Describing the factors related to rural podiatry work and retention in the podiatry workforce: a national survey

This was a cross sectional study of Australian podiatrists using data collected through an online survey from 2017 to 2020. The CHERRIES (Checklist for Reporting Results of Internet E-Surveys) guided the reporting of collected data [18]. The Monash University Human Research Ethics Committee approved this research (19959).

Podiatrists and podiatric surgeons working in Victoria were invited to participate in Waves 1 and 2 (2017–2018) of the survey. The survey was open to all podiatrists and podiatric surgeons in Australia for Waves 3 and 4 (2019–2020). There were an estimated 5429 podiatrists and 36 podiatric surgeons registered in Australia when the final wave closed [19]. There were no restrictions on practice setting.

Data were collected as part of the Podiatrists in Australia: Investigating Graduate Employment (PAIGE) study, and the methodology is published [20]. PAIGE survey questions were based on a longstanding longitudinal medical workforce survey in Australia, the Medicine in Australia: Balancing Employment and Life (MABEL) study [21], tailored to exploring different elements of the podiatry workforce with a core bank of questions each wave and question bank elements added at each wave (Table 1). Data were collected relating to demographics (all waves), measurement of constructs impacting on labour decisions such as job satisfaction (all waves), earnings (Wave 1), impact on family (Wave 1), workplace setting (all waves), and mental health (Waves 2, 3 and 4). All four surveys are provided as Supplementary Files 1, 2, 3 and 4.

Demographic data collected from participants included information about their gender, age, pre-registration education, postcode, current work setting and employee/employer status, number of working locations, time spent working at a location, exposure to regional/rurality placement during education, leave availability and professional development availability.

All waves of the PAIGE study included the 10-item revised job satisfaction scale [22]. Participants were asked to indicate satisfaction relating to different aspects of work. The original 7-point Likert scale used within the MABEL study was reduced to 5-point item scale (1 = very dissatisfied, 2 = moderately dissatisfied, 3 = neutral, 4 = moderately satisfied, 5 = very satisfied) [23]. A not applicable response option was also provided for each item. This adaption was on suggestion from members of the MABEL team who provided advice during survey build [24].

Waves 2, 3 and 4 included the abbreviated Maslach Burnout Inventory (aMBI), a nine-item scale used for assessing burnout [25, 26]. It has three subscales including emotional exhaustion, depersonalization and personal accomplishment [27]. An additional three questions were included on job satisfaction with reference to being a health professional [28]. Items were scored on a seven-point Likert scale (1 = everyday, 2 = a few times a week, 3 = once a week, 4 = a few times a month, 5 = once a month or less, 6 = a few times a year, 7 = never). Higher scores for emotional exhaustion [10‐18] and depersonalisation [10‐18] and lower scores for personal accomplishment (0–9) and job satisfaction (0–9) indicated greater burnout [27].

Podiatrists and podiatric surgeons working in Victoria (Waves 1 and 2) and Australia (Waves 3 and 4) were invited to participate in the online survey every year through its promotion on social media (Facebook, Twitter, LinkedIn and Instagram), at podiatry conferences and through targeted emails from peak bodies such as the Australian Podiatry Association and Australasian College of Podiatric Surgeons. Podiatrists who had completed previous waves and left contact details were emailed directly. Podiatrists who responded were given the opportunity to enter a competition for gift cards or to receive professional development vouchers.

Qualtrics® software (Qualtrics, Provo, UT, USA) was used to collect each wave of the online survey data [29] and subsequent waves linked responses by each participant creating their own unique identifier code. Forced or requested response prompts were used to minimise missing data, and participants could withdraw at any time by closing their internet browser. All non-completed questions were treated as missing data for the remaining non-completed variables. Question logic was used to minimise question blocks if a participant indicated that they had participated in previous waves. These logics included if there were no job changes, or no changes in location, these responses were carried over at each round. Cookies were used to allow responses to be saved up to 4 hours within partial completion. Code routinely collects Internet Protocol (IP) addresses as part of the de-identified metadata in the survey response and IPs were only viewed and used as a last resort to match data where other linking variables were incomplete.

All data were initially cleaned to remove any responses that were partially completed, including where there were no core demographics (core data included gender, age, postcode, recency of practice). As podiatrists were only requested to complete some sets when their job role or living situation had changed, a final per podiatrist response was created with the most recent response, with additional completed data from prior waves inputted as required whereby the most recent response was the one applied to the current analysis (Fig. 1). In response to the coronavirus pandemic, we undertook preliminary analysis to understand if there were distinct differences between Wave 3 (2019) and Wave 4 (2020) cohorts, particularly regarding mental health scores, burnout and any impact on job satisfaction or intent to leave the profession. We did not find significant differences in our domains of interest between waves and their impact on metropolitan or rural responses, therefore all data were analysed using the combined data set from Wave 4.

Descriptive statistics of all variables were grouped and recoded where appropriate (e.g. Satisfied responses were combined with Very Satisfied). The Modified Monash Model (MMM) was used on postcode data to recode location into metro (MMM 1) or rural (MMM 2, 3, 4, 5, 6 and 7) [30]. Univariate and multivariate regression models were used to determine factors associated with location of work (as a proxy measure of recruitment) and intent to stop seeing patients (Yes versus Unknown/No) and intent to leave the profession (Yes versus Unknown/No; as a measure of retention). Univariate logistic regression was used to explore any associations between the variable of interest (location, intent to stop seeing patients, intent to leave the profession) and those known to impact recruitment and retention to build the multiple regression model. Variables known to impact recruitment and retention were chosen based on prior studies supporting their impact on recruitment and retention, including age [3], recency of practice [3], primary work setting (private or public) and business relationship (owner or partner, salaried/contract, locum/not working and other) [31], number of working locations and time spent working at a location [32], exposure to regional/rurality through life or education [6], leave availability [3], professional development availability [33] and working in a location close to family and friends [34].

