A number of studies have been conducted on generational differences among nurses. This is driven by the current nursing shortage, with the number of ‘Baby Boomers’ retiring being greater than replacements from upcoming cohorts.1 Attracting and retaining young adults into nursing is an issue confronting many healthcare services including general practice.2 Understanding generational differences may provide insight into retention strategies, particularly focusing on issues employers could address to combat nurse shortages.3,4 This is especially relevant given that modelling suggests that there will be a shortage of approximately 21,765 primary care nurses in Australia by 2035,1 with an assumption that two-thirds of these will be required for general practice.5 Retaining the expertise of general practice nurses (GPNs) is essential given the current shortage of general medical practitioners, reform efforts by government, challenges to current funding models and the move to enhance interdisciplinary care.6,7
Widger et al8 classify generations as follows: Veterans (born between 1925 and 1945), Baby Boomers (born between 1946 and 1964), Generation (Gen) X (born between 1965 and 1979), Gen Y (also known as Millennials; born between 1980 and 2000) and Gen Z (born between 2000 and 2020), noting some differences in values across the five groups. For example, in the acute sector, Tan and Chin9 found that Baby Boomers were more compliant than Gen X, Y and Z; less technologically savvy; more likely to value discipline and hard work over work–life balance; and satisfied with managerial aspects of their work; this last factor is possibly a reflection of their age, clinical expertise and confidence.
Conversely, Gen X were more comfortable with technology, creative and self-directed than Baby Boomers, and they were seen to value workplaces where their skills are recognised.8 They value education, are slow to commit to managers and are open to change.9 Research suggests that they are more prone to burnout in the workplace than Baby Boomers10 but hold similar values regarding job security and opportunities for promotion.
Gen Y are usually highly skilled with technology, value collaboration and being mentored and seek a work–life balance,3,4,8–10 but they are less committed to the workplace10 and have higher levels of stress and burnout than Boomers or Gen X.11 Gen Z are the most technologically savvy, the least compliant to directives and more likely to value work–life balance when compared with Baby Boomers or Gen X.4,9 They are seen to be less ‘team players’ than the other three generations, but they are reported to work well with Baby Boomers and Gen X.4 This paper reports on generational differences in satisfaction, intention to stay and the intention to pursue further education of GPNs, comparing Veterans/Baby Boomers (Boomers+), Gen X and Gen Y/Z. In light of nurse shortages and the recent Federal Government focus on primary care, understanding GPN intentions, particularly those of younger nurses, is useful for policy planning.
Methods
Data were obtained from the 2023 Australian Primary Health Care Nurses Association (APNA) Workforce Survey. This is the largest and only annual survey of primary health care (PHC) nurses and midwives working in Australian community settings. The purpose of the survey is to describe and understand the PHC nursing and midwifery workforce; their pay and conditions; the services they provide; their commitment to, and satisfaction with, their work; and workforce participation decisions. This self-report survey was conducted during the final quarter of 2023 on the AlchemerTM online survey platform. Recruitment was undertaken from the APNA membership and contact databases, and through organisational channels, professional networks and social media. Although it is known that there are approximately 14,000 GPNs, the response denominator was not calculated, given not all nurses are members of APNA. Eligibility was determined on the basis of self-reported identification as ‘a nurse and/or midwife currently employed in primary health care’. Participation in the survey was voluntary. Ten fortnightly cash rewards of $100 and 2 × $1000 Red Balloon gift vouchers were offered to encourage full completion of the survey. Consistent with all ethical research, participants could withdraw from the survey at any time.
Ethical clearance was granted by Monash University Human Research Ethics Committee through the Nursing and Midwifery School (#39381) and Adelaide University for data specific to GPNs (H-2023-129). The authors entered into a research agreement with APNA to access the data provided by GPNs. Data analysis was performed using IBM SPSS Statistics 29.0.1.0 software. Pearson’s Chi-squared tests were performed to test the relationship between each pair of variables. Significance, effect sizes and confidence intervals (CIs) were also determined.
All variables but one (‘Wish to change hours’) were re-coded to enhance clarity. As a first step, the continuous variable of Age was re-coded to reflect three chosen generational groups. As a result of low numbers, the youngest and oldest nurses from the five generations were collapsed into their closest category to enable more effective analyses, namely ≥60 years (Veterans/Baby Boomers), 44–59 years (Gen X) and 20–43 years (Gen Y and Z).
The ‘Total satisfaction’ variable was calculated by averaging each respondent’s answer over nine questions. The 7-point Likert scale was collapsed into a ‘Dissatisfied/Neutral’ category (containing ‘Very dissatisfied’, ‘Moderately dissatisfied’, ‘Somewhat dissatisfied’ and ‘Neither satisfied nor dissatisfied’) and a ‘Satisfied’ category (containing ‘Somewhat satisfied’, ‘Moderately satisfied’ and ‘Very satisfied’). In the same way, the variable ‘Satisfaction with number of hours’ worked was collapsed from seven categories to two.
