The cancer nursing workforce in Australia: a national survey exploring determinants of job satisfaction

This was a cross-sectional, national survey conducted by the Cancer Nurses Society of Australia (CNSA) and compared with national nurse registration data. The CNSA, founded in 1998, is the peak professional body for cancer nursing in Australia, representing more than 1500 cancer nurses across the country. The CNSA’s mission is to promote excellence in cancer care [21].

The survey was distributed in October 2021 via email to members of the CNSA, promoted in the CNSA newsletter, as well as through other professional networks and on social media platforms such as Facebook™ and Twitter™. The survey remained open until February 2022. In addition, nurse registration data for the year 2021 was obtained from the Australian Health Workforce data [22].

A 68-item survey was developed by the CNSA's Research Standing Committee for this study and was informed by relevant literature, incorporating questions from other published nursing workforce evaluations [23, 24], items from the Nursing Work Index-Revised [25], and in consultation with key stakeholders. The survey is available in the Supplementary file. Domains of job satisfaction included satisfaction with the work and workplace, peers, pay, opportunities for career progression and supervision as well as an overarching question where respondents were asked to rate their job satisfaction on a continuous scale from 0–100 with higher values indicating higher satisfaction. To explore variables at the individual level, the survey included demographic questions such as age, gender, postcode, years of nursing and cancer nursing experience, qualifications, involvement in professional organizations and intention to stay in the nursing workforce. For variables at the organisational level, respondents were asked to provide information on their nursing role, type of facility, full-time equivalent worked, permanency of their position, cancer specialty area, and their usual work activities. Statements about work environments from the Nurse Work Index Revised [25] at the organisational and systems level including rates of pay, satisfaction with pay, and scope of practice and were measured for level of agreement on a five-point Likert scale. There were also free-text options for participants to provide further information about workforce issues and suggestions for initiatives to support the cancer nursing workforce (to be reported elsewhere).

Face validity was determined through pilot testing among a sample of nine cancer nurses who represented a diverse range of nurses working in different settings. Wording was modified based on the feedback received to improve flow. The survey was electronically distributed and managed using the REDCap [26] platform, and included branching logic to reduce survey fatigue. Participants were provided with a participant information sheet and completion of the survey implied consent. The responses did not ask for personal identifiers (names, birthdates) or the names of workplace and were anonymous.

For comparison and to understand the representativeness of the survey data, Health Workforce data from the Australian Department of Health [22] was obtained. These data were collected in 2021 as part of professional registration and provided comparative demographic data for all nurses in Australia as well as one question regarding intention to stay in the workforce- we also included this question in our CNSA survey adding the term cancer ‘how long do you intend to stay in the [cancer] nursing workforce?’.

The study was ethically approved by Monash University Human Research Ethics Committee and the Queensland University of Technology Research Governance and Integrity (Project ID: 30,474, Project ID 6544).

Demographic data were compared between the 2021 Health Workforce survey and the CNSA survey respondents to determine the representativeness of our findings and to describe the national characteristics of the cancer nursing workforce. Data were exported to Excel and analysed using statistical software (Stata IC/16.0) to provide descriptive statistics such as proportions, medians and interquartile ranges that describe the profile of cancer nurses in Australia. We grouped free text responses for nursing roles into categories for analysis based upon classifications in the Australian Nurses Award 2020 with an additional category for Advanced Practice Nurses. Nurses who responded they held a specialist cancer nursing role were grouped into this category. Data were coded by one author and checked by a second. Proportions for individual questions were calculated from the number of respondents for each question. Chi Square test were used to explore differences in the CNSA sample and AHPRA 2021 data. Given job satisfaction scores were not normally distributed, non-parametric Kruskal–Wallis rank test or Mann–Whitney U rank-sum test were used to explore differences in job satisfaction score across categorical variables for individual (e.g. age, years of experience, qualifications), organisational (e.g. Cancer speciality activities involved in), and systems level variables (rates of pay, resources to provide care). A stepwise model building approach was used to develop a final parsimonious linear regression model that best predicted job satisfaction score [27]. Predictor variable were dichotomized where possible. Firstly, bivariate regression models were run to identify significant (P < = 0.05) or near-significant (P< 0.20) associations between each predictor and job satisfaction. Significant predictors were then added to the linear regression model one at a time to establish the effect of each variable on job satisfaction and the other predictors. Non-significant predictor variables from bivariate modelling were then re-added to test their effect on the overall model. The final parsimonious linear regression model was identified with the inclusion of predictor variables that explained the most variation in job satisfaction score [27].

