A snapshot of Australian primary health care nursing workforce characteristics and reasons they work in these settings: A longitudinal retrospective study

Abstract

Aim

This article aimed to provide a snapshot of demographics and professional characteristics of nursing and midwifery workforce in Australian primary health care (PHC) settings during 2015–2019 and factors that influenced their decisions to work in PHC.

Design

Longitudinal retrospective survey.

Methods

Longitudinal data that were collected from a descriptive workforce survey were retrieved retrospectively. After collation and cleaning, data from 7066 participants were analysed using descriptive and inferential statistics in SPSS version 27.0.

Results

The majority of the participants were female, aged between 45 and 64 years old and working in general practice. There was a small yet steady increase in the number of participants in the 25–34 age group and a downward trend in the percentage of postgraduate study completion among participants. While factors perceived most/least important to their decision to work in PHC were consistent during 2015–2019, these factors differed among different age groups and postgraduate qualification holders. This study’s findings are both novel and supported by previous research. It is necessary to tailor recruitment and retention strategies to nurses/midwives’ age groups and qualifications to attract and retain highly skilled and qualified nursing and midwifery workforce in PHC settings.

1. INTRODUCTION

For more than four decades, the World Health Organisation (WHO) (2018) has continued its committed focus on primary health care (PHC). ‘PHC is a whole‐of‐society approach to health that aims to ensure the highest possible level of health and well‐being and their equitable distribution by focusing on people's needs and preferences (as individuals, families and communities) as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to people's everyday environment’ (World Health Organization, & United Nations International Children's Emergency Fund [UNICEF], 2018, p. 2). According to WHO and UNICEF (2018), as the world is changing economically, environmentally, technologically and demographically, the meaning of PHC has also evolved over years and may be interpreted differently in different contexts. In Australia, typically considered the first point of patient contact with the health system, PHC delivers a wide range of services in various settings including referrals to specialist services before more comprehensive care in hospitals is required (Australian Institute of Health and Welfare, 2022a). The importance of PHC has been well established: it improves health and well‐being of communities; plays an important role in disease prevention, treatment of and ongoing care for chronic conditions; and as a result, reduces avoidable burdens to hospitals and improves overall national health outcomes (Swerissen et al., 2018). In the context of Australia's ageing population and increasing health expenditure (Byfield et al., 2019), the role of PHC in the health system is further emphasised as demonstrated through an increasing health policy focus on PHC.

It is projected that health workforce shortages, including shortages of nurses and midwives will continue at a global scale (Global Burden of Disease 2019 Human Resources for Health Collaborators, 2022; World Health Organization, 2020). Such shortages are likely exacerbated by the COVID‐19 pandemic due to exposure to the virus itself (Jackson et al., 2020; Wilensky, 2022), burnout and increased risk factors for burnout such as social‐demographic, social and occupational factors (Galanis et al., 2021). Disruptions by the pandemic to health systems also have a profound impact on nursing and midwifery workforce in PHC worldwide (Khalil‐Khan & Khan, 2023) as well as in Australia (Halcomb et al., 2020). It is thus timely to again seek evidence that could be used to boost recruitment and retention of the workforce by answering the question: what factors influence nurses and midwives' decision to work in the unique workplace settings of PHC. Evidence that is based on longitudinal data provides additional insights into changes (or lack thereof) over time and thus, may have an amplified impact on future policy, education and practice.

2. BACKGROUND

Understanding the demographics and professional characteristics of the workforce in PHC settings is essential to understand the quality and sustainability of PHC services. Such knowledge will be instrumental in policy, practice and education planning in order to attract and retain sustainable quality workforce, to promote necessary integrated care, and ultimately, to improve patient health experiences and outcomes. In this paper examining Australian health care settings, we focus on nurses and midwives, the largest PHC workforce cohorts in the country (Heywood & Laurence, 2018).

While attempts have been made to describe nursing/midwifery PHC workforce, it is limited by cross‐sectional study design (Halcomb et al., 2018; Parker et al., 2011) or data from two non‐consecutive years (Halcomb et al., 2014, 2017; Heywood & Laurence, 2018). Therefore, a research gap remains in investigating trends in workforce characteristics over a longer and consecutive period of time to provide understanding on workforce movement. In addition, although PHC is delivered in a wide range of settings (Ashley, Brown, et al., 2018), research in this area has largely focused on general practice (Heywood & Laurence, 2018). The lack of information about nurses in other PHC settings, like Aboriginal medical services, aged care, maternal and child health services and schools, may undermine future workforce planning and/or policy making that may further impact on the PHC goal of improving health outcomes for communities.

In addition, existing misconceptions about PHC nursing mean a career in PHC is considered by some as less attractive than a career in acute care settings (Byfield et al., 2019; McKenna et al., 2015). Some of these misconceptions include a perceived lower quality of care and lack of continuity of care compared to acute care nursing; lack of transferability of skills gained in PHC or lack of practical relevance as PHC settings were perceived not ideal to consolidate clinical skills as compared to that in acute care settings (Byfield et al., 2019). These negative perceptions could contribute to challenges in recruiting and keeping nurses and midwives to work in PHC. It is therefore important to seek understanding of what nurses and midwives consider important in their decision to work in PHC, and if people with different demographics and/or professional characteristics work in PHC for different reasons. Such knowledge will be essential to design tailored approaches to recruit and retain nurses and midwives in PHC workforce. Such knowledge can be used to explore if the nursing scope of practice meet the desire of nurses and midwives when they decide to enter the PHC workforce. This study thus has been conducted to address these important needs of evidence.

