Retention and attrition of chiropractors in Australia: the Workforce Retention and Attrition Project
Timothy Lathlean
A * , Abbey Chilcott B , Michael Shobbrook AM B , Colleen Papadopoulos B , Rechu Divakar A , Lee Barclay A , Kirsten Hibberd A , Eva Saar A and Jade Tan A
A
B
Abstract
This study aims to understand workforce retention and attrition of chiropractors in Australia.
An online survey of chiropractors in 2024 and a retrospective analysis of 10 years of Australian Health Practitioner Regulation Agency (Ahpra) registration data were undertaken.
Of 1513 surveyed chiropractors, 80.0% intended to continue in the profession, 6.6% intended to leave (excluding retirement), 6.7% were unsure, and the remainder were retired. Seventy percent of those intending to leave planned to do so within 1 year. Top reasons included unsatisfactory remuneration (35.4%), lack of recognition/feeling undervalued (31.3%), work no longer professionally satisfying (31.3%), work no longer fulfilling/meaningful (29.2%), and retirement (29.2%). Those with limited registration status, working outside 20 to 49 h per week, and on casual or temporary contracts are also more likely to not renew or be unsure. Australian Health Practitioner Regulation Agency (Ahpra) data (2014–2023) showed a 12.2% increase in registered chiropractors per 100,000 of the Australian population and a 15.8% rise in replacement rate (with fluctuations).
The overall number of chiropractors has increased from 2014 to 2023, and the replacement rate increased from 2015 to 2023. This highlights growth in the profession despite some issues in workforce stability, particularly among those with limited registration, non-standard work hours per week, and casual/temporary contract status. Addressing intrinsic and workplace factors such as remuneration, workplace recognition, and job satisfaction may improve retention.
Keywords: Australia, chiropractic, chiropractors, health profession, health regulation, health workforce, regulated health workforce, retention.
Introduction
Chiropractors contribute to the provision of health care in Australia and globally,1 with around 16% of Australians seeking care from chiropractors,2 primarily for musculoskeletal complaints such as back and neck pain.2,3 In 2016, the number of chiropractors globally was reported at 103,469, with the United States (US) having the highest number of chiropractors per capita (23.7 per 100,000 population).4 In Australia, chiropractors constitute 0.7% of the regulated health workforce, with 22.4 chiropractors per 100,000 population.5 At 31 December 2024, there were 6734 chiropractors registered in Australia, with 92.6% registered to practice.6
Australia’s growing7 and ageing7,8 population increases demand for health care,7 with musculoskeletal pain being the number one cause of years lived with disability9,10 and the primary reason people seek care from chiropractors. The World Health Organization predicts a health worker shortage of 10 million by 2030,11 resulting in an unmet supply of health practitioners.7,12 Over a 5-year period (2018–19 to 2022–23), Australian Health Practitioner Regulation Agency (Ahpra) data have shown that despite a 14.3% increase in the total number of chiropractors registered with Ahpra, there has been a shift from practising to non-practising registration.13 This data demonstrates that there may be challenges in the chiropractic workforce being able to meet the current and future needs of the Australian population.
A 2017 review of the rate of attrition from the global health workforce found that the total annual attrition rate varied between 3.0 and 44.3%.14 Chiropractic attrition has been reported to be between 4.5 and 27.8%; however, this was based on two US studies published in 2010,15,16 highlighting the need for data that better defines the choices of practitioners within the context of the Australian environment, where the private and the public healthcare systems differ substantially. Research on health workforce attrition and retention is prevalent across several health professions;14,17–20 however, it has not been a focus for the chiropractic profession.21 Given the predicted health workforce shortages and the increased demand for chiropractors treating musculoskeletal conditions in Australia’s ageing population, a more comprehensive understanding of the factors that contribute to chiropractors leaving the profession is required. The Australian Workforce Retention and Attrition Project (WRAP) aimed to identify these factors and provide insights into how to effectively retain practising chiropractors in Australia. This information can then be used to inform future workforce planning and strategies to address the potential challenges of chiropractor shortages.
Methods
The Chiropractic Board of Australia (ChiroBA) and Ahpra’s Research, Evaluation, and Insights team (REIT) conducted this study as part of WRAP.22 Ethics approval was granted by the Metro North Health Human Research Ethics Committee (HREC) B (#100684).
