The Aging Nursing Workforce: How to Retain Experienced Nurses
G R A D U A T E E S S A Y
The Aging Nursing Workforce: How to Retain Experienced Nurses Jeremye D. Cohen, Temple University, Philadelphia, Pennsylvania
E X E C U T I V E S U M M A R Y In the face of an anticipated nursing shortage, bealthcare organizations must evaluate tbeir culture, operations, and compensation system to ensure that tbese elements align witb organizational efforts to retain nurses wbo are approacbing re- tirement age. Management sbould focus on enbancing elements of job satisfaction and job embeddedness that will motivate nurses to remain both in tbe workforce and witb tbeir employer. Although much of this responsibility falls on the nurse manager, nurse managers are often not provided the necessary support by top management and are neither recognized nor held accountable for nurse turnover. Other retention initiatives can include altering working conditions to reduce both physical and mental stress and addressing issues of employee healtb and safety. As for compensation, organizations may be well-served by offering senior nursing staff flexible working hours, salary structures that reward experience, and benefit programs tbat hold value for an aging workforce.
For more information on tbe concepts in this article, please contact Mr. Cohen at [email protected]. Mr. Cohen is tbe first-place winner of tbe graduate division of tbe 2006 ACHE Student Essay Competition in Healthcare Management. For more information on tbis competition, please contact Reed Morton, Pb.D., FACHE, at (312) 424-2800
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W itb national nursing shortages ex- pected to climb from their current
level of 6 percent to 29 percent in 2020 (HHS 2002), bealthcare organizations are growing increasingly competitive with one another over their largest segment of employees. Wbile successful recruitment into the field of nursing would help alleviate staff shortfalls, organizations ought to target retention of their current nursing staff as well. As illustrated in Figure 1, tbe average age of tbe registered nurse (RN) workforce, wbich has risen steadily since tbe mid- 1980s, was 42.1 years in 2002. Tbis number is projected to reach 45.4 years in 2010. In 1983, half of the RN workforce was under age 35; by 2002, bowever, only 22 percent of tbe RN workforce was under 35 (Buerhaus, Staiger, and Auerbach 2004). As the nursing workforce ages, organizations that are able to both retain tbeir aging nursing staff and attract older nurses from outside their organization will be best suited to continue to operate successfully in an increasingly challenging labor marketplace.
An essential element of an effective nursing retention strategy is a culture that appreciates the knowledge, experience, and perspective that older nurses can provide to an organization. Creating tbis culture may necessitate combating preconceived notions about older workers so as to botb receive tbe greatest return from its experienced employees and ensure a work environment tbat is conducive to effective patient care and bigh patient satisfaction.
Concerns that older nurses are, in general, less productive than
other nurses are unfounded. Sterns and Sterns (1995) determined tbat chronological age is a weak predictor of capacity for productive performance. Because senior workers bave the physical and mental capabilities to perform all but the most physically demanding tasks as well as the ability to learn new skills (Bass and Caro 1996), organizations wbose culture, working conditions, and reward systems attract and retain experienced nurses can expect to be better suited to withstand anticipated nursing shortages.
JOB S A T I S F A C T I O N A N D JOB E M B E D D E D N E S S One method for determining the cultural, environmental, and reward and recognition programs that are most valued by older nurses is to assess employee job satisfaction (Jaros 1997). Lambert, Hogan, and Barton (2001) concluded that positive job satisfaction is twice as predictive of employee turnover as employment tenure and is four times as predictive as the perception of alternative employment opportunities, age, gender, and educational level.
Evidence implies that current job satisfaction for nurses bas significant room for improvement. Jaros (1997) discovered tbat 50 percent of employed nurses bave considered leaving nursing as a profession in tbe last two years, primarily because of low satisfaction witb tbeir job. Wbereas older nurses are more likely to leave tbe hospital workforce for otber positions, older nurses wbo do not leave are more satisfied witb
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F I G U R E 1 Age Distribution of RNs: 1980, 2000, and 2020 Projected
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
1980
• * • * * •
*
^ ^ ‘
• 2000
-—»* ^—
— —
2020
,
* • • . ‘ V • ” • •
N
<25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 >=65
Age
•••• 1980 – – – 2 0 0 0 2020
Source: U.S. Department of Health and Human Services, Health Resources and Services Ad- ministration, Bureau of Health Professions, National Center for Health Workforce Analysis. 2002. “Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020.” [Online information; retrieved 11/10/05.] http://bhpr.hrsa.gov/healthworkforce/repons/mproject/report .htm#map2.
and committed to their employer than are younger nurses (McNeese- Smith 2000). Yet, job satisfaction is not necessarily the most accurate predictor of employee turnover. Other common predictor variables include organizational commitment, perceived job alternatives, job-search behavior, and job embeddedness (Holtom and O’Neill 2004). In comparing these variables, Holtom and O’Neill found job embeddedness to be a more effective predictor than a combination of perceived desirability of movement measures (job satisfaction and organizational commitment) and perceived ease of movement measures (job alternatives and job search).
As a result, healthcare organizations would be best served by focusing their retention strategies on the elements of job embeddedness.