3. THE STUDY

3.1. Aims

This study aims to provide a snapshot of nursing and midwifery workforce in Australian PHC settings during the five consecutive years from 2015 to 2019. We aim to explore Australian PHC workforce demographics, professional characteristics, the factors that influenced nurses and midwives' decisions to work in PHC and if these factors change over the 2015–2019 period.

3.2. Design

We applied a longitudinal descriptive design to retrospectively explore the data that were collected in annual national surveys during 2015–2019 hosted by the Australian Primary Health Care Nurses Association (APNA), a professional association for Australian nurses and midwives working in PHC. The longitudinal design is helpful to identify trends in the data over the surveyed period.

3.3. Participants and settings

Participants in this study were nurses and midwives practising in Australian PHC settings during 2015–2019.

3.4. Data collection

Electronic surveys with an embedded URL were annually distributed via APNA's website, e‐newsletters, quarterly magazines, short messaging service (SMS) to members, electronic direct mails (EDM) to membership and non‐member subscriber databases as well as social media platforms such as Facebook, LinkedIn and Twitter. The survey links were also distributed through APNA's network of stakeholders including but not limited to Australian College of Nursing, Australian Nursing and Midwifery Federation, Australian College of Mental Health Nurses and the Coalition of National Nursing and Midwifery Organisations and Primary Health Networks. The surveys were hosted on Survey Monkey™ in 2015 and on Alchemer from 2016 onwards. The survey links were active for 2 months on average and were extended to 3 months in the event the response rate needed boosting. The survey URLs were resent multiple times as a reminder mechanism to boost response rate. No identifiable information from respondents was collected in any of the survey‐year.

The survey tool was developed in 2004 and revised in 2015 based on (a) review of relevant literature and research reports, (b) mapping of existing survey tools published at the time and (c) consultation with stakeholders in primary health care. Modified following a pilot test on a group of nurse academics as well as experts in survey development, nursing policies and workforce, the survey tool included a series of descriptive questions related to (1) demographics; (2) employment conditions; (3) clinical roles, activities and performance; (4) professional support and (5) job satisfaction. The survey incorporated multiple‐choice, yes‐no, Likert‐scale and short open‐ended questions. Key content of the surveys remained the same each year, although additional items were iteratively added, along with several changes to response format. In this study, to ensure consistency, we only included items of the same response format over the five survey‐years.

3.5. Ethical considerations

Ethical approval was granted by the university's Human Research Ethics Committee (Project ID: 27762) prior to data extraction and analysis. All data were non‐identifiable and transferred from APNA to the research team via a password‐secured limited‐access platform (LabArchives). EQUATOR checklist (STROBE guideline) was used to guide the reporting of this paper.

3.6. Data analysis

Non‐identifiable surveyed data from 2015 to 2019 were extracted from the survey hosting platforms. The data were then explored to seek similarities and differences across the survey‐years for data collation purposes. Surveyed items with similar content and response format across the 5‐year period were then extracted and collated (records coded by year of entry) using Excel. The dataset was later examined, cleaned and imported into Statistical Package for the Social Sciences (SPSS) version 27.0 for further exploration using descriptive and inferential analysis (Chi‐square and ANOVA). Ineligible cases (those who only worked in an acute hospital or outside of Australia) and cases with substantial missing data (those who initiated the survey but did not complete any individual section) were removed (n = 1805, 20.3%). Likert‐scale survey data were allocated a numerical value (0 = unimportant, 4 = very important), analysed using ANOVA tests, and mean scores summed and reported here. The reasons for using ANOVA test (a parametric test) for the nominal data were as follows: (1) our sample size was substantial, (2) the variables were normally distributed and (3), according to Norman (2010), parametric tests are more robust than non‐parametric ones.

We have deliberately chosen to report the practical/clinical significance rather than traditional statistical significance. This approach is because, as according to Sullivan and Feinn (2012), p‐values are more likely to be sensitive than to be meaningful when large samples are used (in this study N = 7066). Note that, in doing so, we have taken effect size‐ a sample‐independent statistic indicating ‘magnitude of the difference between groups’ (Sullivan & Feinn, 2012, p. 279) into consideration when interpreting statistical results. In particular, we refer to Cohen's w values for Chi‐square tests (0.1, 0.3 and 0.5 for small, medium and large effect size respectively) and ŋ ² for ANOVA tests (0.01, 0.06 and 0.14 for small, medium and large effect size respectively) (Cohen, 1988). While we do not present p‐values for each and every comparative test, most of the changes over the study period during 2015–2019 were either non‐statistically significant, or statistically significant at p = 0.05 with small or very small effect sizes. For readers' interest, a footnote has been provided at the end of each table to briefly indicate statistical significance.

4. RESULTS

Surveyed data from a total of 8871 nurses and midwives were collected from 2015 to 2019. Between the five survey‐years, surveys in 2018 attracted the highest number of participants (n = 2655, 29.9%). After removing ineligible cases and missing data (n = 1805, 20.4%), data from 7066 (79.7%) participants were then included for further analysis.