Responses were received from 930 cancer nurses, with 858 providing demographic data. Of these, 507 (77%) were members of the CNSA (Table 1). Given the CNSA membership was approximately 1500 at the time of the survey, and 7202 nurses indicated they were cancer nurses in the AHPRA 2021 Workforce survey, our response rate was approximately 34% of CNSA members and 13% for all cancer nurses.

Demographic details from the CNSA sample were compared with the AHPRA 2021 data. The CNSA sample was significantly older, with fewer nurses represented in the 20–34-year age group (19% vs 37%, p = < 0.001). Additionally, the CNSA sample had a higher representation of nurses from less-populated states and regional areas compared to the AHPRA data, and a higher proportion of nurses working in non-clinical areas, such as administration, teaching, or research. Furthermore, the CNSA sample was found to be more likely to leave the workforce within the next five years (29% vs 19%, P = < 0.001) which may be attributed to CNSA members being a comparatively older cohort of nurses.

Most respondents (85%) described themselves as experienced nurses, who predominantly provided clinical cancer nursing care to patients; 35% had 10–19 years of experience and a further 30% had over 20 years of experience working in cancer care. More than 55% had postgraduate qualifications, with 62% having a cancer-related qualification, most commonly a graduate certificate or diploma. Another 27% reported they planned to obtain cancer-related qualification. A wide variety of roles were reported across clinical care, education, administration, and research (Table 2). Significant differences were found when data were stratified by state of residence; nurses in Tasmania were more likely to reside in regional locations, and to have recently (≤ 3 years) graduated. Nurses from Victoria and New South Wales, the most populous states of Australia, were more likely to have cancer-related post-graduate qualifications.

Respondents were asked to self-describe the title of role in cancer nursing returning 89 unique role titles across specialist nurse roles. Some role titles are explained by different disease types, however many, particularly for Advanced Practice Nurses, are ambiguous and widely varied across institutions and geographical locations. The terms ‘Cancer’ and ‘Clinical’ are often used interchangeably, for example, ‘Cancer Nurse Specialist’ and ‘Clinical Nurse Specialist’; ‘Cancer Nurse Consultant’ and ‘Clinical Nurse Consultant’. The impact of non-standardized nomenclature on the clarity and understanding of both patients and other health professionals is unknown. Respondents reported working across different types of cancer facilities, including specialist cancer centres that provide multidisciplinary services through to primary care settings including general practice and community-based services.

Most respondents reported working across multiple disease types and specialties, including rare cancers as well as pediatric, adolescent, and young adult cancer. A variety of activities were reported by most nurses such as delivery of patient education (77%), outpatient care (66%), staff education (59%), treatment and supportive care (55%). There were fewer nurses involved in management (24%), research (22%), radiotherapy (19%), surgical care (12%) and home care (5%) (Table 3).

Managing a high workload was the most frequently reported challenge (88% of respondents) with information overload (53%), insufficient resources (41%) and lack of leadership (39%) contributing to workplace challenges (Table 4). Nurses reported variance in opportunities for career progression, professional development, full use of the extent of their knowledge, and having a clearly defined role and peer support, further contributed to challenges. Selected variables were included in bivariate and multivariate analysis to predict job satisfaction as reported below.

The median score reported for job satisfaction was 75/100 (IQR 65, 88). Those who reported job satisfaction ≤ 50/100 were more likely (P = 0.011) to report intention to stay less than five years. Age was significantly correlated with both job satisfaction (P = 0.003) and intention to stay in cancer nursing (< 0.001), respondent in the older age categories reported higher job satisfaction compared to younger age groups but also had the highest intention to stay less than 5 years. Those in the youngest age category (20–34 years) reported the lowest job satisfaction and while 38% indicated they intended to stay in the workforce more than 20 years, 26% signalled their intention to stay less than 5 years (Table 5).