Backward stepwise multivariate regression was performed where univariate analysis revealed a value of p < 0.20. This analysis took form by removing the variable with the least significant fit in a stepwise procedure until all remaining variables were significant at p < 0.05. Regression analyses were performed using Stata 15 software (StataCorp, College Station, TX, USA).

One thousand one hundred twenty-nine podiatrists consented to participate and completed the majority of demographic questions in at least one of the survey waves. This response rate was estimated to be 21% (1129 of 5429 podiatrists) of the profession as at 2020 [19]. Table 2 displays the summary of participants’ demographics, work setting, employment profile, regional/rural exposure according to total responses, and responses according to those working in a metropolitan or rural location. Mean (SD) age of participants were 39 [11], with no significant differences between metropolitan and rural responses. A total of 412 (42%) participants had graduated greater than 11 years ago. There were 309 (35% of 882) podiatrist responses indicating a likelihood of being impacted by burnout based on having moderate-severe scores in two or more subscales of the aMBI. There were minimal differences of burnout in all four domains between podiatrists working in metropolitan and rural locations.

Podiatrists who had a rural background (MMM2–7) (30%), were less likely to work in a metropolitan location (OR = 0.20, 95% CI = 0.11, 0.37), or more likely to work rurally. Podiatrists who completed a placement in a rural setting (43%), were significantly more likely to work in a metropolitan location (OR = 1.86, 95% CI = 1.38, 2.51). There was no interaction between growing up in a rural location and undertaking a placement in a rural setting and working in a rural location.

There were several significant factors relating to retention (Table 3). Podiatrists who indicated they were planning to leave direct patient care within 5 years (n = 282, 26%), were less satisfied with working conditions (OR = 0.77, 95% CI = 0.66, 0.92), less satisfied with opportunities to use their abilities (OR = 0.83, 95% CI = 0.69, 0.99), perceived less personal accomplishment (OR = 0.94, 95% CI 0.86, 0.94) and less job satisfaction (OR = 0.92, 95% CI = 0.91, 0.98).

Overall, most podiatrists indicated that they were satisfied/very satisfied in all questions relating to job roles (Table 4). Questions with the highest satisfaction levels included freedom to choose their own method of working with 964 podiatrists (85% of 1126) satisfied/very satisfied and 915 podiatrists (85% of 1072) satisfied/very satisfied with their colleagues and fellow workers. The questions with the lowest satisfaction levels included recognition received for good work with 170 podiatrists (15% of 1112) dissatisfied/very dissatisfied, and remuneration with 236 podiatrists (21% of 1118) dissatisfied/very dissatisfied. Generally, job satisfaction levels between podiatrists working in metropolitan and rural locations were very similar, except for remuneration, with 242 (72% of 333) podiatrists in rural locations being satisfied, compared to 520 (66% of 785) podiatrists in metropolitan locations.

Job satisfaction was further explored by asking podiatrists’ levels of agreement with an additional 11 statements. Statements that podiatrists agreed with the most (defined as a response of agree or strongly agree), included the belief that most of their patients have complex, health, and social problems, with 684 podiatrists (62% of 1107) agreeing with this statement, and 676 podiatrists (61% of 1099) agreeing that they can take time off at short notice. Statements that podiatrists disagreed with most (defined as a response of disagree or strongly disagree) related to work hours, with 841 podiatrists (75% of 1124) disagreeing that the hours they work are unpredictable and 704 podiatrists (69% of 1017) disagreeing that they cannot work their preferred hours due to lack of jobs offering those hours. More than half of the podiatrists (55% of 1113) agreed that they often undertook tasks that someone less qualified could do. A total of 473 (44% of 1077) agreed that they have good support and supervision from podiatrists with advanced skills (for example sports, paediatrics, high risk, surgery), however, this was lower in rural locations (40% of 318) compared to metropolitan locations (46% of 759).

Over half of the respondents (58% of 1028) agreed that they didn’t have family or friends in their current location and 418 (41% of 1028) disagreed that there are good employment opportunities for their partner in their current work location (Table 4). This was higher (46% of 314) for participants who lived in rural locations, compared to podiatrists working in metropolitan settings (38% of 714). Exactly half (50% of 314) of podiatrists working in rural locations disagreed that the choice of schools for their children is adequate in their work location.

There were 282 (26% of 1084) podiatrists indicating they were likely/very likely to leave direct patient care within 5 years and 223 (21% of 1104) reported that they were likely/very likely to leave podiatry work entirely within the next 5 years (Table 5). When asked about hours of work, 195 (30% of 654) reported that they would like to decrease their working hours, whereas 125 (20% of 635) would like to have increased their working hours (Table 5).

A total of 706 (87% of 816) of podiatrists had access to paid annual leave, 521 (64% of 816) had access to unpaid annual leave, 570 (70% of 816) had access to paid sick leave and 134 (16% of 816) had no leave available (Table 5). Overall, podiatrists working in rural locations had more access to paid annual leave (98% of 235) and paid sick leave (79% of 239) when compared to podiatrists working in metropolitan locations.

Of the total number of podiatrists, 530 (48% of 1106) reported that they had very good opportunities for continued professional development. From these responses, 392 (50% of 772) of podiatrists in metropolitan locations indicated that they had very good opportunities for continued professional development, compared to 138 (41% of 334) in rural locations. Over half, 51% of 1042) podiatrists reported they had very good opportunities for social interaction for themselves and their family.