4.1. Demographics and professional characteristics

The majority of the 7066 participants were female (n = 6854, 97.1%) and aged between 45 and 64 years old (n = 4657, 65.9%, see Table 1). There was a small yet steady increase in the number of nurses/midwives in the younger age group, 25–34 years old (from 9.6% in 2015 to 15.0% in 2019). The majority of the participants completed their nursing/midwifery qualification in Australia (n = 6111, 87.1%), followed by the United Kingdom (n = 218, 3.1%), New Zealand (n = 102, 1.1%) and the Philippines (n = 44, 0.6%) respectively. The number of registered nurses was steady over the survey periods, accounting for 81.7% of participants working in PHC (n = 5773), while the number of participants who self‐identified as both nurse and midwife were significantly fewer than those registered as either a nurse or midwife (n = 466, 6.6%), and with greater fluctuation, between 5.9% and 9.2% during 2015–2019 (see Table 1).

TABLE 1.

Participant demographic and professional characteristics.

Professional characteristics		Survey years
		2015 (n = 1162)		2016 (n = 1123)		2017 (n = 1063)		2018 (n = 2036)		2019 (n = 1682)		Total (N = 7066)
		n	%	N	%	n	%	n	%	n	%	N	%
Gender*	Female	1120	96.4	1092	97.4	1037	97.6	1991	97.9	1614	96.1	6854	97.1
	Male	42	3.6	29	2.6	23	2.2	42	2.1	64	3.8	200	2.8
	Other self‐identification	—	—	—	—	2	0.2	1	0.0	2	0.1	5	0.1
	<25 years old	15	1.3	14	1.2	8	0.8	36	1.8	39	2.3	112	1.6
	25–34 years old	112	9.6	124	11.0	129	12.1	266	13.1	252	15.0	883	12.5
Age group a , *	35–44 years old	175	15.1	166	14.8	163	15.3	338	16.6	276	16.4	1118	15.8
	45–54 years old	419	36.1	370	32.9	365	34.3	590	29.0	527	31.3	2271	32.1
	55–64 years old	396	34.1	407	36.2	364	34.2	707	34.7	512	30.4	2386	33.8
	65+ years old	45	3.9	42	3.7	34	3.2	99	4.9	76	4.5	296	4.2
Years working as a qualified nurse/midwife b (Mean, SD)***		23.5	11.8	22.7	12.2	22.8	12.0	22.0	12.9	21.1	13.2	22.3	12.6
Country of first qualification	Australia	1019	88.1	980	87.6	928	87.7	1746	87.0	1438	86.0	6111	87.1
	Other	138	11.9	139	12.4	130	12.3	261	13.0	235	14.0	903	12.9
Registration status*	Registered nurse	921	79.3	910	81.0	858	80.6	1707	83.8	1377	81.9	5773	81.7
	Enrolled nurse	109	9.4	108	9.6	125	11.7	208	10.2	158	9.4	708	10.0
	Nurse and midwife	107	9.2	88	7.8	70	6.6	101	5.0	100	5.9	466	6.6
	Nurse practitioner	25	2.2	17	1.5	10	0.9	20	1.0	46	2.7	118	1.7
Employment location**	Victoria	383	33.6	401	38.0	459	45.0	562	28.5	373	23.1	2178	32.0
	New South Wales	332	29.1	301	28.5	252	24.7	527	26.7	453	28.0	1865	27.4
	Queensland	194	17.0	168	15.9	126	12.4	422	21.4	336	20.8	1246	18.3
	South Australia	96	8.4	86	8.2	80	7.9	195	9.9	120	7.4	577	8.5
	Western Australia	66	5.8	40	3.8	39	3.8	143	7.2	182	11.3	470	6.9
	Tasmania	22	1.9	30	2.8	35	3.4	62	3.1	59	3.7	208	3.1
	Australian Capital Territory	39	3.4	15	1.4	13	1.3	35	1.8	41	2.5	143	2.1
	Northern Territory	8	0.7	11	1.0	9	0.9	20	1.0	52	3.2	100	1.5
	Multiple states/ territories	0	0.0	3	0.3	6	0.6	9	0.5	0	0.0	18	0.3
Workplace locality*	Metropolitan	638	55.7	587	55.6	577	56.7	1077	54.5	899	56.0	3778	55.6
	Rural	408	35.6	366	34.7	349	34.3	715	36.2	623	38.8	2461	36.2
	Remote	71	6.2	74	7.0	55	5.4	110	5.6	84	5.2	394	5.8
	Unknown	29	2.5	28	2.7	36	3.5	73	3.7	0	0.0	166	2.4
Multiple employers**		260	22.4	331	29.4	260	24.4	763	37.5	497	29.5	2111	29.9
Employment status in primary job*	Permanent	852	74.3	788	74.7	796	78.1	1459	73.9	1208	73.5	5103	72.2
	Casual	195	17.0	180	17.1	142	13.9	371	18.8	286	17.4	1174	17.2
	Fixed term or temporary contract	55	4.8	41	3.9	44	4.3	84	4.3	79	4.8	303	4.4
	Self‐employed contractor	18	1.6	15	1.4	15	1.5	22	1.1	40	2.4	110	1.6
	Other	26	2.3	27	3.0	22	2.2	39	2.0	30	1.9	148	2.1
Employment basis in primary workplace*	Part time	664	57.9	614	58.2	609	59.8	1110	56.2	815	49.6	3812	55.7
	Full time	300	26.2	278	26.4	268	26.3	528	26.7	542	33.0	1916	28.0
	Casual/unsure/other	182	15.9	163	15.4	142	14.0	337	17.1	286	17.4	1110	16.2

Note: —Nil data for this survey‐year.

