Holding on to primary healthcare nurses

04 October 2018

Sue Randall and Tonia Crawford describe a programme in Sydney, Australia, that helps to recruit and retain community health nursing students.

Many countries, including Britain and Australia, face an increasing incidence of chronic conditions (WHO, 2017). In line with other governments, including the UK’s, successive Australian governments have placed increasing emphasis on primary healthcare (PHC) approaches that prioritise illness prevention and health promotion, typically based in community settings (Australian Institute of Health and Welfare, 2014; Department of Health, 2012).

Despite this emphasis, there has been a tendency for undergraduate nursing programmes in both Australia and the UK to focus on the education needs of the acute care sector, with patchy preparation for nurses working in PHC, illness prevention and health promotion (Ali et al, 2012; Keleher et al, 2010). This consequently impacts on the recruitment of registered nurses into the community setting.

The retention of nurses in PHC is also a pressing issue in both countries. In the UK, more nurses and midwives are leaving the register than joining it (NMC, 2017), and in Australia, high exit rates and low numbers of entrants mean the largest shortfall of nurses in 2030 will be in the PHC sector (Health Workforce Australia, 2014).

Preparing for practice

Given the increasing focus on PHC, Day et al (2014) argue that it is important for university programmes to adequately prepare nursing students for practice in community settings, and to have a sound understanding of PHC principles. However, as Woods (2010) points out, there are many challenges in aligning PHC principles to practice, ensuring students are able to synthesise and apply these principles to community nursing practice when they have a tendency to focus on and prioritise psychomotor skills relevant to the acute care setting.

Addressing these issues and preparing undergraduate nurses for a career in PHC may, in turn, help with retaining staff in PHC settings. This article describes an assessment process in an undergraduate nursing programme in Australia that aims to engage and prepare students for practice in community settings, giving learning experiences that are authentic and relevant to community health.


PHC is based on a social model of health and is underpinned by principles of social justice, empowerment, community participation and equity, focusing on addressing underlying causes of health problems experienced by individuals and communities, thereby reducing health inequality (Keleher, 2001).

Community nurses play an important part in providing access to healthcare services through home visits and clinics, and include roles such as community health assessment and screening, healthcare delivery to individuals, referral and case management, and provision of education and support to individuals and groups (Woods, 2010). Preparation for these diverse roles in ways that engage the students is challenging because they are often better understood through immersion in the community setting.

In order to prepare students for PHC approaches, undergraduate community nursing units incorporate PHC principles with chronic conditions as a focus for promoting the health of individuals, families, communities and populations. Public health is also incorporated, along with knowledge of the meaning of health in various communities, holistic assessment and case management skills, ethical grounding for social justice, as well as clinical experience in a variety of community settings (Callen et al, 2013; Woods, 2010).

Part of the challenge of teaching community nursing and the principles of PHC is due to student inclination to focus on gaining ‘mastery of psychomotor skills, disease symptoms, and individual level interventions’ (Callen et al, 2013). The challenge for academics, therefore, is to develop curricula that are engaging and transformative to enable students’ understanding of the complexity of caring for clients in the community as opposed to the acuity of caring for clients in the acute setting (Woods, 2010). Through gaining a greater understanding of nursing in PHC settings, the recruitment and retention of future nurses may be enhanced.

Nursing curricula in other universities in the UK, US and Australia have used various teaching and learning strategies and authentic assessment tasks to achieve this aim: for example, service learning activities that benefit stakeholders, such as development posters and educational material to meet a perceived educational need (Olinzock et al, 2009); virtual communities capable of reflecting real problems and health services (Day et al, 2014); the adaptation of the public health intervention model to facilitate student nurses’ understanding of the principles of PHC (Woods, 2010); and case studies that form the basis for learning about community profiles (Granger 2014; Callen et al, 2013).

Sydney programme

This article describes an assessment that is designed to engage students and transform their learning by being relevant to many community nursing roles. Developing a community profile forms the basis of an assessment for a community health nursing unit on a bachelor of nursing programme in Sydney.

Community health nursing comprises two main areas: providing care to people in their own homes, and public health. Both are included in this unit to emphasise the importance and breadth of community nurse roles (van Loon, 2011).

A community profile is an exercise in social analysis in which specific characteristics of a geographically defined community of people are researched and analysed. Community information gathering, and awareness of community strengths, needs and problems, are necessary dimensions of community nursing that go towards prioritising, resolving or modifying health problems (Chan et al, 2008).

As community nurses work in diverse geographical locations, having a thorough knowledge of the area in which the nurse works offers opportunities to target interventions and vulnerable groups (James et al, 2007). Undertaking a community profile is therefore a means of gaining this information.

Students choose a local government area (LGA) and are guided through accessing census data from the Australian Bureau of Statistics (2016), which includes population characteristics and demographics, for example age groups by sex, country of birth, language spoken at home, indicators of socioeconomic status, household type and marital status.

Students are also challenged to find pertinent information relating to a chosen public health problem, sourcing information from sources such as government websites, organisations related to the health problem (for example, the Cancer Council), and local health facilities. The public health problem – for example, chronic airways limitation (CAL) or type 2 diabetes – is chosen from a prescribed list, and links are made between the prevalence and risk factors of the health problem and the characteristics of the LGA.

For example, students may consider the prevalence of CAL in the area in relation to the amount of industry or levels of traffic pollution, or linking the risk factors for diabetes, such as age, gender, country of birth and socioeconomic status, to the demographic data of the chosen LGA.

The Socioeconomic Indexes for Areas (SEIFA) tool is useful for this part of the assessment because it enables the students to reflect on social determinants and how the environment in which people live, work and play has the potential to affect their health and quality of life. The roles of the community health nurse in relation to phases of primary, secondary and tertiary prevention and health promotion to manage the chosen public health problem are then discussed.


One aim of this form of assessment is to enable deep and transformative learning about community nursing, which may lead to a career in a PHC setting. In the UK, the PHC workforce is typically older, with a third of practice nurses over 55 years of age (Nuffield Trust, 2018). Similar figures are seen in Australia, with 28% of PHC nurses in the 55 to 64 age bracket.

Upcoming retirements in both countries are likely to affect the skill mix and experience of nurses in this setting. Training the next generation of nurses in PHC is therefore crucial.

This assessment reflects the practice of community nurses, enabling students to use local physical contexts in PHC to understand the link between social determinants and the prevalence of chronic conditions. Douglas et al (2009) describe this as important knowledge and skills, which help to form a strong understanding of some critical factors that underpin PHC nursing.


This programme in Australia shows a way forward for UK community practitioners too. Nurse educators are ideally placed to contribute to the recruitment and retention of the PHC workforce. By including an assessment that reflects real-world roles, community health students are engaged in meaningful learning that is relevant to public health and community nursing practice. This may subsequently enable them to fully consider a career in PHC nursing.

Sue Randall is a senior lecturer in PHC nursing, and Tonia Crawford is a lecturer in community/PHC nursing at the University of Sydney’s Susan Wakil School of Nursing.

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