‘Employment status’ was separated into ‘Permanent’, ‘Fixed term’, ‘Full time, ‘Part time’ and ‘Casual’, with self-employed not recorded here given the low numbers. It was decided that the number of hours worked and control over choosing those hours were major reasons influencing intention to stay, given the interest in work–life balance of younger generations. These were recorded as Dissatisfied/Satisfied/Neutral and Yes/No.
‘Level of education’ was initially separated into seven categories; however, it was deemed more logical to re-code into three categories: ‘Diploma/Undergraduate certificate’, ‘Graduate’ and all who have undertaken ‘Postgraduate’ education. In examining intention to undertake further education, the initial three time frames were re-coded to those who did intend to study (‘Yes’) and those who did not (‘No’).
Information on intention to stay in nursing and their current employment sector, for both the 12-month variable and the 2–5-year variable, was recorded on a 5-point Likert scale as ‘Very unlikely’, ‘Unlikely’, ‘Unsure’, ‘Likely’ and ‘Very likely’. These were collapsed into two categories of ‘Not likely’ and ‘Likely’.
Results
Of the total (2530) survey respondents, 56% were GPNs. They held registration status as enrolled nurses (182), nurse practitioners (32), midwives (10), registered nurses (1166) and registered nurses/midwifes (41). Table 1 provides a demographic overview, with some minor discrepancies in numbers due to missing values. A summary of the percentages for all variables across generations is presented in Table 2.
|
Table 1. Demographic overview of general practice nurse respondents |
| Variable |
Boomers+ (aged ≥60 years) |
Gen X (aged 59–44 years) |
Gen Y/Z (aged 43–20 years) |
| Female |
Count |
341 |
614 |
432 |
| |
Percentage |
24.60% |
44.30% |
31.10% |
| Male |
Count |
6 |
9 |
22 |
| |
Percentage |
16.20% |
24.30% |
59.50% |
| Non-binary/gender diverse |
Count |
0 |
0 |
1 |
| |
Percentage |
0% |
0% |
100% |
| Total |
Count |
347 |
623 |
455 |
| |
Percentage |
24.40% |
43.70% |
100% |
| Table 2. Percentages obtained in each generation for all variables |
| Variable |
Category |
Boomers+ (aged ≥60 years) |
Gen X (aged 59–44 years) |
Gen Y/Z (aged 43–20 years) |
| Satisfaction |
Dissatisfied/Neutral |
30.0% |
33.5% |
34.7% |
| |
Satisfied |
70.0% |
66.5% |
65.3% |
| Employment status |
Full time |
17.6% |
27.6% |
31.5% |
| |
Part time |
55.1% |
56.2% |
51.8% |
| |
Casual |
27.3% |
16.2% |
16.7% |
| Hours worked |
Dissatisfied/Neutral |
18.6% |
13.2% |
15.3% |
| |
Satisfied |
81.4% |
86.8% |
84.7% |
| Wish to change hours worked |
Yes, decrease |
27.0% |
26.8% |
17.1% |
| |
No |
59.5% |
57.4% |
60.0% |
| |
Yes, increase |
13.5% |
15.8% |
22.8% |
| Education |
Diploma/Undergraduate certificate |
45.3% |
26.2% |
18.9% |
| |
Graduate |
13.7% |
30.8% |
47.1% |
| |
Postgraduate |
41.0% |
43.0% |
33.9% |
| Likely to stay: 12 months |
Not likely |
25.0% |
15.8% |
18.2% |
| |
Likely |
75.0% |
84.2% |
81.8% |
| Likely to stay: 2–5 years |
Not likely |
53.0% |
30.2% |
34.6% |
| |
Likely |
47.0% |
69.8% |
65.4% |
| Intention to study |
Yes |
15.9% |
42.9% |
81.1% |
| |
No |
84.1% |
57.1% |
18.9% |
Generation and satisfaction
GPNs were asked about satisfaction with their work and their employment contract, with the assumption being that these factors would affect intention to stay and to pursue further education. Results of these two issues suggest that satisfaction increases with age, although this was not statistically significant (Pearson’s Chi-squared = 1.950, P = 0.337).
Employment status
Results showed that most Boomers+ (52%), Gen X (56%) and Gen Y/Z (55%) GPNs worked in a part-time capacity. Gen Y/Z had the highest percentage of full-time nurses, whereas Boomers+ had the highest percentage of casual workers. However, Gen Y/Zs and Gen Xs were more likely to work full time (Pearson’s Chi-squared = 31.766, P <0.001), with a small standardised effect size; Cramer’s V = 0.150 (CI = 0.079–0.209).
Wish to change hours of work and current education
The majority in each generation were happy with the contracted hours they were working; however, over a quarter of Gen X and Boomers+ noted that they would prefer to reduce their hours. Gen Y/Z (22%) indicated they would like to increase their hours (Pearson’s Chi-squared = 21.897, P <0.001), with a small-to-medium standardised effect size; Cramer’s V = 0.092 (CI = 0.061–0.134).