^a Mean age (of all participants): 49.2 years (SD = 11.1).

^b Excluding absence from workforce >6 months.

^* p‐values <0.05 with very small effect size (w < 0.1).

^** p‐values <0.05 with small effect size (w ≥ 0.1).

^*** p‐values <0.05 with medium effect size (w ≥ 0.3, or ŋ2 ≥ 0.06).

There was little change in the distribution of participants working in different localities of Australia during 2015–2019. Consistently over the survey period (except for the year 2019), Victoria recorded the largest cohort of PHC nursing/midwifery participants (n = 2178, 32.0%), followed by New South Wales (n = 1865, 27.4%) and Queensland (n = 1246, 18.3%) respectively. It is noted, however, that the proportion of Victorian participants varied the most, peaked in 2017 (n = 459, 45%) and dropped in 2019 (n = 373, 23.1%). More than half of the participants worked in metropolitan settings (n = 3778, 55.6%) and on a part‐time basis (n = 3812, 55.7%). Most had a permanent appointment (n = 5103, 72.2%), while 29.9% (n = 2111) of the participants had more than one employer.

4.2. Postgraduate qualifications

Over one‐third of the participants (n = 2455, 35.1%) had completed postgraduate study (see Table 2). There was a downward trend in the percentage of postgraduate study completion among the participants since 2015 (from 42.8% in 2015 to 33.0%–34.0% in the four subsequent survey‐years). The participants were further asked to identify which postgraduate qualifications they had completed or were working towards. Participant engagement in postgraduate degrees (n = 2219, 31.4%) is considerably lower than that in short courses (n = 4782, 67.7%). The number of participants completed or studying postgraduate degrees decreased substantially (from n = 446, 38.4% in 2015 to n = 359, 21.3% in 2019), while the number of participants completed or studying short courses only slightly fluctuated during 2015–2019. The number of participants completed or studying towards a speciality in PHC or general practice was higher than those completed or studying PHC or general practice at both certificate/diploma and master levels. The number of participants participating in a nurse practitioner course fluctuated substantially during 2015–2019. With regards to short courses, the number of participants participating in educator courses including (a) asthma and respiratory educator, (b) diabetes educator and (c) cardiovascular disease educator increased substantially from 2015 to 2018 before dropping in 2019. Meanwhile, the number of participants completed or studying short courses in mental health nursing steadily increased over the five survey‐years (from n = 49, 4.2% in 2019 to n = 606, 8.3% in 2019, see Table 2).

TABLE 2.

Participant enrolments in postgraduate education.

Postgraduate qualification	Survey years
	2015 (n = 1162)		2016 (n = 1123)		2017 (n = 1063)		2018 (n = 2036)		2019 (n = 1682)		Total (N = 7066)
	n	%	n	%	n	%	n	%	n	%	N	%
Completed postgraduate qualification*	496	42.8	366	33.0	359	34.0	669	33.4	565	34.0	2455	35.1
Completion/currently studying in postgraduate degrees (total)**	446	38.4	407	36.2	405	38.1	602	29.6	359	21.3	2219	31.4
1. Certificate/diploma in a PHC/GP‐related specialty a , *	185	15.9	125	11.1	138	13.0	240	11.8	197	11.7	885	12.5
2. Certificate/diploma in PHC/GP nursing*	169	14.5	119	10.6	143	13.5	237	11.6	175	10.4	843	11.9
3. Nurse practitioner**	90	7.7	128	11.4	96	9.0	203	10.0	4	0.2	521	7.4
4. Master in a PHC/GP‐related specialty b , *	59	5.1	56	5.0	49	4.6	78	3.8	103	6.1	345	4.9
5. Master of PHC/GP Nursing	32	2.8	21	1.9	21	2.0	41	2.0	44	2.6	149	2.1
6. Professional doctorate/Doctor of philosophy*	9	0.8	0	0.0	11	1.0	14	0.7	18	1.1	55	0.8
7. Other postgraduate courses**	151	13.0	139	12.4	152	14.3	0	0.0	0	0.0	442	6.3
Completion/currently studying in short courses (total)*	765	65.8	782	69.6	736	69.2	1400	68.8	1099	65.3	4782	67.7
8. Nurse immuniser	637	54.8	651	58.0	611	57.5	1178	57.9	940	55.9	4017	56.8
9. Cervical screening test provider	300	25.8	303	27.0	261	24.6	529	26.0	437	26.0	1830	25.9
10. Asthma and respiratory educator*	168	14.5	208	18.5	205	19.3	363	17.8	230	13.7	1174	16.6
11. Diabetes educator *	127	10.9	186	16.6	153	14.4	304	14.9	219	13.0	989	14.0
12. Mental health nursing*	49	4.2	113	10.1	86	8.1	184	9.0	177	10.5	609	8.6
13. Cardiovascular disease educator*	47	4.0	103	9.2	99	9.3	190	9.3	149	8.9	588	8.3

Note: p‐values <0.05 with medium effect size (w between 0.3 and 0.5).

Abbreviations: GP, general practice; PHC, primary health care.

^a Including business, chronic disease management, etc.

^b Including health promotion, public health, etc.

