than women and a stronger impact of WIF on turnover intentions for women . While research on physicians' health and well-being has increased during the last years, investigations of relationships between Work-Family Conflict and various outcome measures among German physicians do not exist to our knowledge. Thus we address these parameters with regard to WIF in physicians:
Key Question III a: Which relationships exist between WIF and various job-related outcomes (e.g., job satisfaction, intention to leave, work ability), personal distress (e.g., cognitive and behavioural stress symptoms, personal burnout, general health status), and perceived quality of life (i.e., satisfaction with life)?
Key Question III b: Are there any gender differences for these outcomes among hospital physicians?
Key Question III c: Do outcome levels of WIF in hospital physicians differ from those of the general German population?