Table 6 further explores differences in average job satisfaction scores across characteristics of the sample. There were minimal differences in satisfaction across the states and territories of Australia (data not shown). The highest rates of job satisfaction were reported by those working in Primary Care (med 85 (IQR 71–90) and the lowest for those in a cancer unit (med 73 (IQR 60.5–85)) (P = 0.004). Those in Registered Nurse and Researcher/Academic positions had the lowest and highest median job satisfactions scores, respectively (med 73 (IQR 59–85); med 83 (IQR 75–86)) (P = 0.082). Nurses with more than 20 years of nursing experience (med 78 (IQR 65–90)) and 5 years or less (med 80 (IQR 68–88)), reported the highest levels of job satisfaction (P = 0.002), as did those aged 55 years and older (55–64 years: med 80 (IQR 70–90); 65 + : med 82 (IQR 73–95)) (P = 0.003). Those who intended to stay in the nursing workforce 5 years or less had the lowest median levels of job satisfaction (med 72 (IQR 50–83); P = 0.001). Job satisfaction scores increased the more nurses agreed they had professional development opportunities (P = 0.001), career development opportunities (P = 0.001), adequate peer support (P = 0.001) and a clearly defined scope of role (P = 0.001). Conversely, job satisfaction scores decreased the more people agreed there was a lack of leadership (P = 0.001) and they had insufficient resources to provide quality care (P = 0.001).

Table 7 presents the parsimonious linear regression model for predictors of job satisfaction score, adjusting for age and CNSA membership, given the sample characteristics are significantly different to the AHPRA data. Positive Beta (ß) values imply a positive association between variables. Significantly higher scores on job satisfaction were determined by those who “agreed/strongly agreed” they had career progression opportunities (ß 5.64 [2.56–8.73]; P < 0.001) and adequate peer support (ß 6.53 [3.29–9.77]; P < 0.001), compared to responses in all other categories (“strongly disagree/disagree/neutral”). Conversely, those who “agreed/strongly agreed” they had insufficient resources to provide quality care and lack of leadership had significantly lower scores on job satisfaction, compared to all other categories (ß -4.99 [-7.86- -2.11]; P = 0.001 & ß -6.11 [-9.12- -3.11]; P < 0.001). Intention to stay in nursing for longer than 5 years (compared to less than 5 years), satisfaction with pay (compared to not satisfied) and using knowledge and skills often or most of the time (compared to none of the time) were also significant predictors of higher job satisfaction score.

As a cross-sectional study, our research has certain limitations that must be acknowledged including selection bias. Our response rate is estimated at 34% of CNSA members and 13% of all cancer nurses affecting generalisability. Indeed, we identified respondents to the CNSA survey differed in characteristics from the data available from AHPRA regarding cancer nurse demographics. Overall, these findings suggest that the CNSA sample may be an older, more experienced segment of the cancer nursing workforce and may have different characteristics and experiences compared to the broader population of cancer nurses in Australia. We did however control for CNSA membership and age in our analyses of job satisfaction to mitigate this limitation.

We were not able to detect temporal changes over time. This further highlights the importance of understanding and documenting the issues identified in this study for future reference. Our findings may not be representative of cancer nurses from other nations, with different health service funding models, cultures, and opportunities for professional development.

Strengths of this study include our comparison with national registration data, allowing readers to determine generalisability to their specific setting. Additionally, we had a relatively large sample size of respondents which increases the confidence in our findings.

Workforce issues are highlighted as priorities for cancer nursing research [40, 41], and this study contributes to the scant evidence base, raising awareness of the factors that contribute to job satisfaction, which may positively influence retention in the workforce. Findings may be used at the individual, service, and systems level to advocate for greater recognition of the contribution of cancer nurses in health policy.

We have highlighted workplace factors that contribute to lower job satisfaction; understanding these can be used to develop strategies, and to identify opportunities for growth and sustainability in the workforce. Further research is required to describe and evaluate the changing scope of nursing practice and roles and effects on patient outcomes [42]. It is also critical to explore strategies to retain the wealth of knowledge in the ageing workforce who have signalled their intention to leave. The next 10 years provide a window of opportunity to harness knowledge and experience and to embed sustainable ways to share this with new generations and future leaders in cancer nursing [29].