^* p‐values <0.05 with very small effect size (w < 0.1).

^** p‐values <0.05 with small effect size (w ≥ 0.1).

4.3. Employment settings

A variety of PHC employment settings and contexts were reported, ranging from general practice to self‐employed consultancy. Approximately two‐thirds of the participants worked in general practice (n = 4682, 66.2%; see Table 3). Three other most common workplace settings were acute hospitals while concurrently holding a position in PHC (n = 386, 5.5%), community health associated with an acute hospital (n = 345, 4.9%) and community health not associated with an acute hospital (n = 348, 4.9%). Each of the 22 other settings, such as non‐government organisations, Aboriginal medical services, refugee health and boarding houses, were the workplace of less than 5% of the total participants.

TABLE 3.

Participant employment settings.

Employment settings	Survey years
	2015 (n = 1162)		2016 (n = 1123)		2017 (n = 1063)		2018 (n = 2036)		2019 (n = 1682)		Total (N = 7066)
	n	%	n	%	n	%	n	%	n	%	N	%
1. General practice**	717	61.7	707	63.0	608	57.2	1587	77.9	1063	63.2	4682	66.2
2. Acute hospital a , *	87	7.5	58	5.2	34	3.2	118	5.8	89	5.3	386	5.5
3. Community health associated with acute health services*	43	3.7	30	2.7	45	4.2	162	8.0	65	3.9	345	4.9
4. Community health not associated with acute health services*	35	3.0	47	4.2	53	5.0	142	7.0	71	4.2	348	4.9
5. Specialist medical rooms**	26	2.2	42	3.7	37	3.5	175	8.6	43	2.6	323	4.6
6. Non‐government organisation**	14	1.2	52	4.6	33	3.1	150	7.4	54	3.2	303	4.3
7. Medicare local/Primary health network*	32	2.8	51	4.5	28	2.6	88	4.3	52	3.1	251	3.6
8. Aged care facility*	26	2.2	33	2.9	14	1.3	83	4.1	52	3.1	208	2.9
9. Aboriginal medical service*	25	2.2	20	1.8	24	2.3	78	3.8	54	3.2	201	2.8
10. Consultant/Contractor (self‐employed)*	13	1.1	37	3.3	41	3.9	54	2.7	42	2.5	187	2.6
11. Correctional services/Prison*	4	0.3	25	2.2	8	0.8	40	2.0	37	2.2	114	1.6
12. University/Technical and further education (TAFE) clinic	15	1.3	15	1.3	14	1.3	22	1.1	27	1.6	93	1.3
14. Maternal and child health service	13	1.1	7	0.6	8	0.8	28	1.4	21	1.2	77	1.1
15. School/Pre‐school	10	0.9	11	1.0	11	1.0	27	1.3	16	1.0	75	1.1
16. Refugee health*	10	0.9	3	0.3	7	0.7	25	1.2	9	0.5	54	0.8
17. Mental health service/facility*	6	0.5	8	0.7	9	0.8	17	0.8	8	0.5	48	0.7
18. Workplace health centre*	4	0.3	6	0.5	1	0.1	29	1.4	5	0.3	45	0.6
19. Sexual health clinic*	2	0.2	3	0.3	3	0.3	24	1.2	8	0.5	40	0.6
20. Military medical facility	5	0.4	6	0.5	6	0.6	8	0.4	9	0.5	34	0.5
21. Palliative care service/facility*	3	0.3	1	0.1	8	0.8	17	0.8	3	0.2	32	0.5
22. Telehealth/Call centre*	2	0.2	3	0.3	1	0.1	15	0.7	4	0.2	25	0.4
23. Drug and alcohol clinic*	7	0.6	2	0.2	3	0.3	16	0.8	2	0.1	30	0.4
24. Community residential care (e.g. young disabled, group home)	3	0.3	1	0.1	4	0.4	13	0.6	3	0.2	24	0.3
25. Boarding house/Outreach to homeless	3	0.3	3	0.3	2	0.2	4	0.2	8	0.5	20	0.3
26. Social services*	0	0.0	4	0.4	1	0.1	10	0.5	2	0.1	17	0.2

Note: The total percentage by column (survey‐year) is not equivalent to 100% due to missing data and/or multiple employments worked by the participants.

^a These participants worked in acute hospital while also having another employment in primary health care settings.

^* p‐values <0.05 with very small effect size (w < 0.1).

^** p‐values <0.05 with small effect size (w ≥ 0.1).

4.4. Why a career in primary health care settings?

Twelve items in the format of Likert‐scale questions with five answer options ranging from ‘unimportant’ to ‘very important’ were used to explore the factors that contributed to participants' decision to become a PHC nurse/midwife. Overall, three items believed most important to participants' decision to work in PHC were related to (a) work‐life balance reasons (M = 3.4, SD = 0.8), (b) perception of lifestyle suitability (M = 3.4, SD = 0.9) and (c) opportunity to increase job satisfaction (M = 3.1, SD = 0.9; see Figure 1). Meanwhile, three least important reasons were (i) salary and benefits (M = 2.1, SD = 1.1), (ii) proximity of the employment location to home (M = 1.9, SD = 1.4), and (iii), first job opportunity that arose (M = 1.2, SD = 1.3). These results were consistent across surveyed years and participants' age groups, registration status, as well as workplace locality.

FIGURE 1.

