Primary healthcare workers' work motivation is closely related to the quality and accessibility of health services. Autonomous motivation represents a higher-quality form of motivation, yet it is not fixed and may change with factors such as career experience and the institutional context, thereby exerting potential effects on work-related outcomes.

Drawing on Self-determination Theory (SDT), this study compared primary healthcare workers' initial (entry) motivation for practicing medicine with their current work motivation to describe changes in autonomous motivation (i.e., engaging in an activity based on full willingness and autonomous choice) and to examine the reasons for such changes and their associations with key work outcomes.

A mixed-methods design was adopted. Using multistage cluster sampling, we selected three cities in Shandong Province, China (Yantai in the east, Zibo in the central region, and Liaocheng in the west). In each city, three districts/counties were selected, and four primary healthcare institutions were sampled within each district/county, yielding 36 survey sites. On the survey day, all on-duty healthcare workers (including physicians, nurses, public health workers, and medical technicians) were invited to complete a questionnaire. Of 1 271 questionnaires distributed, 1 113 were valid (effective response rate: 87.6%). In addition, 107 participants were purposively sampled for in-depth interviews. Initial motivation for practicing medicine was measured using a self-developed questionnaire, while current work motivation was assessed with a revised Work Motivation Scale. Based on SDT, both initial and current motivations were classified into two types: autonomous motivation and non-autonomous motivation. By comparing the dominant type of initial and current motivation, a "motivation change" variable was constructed, yielding four categories. Four key indicators of work attitudes and behaviors were assessed: turnover intention, job burnout, job satisfaction, and job performance. Questionnaire data were analyzed using descriptive statistics, analysis of variance (ANOVA), and multiple linear regression. Interview data were analyzed using the thematic framework approach.

For initial motivation, 545 (49.0%) participants were classified as having autonomous motivation and 568 (51.0%) as having non-autonomous motivation. For current work motivation, 713 (64.0%) participants had autonomous motivation and 400 (36.0%) had non-autonomous motivation. The 2×2 "motivation change" variable produced four categories: stable autonomous motivation (n=403, 36.2%), stable non-autonomous motivation (n=258, 23.2%), autonomization (n=310, 27.8%), and de-autonomization (n=142, 12.8%). Scores for turnover intention, job burnout, job satisfaction, and job performance differed significantly across the four categories (all P<0.05). Specifically, compared with the stable autonomous motivation group and the autonomization group, the stable non-autonomous motivation group and the de-autonomization group reported higher turnover intention and job burnout (P<0.05) and lower job satisfaction and job performance (P<0.05). In addition, the autonomization group had higher turnover intention and job burnout (P<0.05) and lower job satisfaction and job performance (P<0.05) than the stable autonomous motivation group. Multiple linear regression indicated that, relative to the stable autonomous motivation group, the other three groups had higher regression coefficients in the models for turnover intention and job burnout (P<0.05) and lower regression coefficients in the models for job satisfaction and job performance (P<0.05). Interview findings suggested that changes in motivation were mainly influenced by the needs for meaning, competence, and relatedness.

Autonomous motivation is associated with better work performance among primary healthcare workers. Greater resource investment and institutional improvements are needed to foster a more supportive organizational context—such as strengthening health information systems, improving training mechanisms, and innovating doctor-patient communication-to satisfy primary healthcare workers' basic psychological needs and thereby enhance autonomous motivation.

基层卫生人员的工作动机关系到卫生服务的质量与可及性，其中自主性动机是更高质量的动机类型。但自主性动机并非固定不变，可能在职业经历与制度情境等因素的作用下发生变化，从而对个体的工作结果产生潜在影响。

基于自我决定理论，对比基层卫生人员从医动机与当前工作动机，揭示自主性动机（指个体在完全自愿和自主选择的基础上从事某项活动）的变化情况，并分析其变化原因及对工作结果的影响。

采用混合方法学研究设计，使用多阶段整群抽样，选择山东省东部的烟台市、中部的淄博市、西部的聊城市3个城市，在每个城市内选择3个区县，在每个区县选择4家基层卫生机构，总计选择36家基层卫生机构作为调查点。调查当天，对所有在岗的卫生人员（包括医生、护士、公共卫生人员和医技人员）进行问卷调查。共计发放问卷1 271份，收回有效问卷1 113份，有效回收率为87.6%。使用目的抽样对其中107人进行深入访谈。采用自制问卷调查基层卫生人员的从医动机，采用工作动机量表修订版调查基层卫生人员的当前工作动机，将调查结果按照自我决定理论划分为"自主性动机"和"非自主性动机"两种类型。比较从医动机和当前工作动机的主导类型，构建"动机变化"变量。同时测量反映基层卫生人员工作态度与行为表现的4项关键指标：离职意愿、职业倦怠、工作满意度、工作绩效。使用描述统计、方差分析和多元线性回归对问卷数据进行分析，使用主题框架法整理分析访谈资料。

从医动机中，自主性动机人员共545人，占49.0%；非自主性动机人员共568人，占51.0%。当前工作动机中，自主性动机人员为713人，占64.0%；非自主性动机人员为400人，占36.0%。"动机变化"为一个"2×2"的组合型变量，共形成4种动机变化类型，分别为维持自主性动机403人（36.2%），维持非自主性动机258人（23.2%），动机自主化310人（27.8%），动机去自主化142人（12.8%）。4种动机变化类型者离职意愿、职业倦怠、工作满意度、工作绩效得分比较，差异均有统计学意义（P<0.05）；其中维持非自主性动机者和动机去自主化者离职意愿和职业倦怠得分均高于维持自主性动机者和动机自主化者（P<0.05），工作满意度和工作绩效得分均低于维持自主性动机者和动机自主化者（P<0.05）；动机自主化者离职意愿和职业倦怠得分均高于维持自主性动机者（P<0.05），工作满意度和工作绩效得分均低于维持自主性动机者（P<0.05）。多元线性回归分析结果显示，与维持自主性动机者相比，其余3个类别在离职意愿和职业倦怠模型中回归系数均更高（P<0.05），在工作满意度和工作绩效模型中回归系数均更低（P<0.05）。访谈结果表明，动机变化主要受意义需要、胜任需要和关系需要的影响。

自主性动机能让基层卫生人员有更好的工作表现，应通过资源投入与制度建设创造更有支持性的组织环境，如加强信息化建设、完善培训机制、创新医患沟通机制等，以此满足基层卫生人员的基本心理需要，进而提高其自主性动机。