Design
The study consisted of an online survey of chiropractors and a retrospective analysis of 10 years of Ahpra’s chiropractor registration data (30 June 2014 to 30 June 2023).
Participants were recruited via email from Ahpra’s database and invited to complete a survey (Supplementary material file S1). Participants included registered chiropractors (as of 31 December 2023) and those who had been registered at any point in the preceding 5-year period (1 January 2019 to 31 December 2023). The survey, administered through QualtricsXM,23 was open for 1 month (12 February 2024 to 12 March 2024).
Data analysis
Sample representativeness was assessed by comparing survey demographics to Ahpra data.
Factors influencing respondents’ intentions were analysed using a binomial logistic regression, considering the following factors: self-identification as Aboriginal and/or Torres Strait Islander, age, gender, principal place of practice (PPP), remoteness (using the Modified Monash Model),24 profession, years of experience, work hours, employment type, self-employment status, further qualifications, and registration status (general, non-practising, and limited). The dependent variable (practitioner intention) had two categories: intention to stay (including those re-registering or transitioning from non-practising to general registration) and intention to leave or being unsure (no, currently unregistered and do not intend to re-register, and transitioning from general to non-practising registration). Retired respondents were excluded from this analysis.
Sparse categories were grouped: work hours <20 h or >50 h were grouped as ‘outside 20–49 h’, Practice owner and Contractor were categorised as ‘Owner/Contractor’, and Non-practising and Unregistered registration status were merged. Levels with <10 observations were removed.
Statistical modelling
All analyses were done in R (version 4.3). All predictors were screened using univariate likelihood-ratio tests (threshold P = 0.2) and collinearity tests threshold (VIF = 2). A forward-selection procedure then added variables one at a time, retaining ones that lowered Akaike’s Information Criterion by more than two and where the likelihood-ratio test remained below 0.20. Pre-specified interactions (Work Hours × Gender, Work Hours × Age, Employment Type × Gender) were tested subsequently. Model fit was summarised with McFadden’s R², area under the receiver operating curve (AUROC), and the Hosmer–Lemeshow goodness-of-fit test. Events-per-variable was monitored to be above 10.
To maximise sample size, variables with high number of missing data caused by Qualtrics skip-logic – Work Hours, Employment Type, Self-employment, and Remoteness – were excluded from the first pass analysis. In the second pass analysis, these were added into the model and stability was examined relative to the baseline model.
Registration data trends were analysed over a 10-year period (30 June 2014 to 30 June 2023). Table 1 outlines the different registration types.
| Registration Status | Description | |
|---|---|---|
| Active | ||
| Current | Registrations were valid and within specified registration period | |
| In force | Registrations where period had lapsed but an application for renewal had been received | |
| Late period | Registration period had lapsed and no application for renewal had been received within the 1-month grace period after the end of registration | |
| Inactive | ||
| Non-practising registration | Retired, temporarily not practising, practising overseas | |
| Not-renewing | Practitioner opted not to renew | |
| Not-renewed | Lapse date reached while status ‘not renewing’ | |
| Failed to renew | Lapse date reached, no renewal application submitted | |
| Refused | Renewal application denied | |
| Withdrawn | Renewal application withdrawn | |
| Other | Cancelled, suspended, surrendered (voluntarily), deceased | |
The availability of chiropractors relative to population was assessed by calculating the number of ‘active’ chiropractors per 100,000 population. Workforce sustainability was estimated through replacement rate, defined as the ratio of entrants to exits. Entrants include new registrants joining the profession for the first time and practitioners returning to active registration from inactive statuses. Exits refer to the number of practitioners who moved from ‘active’ in the previous year to ‘inactive’ in the current year.
Results
Demographics
Of the 7109 survey invitations sent, 1798 chiropractors started the survey (25.3%) and 1513 completed it in full (21.3% response rate) (Fig. 1).
The distribution of survey responses received from chiropractors is presented, with the rightmost column showing the raw responses from chiropractors. Some responses have been grouped under intention to ‘Stay’, while others are categorised as ‘Leave/Unsure’. A portion (n = 100) of respondents retired.