Factors influencing participants at different age groups to work in primary health care. Note: 0 score = Unimportant. 4 score = Very important. Mean scores for all participants of all survey‐years are presented. The differences between the four participant age groups for all 12 factors were statistically significant (p < 0.001, except for factor 6 with p = 0.028) with small (factor 1, 2, 4, 9, 10 and 12) or very small effect sizes (factor 3, 5, 6, 7, 8 and 11).

There were, however, some differences when looking closely at how each of the 12 items were related to participants' personal and professional characteristics. Based on the difference in mean scores, we found that participants under 25 years old (n = 112) rated the first employment opportunity that came up (M = 2.6, SD = 1.4) highest among all other age groups (M = 1.2, SD = 1.3). Participants of younger age groups (<25, and 25–34 years old) also rated opportunity to advance nursing/midwifery career and (c) salary and benefits of PHC employments’ substantially higher than those aged more than 35 years old (see Figure 1). In contrast, nurse practitioner participants' preference for professional factors appeared to be most noticeable among all other registration groups. These participants (n = 118) rated (1) opportunity to advance nursing/midwifery career (M = 3.0, SD = 1.0), (2) autonomy in practice (M = 3.4, SD = 0.9), (3) consolidation of knowledge (M = 3.1, SD = 1.0), and (4), interest for a career in PHC (M = 3.2, SD = 1.0) highest among all other registration sub‐groups (see Figure 2).

FIGURE 2.

Factors influencing participants with different registration statuses to work in primary health care. Note: 0 score = Unimportant. 4 score = Very important. Mean scores for all participants of all survey‐years are presented. The differences between the four participant age groups for the 12 factors were statistically significant (p < 0.001, except for factor 3 with p = 0.002) with small (factor 9 and 10) or very small effect sizes (all remaining factors).

5. DISCUSSION

This study presented findings from a longitudinal analysis of retrospective data to describe a snapshot of Australian primary health care nursing workforce characteristics during 2015–2019 and factors they deemed important in their decision to work in PHC. Our study found no substantial changes in most of the participants' demographics, employment settings or factors contributing to their decision to work in PHC over the five survey‐years. However, there was a noticeable decline in the number of participants completing/studying postgraduate degrees especially during 2018–2019. We found novel findings related to how factors influencing nurses/midwives' decision to work in PHC differed among diverse participants' demographic and professional characteristics. These findings will be discussed further below in more detail.

There was an increase in the number of participants during 2018–2019 as compared to the 2015–2017 period. Such an increase might reflect the growth of APNA, its reach to PHC nurses and midwives, and perhaps more effective survey coverage. Note that there are a series of important national policies over the last decade intended to improve the access to and/or delivery of PHC in Australia including but not limited to Practice Nurse Incentive Program (PNIP, now Workforce Incentive Program‐WIP) (Department of Health, 2020), Health Care Homes (Department of Health, 2018c) and Council of Australian Governments Section's Section 19(2) Exemptions Initiative on Improving Access to Primary Care in Rural and Remote Areas (Department of Health and Aged Care, 2022). We are, however, due to the retrospective design of the study, unable to identify if there were any association between these policies and the increase in number of survey respondents who were working in PHC settings.

5.1. Demographics, qualifications and employment settings

Our participants were older than the overall Australian nursing/midwifery workforce in the same period. This aspect is reflected through both higher average age (48.2–49.9 years old) and higher percentages of participants above 45 years old (68.6%–74.1%) than that of the general nursing/midwifery workforce (43.6–44.4 years old, 48.2%–51% respectively) (Department of Health, 2017, 2018b, 2019). On the other hand, there was a small yet consistent increase in the percentage of participants in 25–34 age group (9.6%–15%) which may indicate early signs that younger nurses/midwives were becoming interested in a career in PHC. This is also in line with the steady increase of nurses/midwives aged less than 34 years in the overall Australian nursing/midwifery workforce between 2015 and 2020 (Australian Institute of Health and Welfare, 2022b). Our findings suggest a need for strategic, targeted programs to further attract and retain younger nurses/midwives in Australian PHC settings to ensure a sustainable workforce in this growing area of the health system.

The substantial decrease in engagement in postgraduate degrees among our participants over the 2015–2019 period might indicate the existence of barriers to postgraduate study. Although we did not explore reasons contributing to this decrease, findings from previous research identifying barriers to general practice nurses from undertaking postgraduate studies may be relatable to our participants. These reasons include time constraints, cost, perceived lack of benefits from further education, unfamiliarity with education within university settings (Halcomb et al., 2009), a perception of being regarded as less important than their colleagues in acute care settings, limited recognition for the practice role, absence of relief staff, or geographical distance (Parker et al., 2011). In a more recent study involving 568 Australian nurses from both acute care and PHC settings, Ng et al. (2016) again confirmed the inhibiting impact of financial constraints and further identified challenges in balancing study, work and personal life. These authors also identified that employer support, professional requirement and recognition are strongly associated with nurse motivation to pursue postgraduate education (Ng et al., 2016). These findings, therefore, warrant future research exploring the availability and, importantly, sustainability of organisational support for PHC nurses/midwives to undertake postgraduate education.