In relation to education, the Boomers+ group had the lowest percentage of those who had university qualifications, reflecting the possibility of being hospital trained with a diploma qualification. However, it is notable that 55 Boomers+ (15.9%) had undertaken postgraduate studies (Pearson’s Chi-squared = 124.781, P <0.001), with a small-to-medium standardised effect size; Cramer’s V = 0.210 (CI = 0.179–0.244). Gen Y/Z, the youngest generation, were the most highly qualified, with a combined total of graduate and postgraduate qualifications reaching 81%, with Gen X at 73.8%.
Intentions to stay
Given the overall findings on satisfaction, hours of work and education, we examined intention to stay within the next 12 months and within the next 2–5 years. There was a greater proportion of GPNs in Gen X who indicated they were likely to stay than in Gen Y/Z or Boomers+. The Boomers+ group was over-represented in the ‘unlikely to stay’ category (Pearson’s Chi-squared = 11.343, P = 0.003), with a small standardised effect size; Cramer’s V = 0.094 (CI = 0.043–0.158). When the time frame under consideration increased from 12 months to 2–5 years, there was a reduction in every generation of those who believed they would still be working as a GPN (Pearson’s Chi-squared = 47.012, P <0.001), with a small-to-medium standardised effect size; Cramer’s V = 0.191 (CI = 0.141–0.246). Over half of the Boomers+ believed they would no longer be working in the sector in five years.
Intention to pursue further study
We examined intention to undertake further study and found that the relationship between generation and intention to undertake future study was statistically significant. Boomers+ had already indicated that they were much less likely to be working in the industry in the next five years. Commensurate differences were found in the other generations according to the likelihood that they will remain in the industry. For example, a much greater proportion of Gen Y/Z had an intention to pursue further study when compared with the other generations (Pearson Chi-squared = 347.550, P <0.001), with a very large standardised effect size; Cramer’s V = 0.495 (CI = 0.455–0.536).
Discussion
As Halcomb et al12 note, understanding workforce issues for GPNs is important for employers, managers and policymakers. Further to this, they argue that nurse satisfaction and intention to stay depends on the clinical context, and one of the keys to this is work–life balance and security of tenure.12 Several relevant findings separate out Gen Y and Gen Z. Although overall 65.3% are satisfied with their work, with 31.5% working full time, 22.8% would like to increase their hours, with 81.1% intending to take up additional study. In response to questions about future intentions, 81.8% of Gen Y/Z expect to remain in the sector over the next 12 months, but this reduces to 65.4% when asked the same question projecting 5 years ahead. Although a high percentage of Gen Y/Z would like more hours of work, approximately 85% are satisfied with their overall hours of work.
These findings provide useful background data to recent funding and workforce policy discussions within general practice.13 These are the Scope of Practice Review,14 the Review of General Practice Incentives6,15 and the Working Better for Medicare Report.7 Although these reviews are still at the stage of inviting comment, and the evidence for alternative funding models is mixed,6,16 they are all consistent in calling for increased interdisciplinary care, a widening of the scope of practice of nurses and shifts in payment mechanisms to include Medicare reimbursements that are more flexible in who is funded and how the funds are distributed. One way forward for general practice would be to extend the current Workforce Incentive Program linking funding to further education in identified primary care and health promotion activities, with the aim of extending the scope of practice of GPNs.17 This may require further education, either formal or non-formal. Mechanisms for further non-formal education to enhance interdisciplinary care and professional recognition for GPNs are already available through APNA.18 However, opportunities to take up education programs such as that offered by APNA would benefit from increased scholarship funding given that GPN salaries are lower than those of nurses working in the acute sector.13 What the survey does show is that Gen Y/Z GPNs are prepared to do further study, either non-formal or tertiary.
The APNA survey data have established a high degree of satisfaction with hours of work, and aspirations for further education and training for younger GPNs, suggesting that the time is ripe for GPs to take the leadership in shaping the interdisciplinary team through partnership with GPNs, supporting policy that increases funding for their employment and further education.
Limitations
This is a secondary data source from the APNA 2023 Workforce Survey. The sample size was small, with the estimated number of nurses working in general practice being skewed towards Baby Boomers+. In reality, over 52% of GPNs are from Gen Y/Z.13 Given our focus on generational differences, we have not provided any comment on similar Australian surveys of GPNs, nor commented on the number of respondents given the absence of a register for nurses working in general practice. However, our findings regarding the strong association between job satisfaction and turnover intention mirror patterns observed in research by Halcomb et al.12
Conclusion
This study highlights some of the key work experiences and aspirations of the GPN workforce in Australia that may affect recruitment and retention into the future. Understanding the experiences and aspirations of the younger members of this workforce may further enrich general practice and the longer-term retention of nurses within this setting, leading to improved satisfaction for GPNs, GPs and their patients.