Survey respondents were generally representative of Ahpra’s 2022–23 registered chiropractors. Those over 60 years were overrepresented (survey: 23.1%, registered: 11.6%) and those under 35 years were underrepresented (survey: 20.7%, registered: 33.3%). There was some difference in the proportion of ‘general – practising’ respondents (survey: 82.1%; registered: 93.4%). Consistent with Ahpra’s workforce demographics, most respondents were male (survey: 61.4%, registered: 58.0%), aged 35–60 (survey: 56.3%, registered: 55.1%), from metropolitan areas (survey: 67.4%, registered: 73.4%), and from the states of New South Wales, Victoria, and Queensland (survey: 77.2%, registered: 76.4%). A detailed demographic breakdown is in the Supplementary material, Table S1.
Reasons for staying, leaving, or being unsure of a future within the profession
Eighty percent (1211) of respondents indicated they intended to maintain registration and continue working (Fig. 1), with 56.7% seeing their entire career in the profession, 30.5% expecting to be working in 5 years, 10.5% in 1 year, and 0.4% returning to the profession.
Primary motivations for staying registered included enjoyment of the work, flexible work–life balance, work being fulfilling and meaningful, a sense of achievement, and work being mentally stimulating (Table 2). Factors that would encourage chiropractors to stay include higher remuneration, improve status of the profession, more opportunities for career progression and a greater recognition of their work as well as more flexible work-life balance (Table 3).
| Reason for staying | N | % | ||
|---|---|---|---|---|
| 1 | I enjoy the work | 861 | 71.1 | |
| 2 | Hours/flexible work-life balance | 822 | 67.9 | |
| 3 | Work fulfilling and meaningful | 812 | 67.1 | |
| 4 | Sense of achievement | 653 | 53.9 | |
| 5 | Work mentally stimulating | 646 | 53.3 | |
| 6 | Positive workplace/interpersonal relationships | 613 | 50.6 | |
| 7 | It is what I trained for | 581 | 48.0 | |
| 8 | Ability to work autonomously | 560 | 46.2 | |
| 9 | Opportunities for personal growth and/or development | 366 | 30.2 | |
| 10 | Renumeration | 294 | 24.3 |
| Factors that may encourage staying | N | % | ||
|---|---|---|---|---|
| 1 | Higher renumeration | 42 | 42.0 | |
| 2 | Improved status of the profession | 38 | 38.0 | |
| 3 | More opportunities for career progression | 34 | 34.0 | |
| 4 | A greater recognition of work | 21 | 21.0 | |
| 5 | Hours/flexible work-life balance | 18 | 18.0 | |
| 6 | Job security | 18 | 18.0 | |
| 7 | Feeling a sense of achievement | 15 | 15.0 | |
| 8 | Greater variation in the workload | 15 | 15.0 | |
| 9 | More fulfilling and meaningful work | 15 | 15.0 | |
| 10 | More mentally stimulating work | 15 | 15.0 |
Of 202 respondents (13.4%) unsure or intending to leave, 50.5% were unsure, 24.2% were unregistered and not returning, and 25.2% were registered but planning to leave – 36 (70.6%) of whom planned to do so within 1 year.
The top next career path was transitioning to another regulated health profession, followed by managerial roles, education, corporate/finance/insurance, and retirement. Primary motivations for leaving included unsatisfactory remuneration, lack of recognition/feeling undervalued, work no longer satisfying, lack of meaningful work, and retirement (Tables 4 and 5). Reasons for uncertainty included demotivation, low/stable income, ageing/health/family issues, registration challenges, and considering retirement/career change.