Previous research also found potential expansion of scope of practice, increase in job satisfaction and practice autonomy as both facilitators and desired outcomes of postgraduate education (Hallinan & Hegarty, 2016). The impacts of postgraduate qualifications have further been reported to boost nurses' perceived improvement in management and leadership skills (Drennan, 2012), confidence and competence (Baxter & Edvardsson, 2018) as well as knowledge and skills in clinical practice (Abu‐Qamar et al., 2020; Hallinan & Hegarty, 2016). We, therefore, recommend PHC organisations to clearly articulate education and career pathways to ensure a quality PHC workforce after completing postgraduate education. Such quality workforce is in high demand, especially in the context of the aging population and rising burden of chronic conditions in Australia where preventative care and management of complex/chronic health conditions will continue to be recognised as a national health priority (Australian Institute of Health and Welfare, 2020; Department of Health, 2018a).

In addition to previous PHC profiling papers, this study further showed a widening distribution of participants with 25 other surveyed workplace settings other than general practice. Although the participants working in each of these 25 PHC settings other than general practice represented less than 10% of all participants, it is necessary to understand and acknowledge the contribution of PHC nurses/midwives in settings that are not well recognised, yet integral to the delivery of quality care in the Australia's health care system. This includes schools/pre‐schools, workplace health centres, refugee health centres, Aboriginal medical services and telehealth/call centres. Their participation may indicate the expanding scope of APNA as a national association in PHC for nurses and midwives, as well as the evolvement of the workforce survey to increase relevance and responses from the wider PHC nursing workforce. Given the fact that ‘PHC workforce planning has tended to focus on general practice’ (Murray‐Parahi et al., 2020, p. 272), there is a clear need for a well‐designed workforce survey to improve the visibility of not only general practice nurses/midwives but also those working in non‐general practice settings to ensure they are included in future PHC policy making and planning.

5.2. Factors influencing decision to pursue a career in primary health care

The factors influencing participants' decision to work in PHC during 2015–2019 were similar to those that have been linked to job satisfaction/dissatisfaction among PHC nursing workforce in previous studies (Ashley et al., 2017; Ashley, Peters, et al., 2018; Halcomb & Ashley, 2017). For example, in this study factors considered most important to work in PHC (work‐life balance reasons, suitability to lifestyle and improvement in job satisfaction) resonated with factors that were identified as related to work satisfaction, future career intention and planning (Ashley, Peters, et al., 2018). On the other hand, one of the factors considered least important to the participants' decision to pursue a PHC career was salary and benefits, which is related to the least satisfying aspect of nursing work in PHC as reported by Halcomb and Ashley et al. (2017). Although low wage was identified as an offset for some other aspects of employment conditions (i.e. more convenient working hours), it was considered one of the factors contributing to perceived lack of recognition for the effort and further education/training that PHC nurses committed to upskill themselves (Halcomb & Ashley, 2017). Recruitment and retention strategies will need to consider improving PHC nurse/midwife wages to reflect recognition of their broad skillsets and contribution to the workforce and population health outcomes.

Our study has built on previous studies to further identify to whom (i.e. nurses/midwives from different age groups or registration statuses) and what factors (i.e. professional or personal factor) were considered most important when considering PHC employment. These novel findings will be essential in designing future education, training, recruitment and retention strategies to target certain demographic groups as part of long‐term PHC workforce planning. For example, we found that nurse practitioners highly valued professional autonomy and opportunities for career advancement as reasons why they chose to work in PHC (see Figure 2). Note that the number of participants identified as nurse practitioners is rather limited (n = 118) in our relatively large dataset (N = 7066). Due to their impactful contribution to patient outcomes, our findings indeed indicate an urgent need to entice nurse practitioners to the PHC workforce based on factors that are deemed crucial to them. Given that current legislative barriers impact on nurse practitioner autonomy and scope of practice (Australian Nursing and Midwifery Federation, 2020; Medicare Benefits Schedule Review Taskforce, 2020), there is an opportunity to reform national policies to encourage new and retain existing nurse practitioners in the workforce. More specifically, the Nurse Practitioner Reference Group released 14 recommendations to improve all Australians' access to high‐quality care by nurse practitioners (Medicare Benefits Schedule Review Taskforce, 2020). These recommendations focus on four main aspects: (1) supporting coordinated care for people with chronic conditions and/or for Aboriginal/Torres Strait Islander peoples; (2) enabling patient access to rebated nurse practitioner care through Medicare Benefit Schedule; (3) addressing legislative inefficiencies related to Medicare Benefit Schedule and (4) improving patient access to telehealth services by nurse practitioners (Medicare Benefits Schedule Review Taskforce, 2020). These recommendations reflect the profound impact of national funding models on nurse practitioner scope of practice, continuity of care as well as ability to work autonomously as well as collaboratively with other health care professionals in Australia. These issues are not confined to the Australian context but also reported in other countries such as Canada (Marceau et al., 2021) and the United States (Kleinpell et al., 2022; Schirle et al., 2020). Because funding models and reimbursement schemes can subsequently influence the sustainability of nurse practitioners' practice (Marceau et al., 2021), implementation of the Nurse Practitioner Reference Group's recommendations would further support the nurse practitioner workforce to work autonomously and to their full scope of practice, which in turns, contribute more effectively and economically to Australians' health outcomes (Australian College of Nurse Practitioners, 2019). In contexts outside of Australia, we also recommend the review of funding models to understand and perhaps, to design targeted strategies to allow greater contribution of highly skilled nurse practitioner workforce to populations' health.