| Reason for leaving | N | % | ||
|---|---|---|---|---|
| 1 | Unsatisfactory renumeration | 17 | 35.4 | |
| 2 | Lack of recognition/feeling undervalued | 15 | 31.3 | |
| 3 | Work no longer professionally satisfying | 15 | 31.3 | |
| 4 | Retirement | 14 | 29.2 | |
| 5 | Work no longer fulfilling/meaningful | 14 | 29.2 | |
| 6 | I do not have access to job security | 12 | 25.0 | |
| 7 | Lack of career advancement opportunities | 12 | 25.0 | |
| 8 | Work is no longer mentally stimulating | 12 | 25.0 | |
| 9 | Lack of opportunities for personal growth and/or development | 11 | 22.9 | |
| 10 | Mental burnout | 10 | 20.8 |
| Factor | Level | Reason for leaving | N | |
|---|---|---|---|---|
| Age group (years) | Under 35 | I do not have access to job security | 8 | |
| Work is no longer fulfilling/meaningful | 7 | |||
| Work is no longer professionally satisfying | 6 | |||
| Unsatisfactory remuneration | 6 | |||
| Work is no longer mentally stimulating | 5 | |||
| 35–60 | Unsatisfactory remuneration | 9 | ||
| There is no recognition of my work/feel undervalued | 8 | |||
| Lack of opportunities for career advancement | 7 | |||
| Mental burnout | 6 | |||
| Lack of opportunities for personal growth | 6 | |||
| Over 60 | Retirement | 10 | ||
| Gender | Male | Retirement | 11 | |
| Work is no longer fulfilling/meaningful | 7 | |||
| Unsatisfactory remuneration | 6 | |||
| Lack of opportunities for career advancement | 5 | |||
| Female | There is no recognition of my work/I feel undervalued | 11 | ||
| Unsatisfactory remuneration | 10 | |||
| Work is no longer professionally satisfying | 9 | |||
| I do not have access to job security | 9 | |||
| Work is no longer fulfilling or meaningful | 7 |
Factors associated with intention to stay, leave, or being unsure
A total of 1413 responses were included in the regression analysis. Demographic predictors were almost complete (≤4% missing), whereas predictors influenced by skip-logic were missing by 12–13%. The complete-case logistic model, fitted to the entire cohort (n = 1413), retained three predictors – gender, further qualifications, registration status (AUROC = 0.81, Hosmer–Lemeshow P = 0.84), with only registration status being significant. Respondents with limited and non-practising/unregistered registration were more likely to leave (odds ratio (OR) > 5.0, 95% confidence interval (CI) 1.4 to 14.8, P < 0.001). However, adding the skip-logic affected variables back into the model results in marked changes to effect sizes. Several job-related factors now correlated with intention to leave or being unsure, including casual or temporary employment (OR = 4.7, 95% CI 1.5 to 15.1, P = 0.02), weekly hours outside 20–49 h (OR = 2.0, 95% CI 1.1 to 3.6, P = 0.01), and limited registration (OR = 4.4, 95% CI 1.0 to 13.7, P = 0.03) (Table 6).
| Factor | Level | Odds ratio | 95% confidence interval | P-value | |
|---|---|---|---|---|---|
| Work hours per week | 20–49 h | – | – | – | |
| Outside 20–49 h | 2.00 | 1.11–3.57 | 0.020 | ||
| Employment type | Permanent full-time | – | – | – | |
| Casual/temporary | 4.77 | 1.50–15.08 | 0.007 | ||
| Registration | General practising | – | – | – | |
| Limited | 4.04 | 1.01–13.69 | 0.032 |
Ahpra registration data analysis
The number of chiropractors per 100,000 population increased by 12.2% from 2014 to 2023, rising from 19.4 to 22.1%, with an average annual increase of 1.4% (Fig. 2a).
Analysis of Ahpra registration data showing retention and attrition trends. Subplot (a) shows retention rates per 100,000 population. Subplot (b) displays the overall replacement rate. Subplot (c) depicts replacement rates by gender: female and male. The replacement rate for a given year represents how many new or returning chiropractors enter the workforce for each one that leaves.
Despite notable fluctuations, the replacement rate rose 15.8% from 2015 to 2023 (Fig. 2b). Fluctuations were greater for female practitioners, with peaks in 2016 and 2021 followed by sharp falls the following year. Female chiropractors consistently exhibited higher replacement rates compared to male practitioners. While replacement rates for male practitioners also show some fluctuations, they show a more stable upward trend (Fig. 2c).
Exits among those aged under 35 peaked in 2017 prior to showing a general decreasing trend. The 35–60 year age group had the highest number of chiropractors’ exits overall, and contributed to the largest share of exits in the past 4 years. In contrast, exits in the over 60 years age group remained relatively stable (Fig. 3).
Discussion
In Australia, the number of chiropractors per 100,000 and the replacement rate are growing. Furthermore, 80.0% of chiropractors intend to remain in the profession, which is higher than most professions surveyed in the WRAP.22 These are promising signs for chiropractic in Australia.
Despite positive signs of growth for the profession, 13.4% of surveyed chiropractors intend to leave or are unsure about their future. Reasons cited included remuneration, a lack of meaningful and satisfying work, and retirement. Although attrition due to retirement is natural in any profession, particularly given those over 60 years were overrepresented in the survey, the concerns about remuneration and a lack of meaningful or satisfying work require further consideration. Research in other health professions has identified both intrinsic and extrinsic occupational factors that influence workplace satisfaction.25 Intrinsic factors may include a narrow scope of practice as well as a lack of progression opportunities,26 which, if addressed, could ensure work is more meaningful and satisfying. Workplace support has been identified as an extrinsic occupational factor and appears to be influential on workplace satisfaction.25 It is outside the scope of this study as to which factors contributed to intentions to leave; however, given the trends in attrition for those aged under 35 years, it would be a useful pathway for future research.
Registration status, employment type, and work hours per week were significantly associated with an increase in the intention to leave or be unsure. Despite Victoria having one of the highest proportions of registered chiropractors,13 and ACT one of the lowest, there may be limitations to using a metric such as PPP. Those with limited or non-practising registration, on casual or temporary contracts, or working outside 20–49 h per week may be in the process of leaving the profession. Additional potential findings related to PPP could be important in future studies, but were not significant according to the statistical analysis within this study.
Potential strategies to retain chiropractors in Australia
Building on the outcomes of this study, further research could explore the identified trends in greater depth. Metrics such as replacement rate can be monitored to inform strategies addressing those leaving. For example, the greater number of fluctuations in the replacement rate for female practitioners may indicate additional challenges such as returning to the workforce following child caregiving responsibilities. Furthermore, those with non-practising or limited registration may be considering transitioning to another health profession or transitioning out of health care. Interventions that address flexibility and/or remuneration may be effective in these circumstances. Other methodologies, such as interviews and focus groups, could identify both intrinsic and extrinsic factors related to retention and attrition in further depth, particularly in cohorts with the highest risk of intending to leave (i.e. limited and non-practising registrants or those practising in Victoria). The approach of this study, where multiple professions were involved, is useful in helping to determine issues that may extend beyond only chiropractors.
Limitations and strengths
The findings of this study need to be viewed in light of three key limitations. First, there was a lower proportion of those under the age of 35 and a higher proportion of those aged over 65 years, which most likely contributed to a higher number of practitioners indicating they were intending to leave due to retirement. Second, the questions in the survey and the registration data analysis provided a summary of the potential issues related to retention and attrition, and we were unable to further explore a specific rationale for reasons to leave. Research that involves qualitative methods (e.g. interviews and focus groups) would help to elicit why chiropractors are intending to leave in further detail. Third, due to some subgroup variables having low sample size (e.g. NT for PPP), there was some exclusion of variables in the approach to data analysis. A strength of the study was the response rate of 21%, which was higher than the average 18% across the WRAP professions.22
Conclusion
Over a decade, the number of chiropractors per 100,000 Australians and the replacement rate have risen by 12.2 and 15.8%, respectively, signalling robust growth despite fluctuations. Notably, 80% intend to stay, yet those with limited or non-practising registration and in Victoria face higher attrition risks. Tackling remuneration, recognition, and job satisfaction through targeted interventions – such as enhanced workplace support or professional development – could bolster retention. Further research should explore drivers for high-risk groups, especially younger chiropractors, to sustain this vital workforce amid growing healthcare demands.
Data availability
The data that support this study cannot be publicly shared due to ethical or privacy reasons.
Declaration of funding
This research did not receive any specific grant from funding agencies in the public, commercial, or non-for-profit sectors. This study was funded by the Australian Health Practitioner Regulation Agency (Ahpra) as business-as-usual research work.
Acknowledgements
The authors would like to acknowledge the support and input of the Chiropractic Board of Australia (ChiroBA). The authors wish to acknowledge the contributions that Prof Sarah Anderson, formerly National Manager of Research Evaluation and Insights at Ahpra, provided in the conceptualisation and early stages of the Workforce Retention and Attrition Project.
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