Our findings further suggest that it is essential to provide nurses/midwives less than 34 years old with practical opportunities to advance their nursing/midwifery career while allowing those above 35 years old to access flexible work arrangements to suit their personal lifestyle and family commitments (see Figure 1). These findings may be also relevant to settings other than Australia and countries that are experiencing the need to improve recruitment and retention of nurses/midwives in particular age groups.

On the other hand, we also found that professional factors including (1) pursuing interest in PHC, (2) opportunity to advance participants' nursing/midwifery career and (3) autonomous aspects of PHC work were not considered as important as personal factors (see Figures 1 and 2). While we recommend providing nurses/midwives with the benefits they desire to support personal lifestyles and family commitments to enhance recruitment and retention in the PHC workforce, we also recommend PHC stakeholders promote the importance of PHC through education and public communication in order to promote new nurses'/midwives' interest to work in PHC settings. Our recommendations are in the context of (1) prolonged dominance of acute nursing content in Australian nursing curricula over decades (Keleher et al., 2010; Murray‐Parahi et al., 2020), (2) exisiting students' misconception about the complexity and autonomy required for nursing roles in PHC (Byfield et al., 2019; Calma et al., 2019) and (3) students' undesirable views about a future career choice in PHC (Byfield et al., 2019; Murray‐Parahi et al., 2020). It is pivotal that education providers address necessary changes to ‘[reorientate] nursing education to increase the emphasis on primary health care’ by increasing content in chronic disease prevention and management and further clinical placements especially in rural/remote settings (Schwartz, 2019, p. 56). Major PHC organisations also need to be more actively promoting PHC among early career nurses/midwives in order to prepare a skilled and sustainable nursing/midwifery PHC workforce to take care of the aging population burdened by chronic diseases.

5.3. Strengths and limitations

This study expands previous research that describe nursing/midwifery workforce in PHC settings using much smaller and/or limited datasets. In this study, the longitudinal design captured the demographic and professional characteristics of a large number of participants (N = 7066) working in PHC nursing/midwifery workforce over a consecutive 5‐year period. We also found novel findings built on published research by reporting the link between participants' age group as well as qualifications and factors contributing to their decision to work in PHC. The findings from the longitudinal data will add value in policy making; and education, training and practice planning that is more targeted to meet the PHC needs of Australian communities.

There are also several limitations inherent in this study. First, the retrospective design limited options to explore the data in greater depth and detail. Second, the data were collected using a relatively long self‐administered survey which might result in participants' survey fatigue and thus, lead to suboptimal quality of responses. Third, the surveys were distributed using only web‐based methods. Although a number of strategies were in place to maximise the reach of the national surveys and to increase response rate, there was a potential coverage bias and therefore this sample might not be representative of the wider nursing/midwifery PHC workforce in Australia.

6. CONCLUSION

Our study adds value to the literature by describing a snapshot of the Australian workforce characteristics over five consecutive years with both findings supported by previous research and novel findings. From these findings, implications for policy, practice, education and research are also identified. In terms of practice, it is necessary to tailor recruitment and retention strategies to nurses/midwives' age groups and qualifications to attract and retain highly skilled and qualified PHC workforce. We recommend implementing strategies that enable nurses to work autonomously within their full scope of practice for nurse practitioners; opportunities to advance nursing/midwifery career for nurses/midwives with a nursing practitioners or less than 35 years of age; and access to family‐friendly working arrangements for those above 35 years of age. In terms of education and training, nursing and midwifery education accreditation bodies, educational providers and PHC organisations need to further emphasise PHC nursing in both theoretical and clinical components of pre‐registration nursing programs to better prepare and entice students into PHC jobs, as well as to better promote student awareness of the importance of PHC and highlight it as a potential for future career in a variety of PHC settings. In terms of research, we recommend the use of well‐designed longitudinal workforce survey to capture high‐quality data in a variety of PHC localities and workplace settings in order to increase nurses/midwives' visibility in national workforce policy planning. We also recommend explorations into the nature of PHC nursing/midwifery work in a variety of PHC settings and the longitudinal changes (or otherwise) in the scope of practice of PHC nurses/midwives as it evolves. Such high‐quality research will help inform further recommendations for policy, education and practice in PHC nursing/midwifery.

AUTHOR CONTRIBUTIONS

All authors have met the authorship criteria of the International Committee of Medical Journal Editors (ICMJE). VNBN, GB and JM substantially contributed to the conception of the study. SG retrieved the data. VNBN conducted data analysis. All authors contributed to the interpretation of findings. VNBN drafted the manuscript. All authors revised it critically and have approved the final version of the manuscript. The whole team agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

CONFLICT OF INTEREST STATEMENT

There is no financial conflict of interest to declare. However, four authors of the team (SG, SM, LC and KG) were/are employees of the Australian Primary Health Care Nurses Association (APNA) whose data were used in this study. The data ownership does not affect the interpretation and dissemination of findings.

Nguyen, V. N. B. , Brand, G. , Gardiner, S. , Moses, S. , Collison, L. , Griffin, K. , & Morphet, J. (2023). A snapshot of Australian primary health care nursing workforce characteristics and reasons they work in these settings: A longitudinal retrospective study. Nursing Open, 10, 5462–5475. 10.1002/nop2.1785

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from Australian Primary Health Care Nurses Association. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the authors with the permission of Australian Primary Health Care Nurses Association.