The critical aspects of job embed- dedness, as identified by Holtom and O’Neill, are as follows:
1. Fit: the extent to which an em- ployee’s job and community are similar to or fit with the other aspects of the employee’s life. Fit is indicative of an employee’s perceived comfort with an or- ganization and his or her work environment.
2. Links: the extent to which em- ployees have links to other people
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or activities. Links are formal or informal connections between the employee, institutions, and other people.
3. Sacrifice: the ease with which links can be broken—what employees would give up if they left, especially if they had to physically move to another city or home. Sacrifice consists of the perceived costs incurred or the benefits forfeited by leaving one’s job.
A nursing retention strategy that focuses on job embeddedness may entail a wide range of initiatives aimed at increasing employee at- tachment to the work group and the organization. Nurses, as compared to other healthcare workers, were found by Holtom and O’Neill to assign particular value to community. By offering opportunities for mentoring relationships, providing more flexible work arrangements, and developing managerial leadership skills, employers may increase an employee’s job embed- dedness (Holtom and O’Neill 2004). Additionally, providing experienced nurses with opportunities to represent the organization within the community links these employees with educational institutions, professional groups, and community resources (Holtom and O’Neill 2004).
Sources of Job Dissatisfaction In addition to enhancing elements of job satisfaction and job embeddedness, the organization should address those dissatisfiers that lead to deflated morale, low job satisfaction, and increased employee turnover. A
plethora of staff surveys have been published that identify those issues that most often lead to low job satisfaction among nurses. In a study by Hart (2001), low morale in the workplace was reported by approximately 68 percent of working nurses and by 81 percent of nurses considering changing careers. According to Hart (2001), the top reason, besides retirement, that 56 percent of nurses leave patient care is to seek a job that is less stressful and less physically demanding. High levels of job dissatisfaction have also been attributed to scheduling, unrealistic workloads, mandatory overtime, and hospital administrators’ perceived lack of responsiveness to nurses’ concerns (Gerson and Oliver 2005). According to Reineck and Furino (2005), the most frequently reported work-environment issues identified by RNs are increased paperwork (82 percent), increased severity of illness (70 percent), government regulations (64 percent), RN turnover (61 percent), need for second-language skills (58 percent), voluntary overtime (53 percent), and pressure to reduce time on the clock (51 percent).
Reineck and Furino surveyed RNs not employed in nursing so as to determine their reasons for leaving the workforce. The reasons cited include family responsibilities (40 percent), retirement (28 percent), and stress (26 percent). Interestingly, the same survey indicated that among RNs who do not work in nursing, 65 percent are not primary wage earners in their households, implying a relatively low economic need to work among this
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group. In determining a retention strategy, organizations must keep in mind that often a one-size-fits-all solution—for example, targeting only salary—may not necessarily be the most effective approach, particularly when considering those employees whose economic need for work is secondary.
Desired Job Attribufes Nursing surveys have also identified qualities that nurses would like embedded in their jobs and in their working environment. Hart (2001) found that 22 percent of nurses leaving the profession are seeking more regular hours, 18 percent desire more money, and 14 percent want better advancement opportunities. In addition, 74 percent of nurses said they would stay at their jobs if changes such as increased staffing, less paperwork, and fewer administrative duties were implemented (JCAHO 2002). Irvine and Fvans (1995) identified the inability to moderate aspects of the work environment as the main reason for turnover. They also found high decision latitude to be a significant factor of job satisfaction. Upenieks’ (2002) results are similar, attributing autonomy and control over the practice as indicators of job satisfaction.
Other surveys have targeted older nurses in particular. Kuhar and colleagues (2004) identified the following, in descending order of importance, to be the top 12 retention items among staff nurses older than 56 years: Coworker support, teamwork, retirement benefits.
adequate equipment, healthcare benefits, open-door policy, respect from physicians, job security, shift of choice, paid-time-off per year, respect from administration, and educational opportunities. While Beatty and Burroughs (1999) found that workers who are 40 to 49 years old rank money, enjoyment, and ‘usefulness’ in order of importance, workers age 50 to 59 rank enjoyment of work, ‘usefulness,’ and money in sequence. McNeese-Smith and Crook (2003) found that as workers grow older they increasingly value the aesthetics of the work environment while attributing increasingly less value to economic returns, prestige, and variety.
NURSE MANAGERS Taunton and colleagues (1997) identified manager behavior as the intervention most likely to improve retention of hospital staff nurses. The degree to which managers consider the comfort, well-being, status, and contributions of their staff is of greater value in predicting turnover of nursing staff than is stress, commitment, job enjoyment, autonomy, or personal power (Taunton et al. 1997). In fact, in studying exit interviews with 20,000 employees, Branham (2001) found that poor supervisory behavior is the top reason cited for their leaving.
Because good supervisory relations are essential for employee retention, it is critical that nurse managers are actively involved with their staff (Taunton et al. 1997). Nurse managers must have the ability to provide the moral support necessary to assist their nurses in developing the personal
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qualities, integrated knowledge, and self-awareness that will allow them to handle the demands of the work environment (Severinsson and Kamaker 1999). Severinsson and Kamaker found that nurses with effective supervision experience significant improvement in their ability to manage stress associated with moral dilemmas, manage organizational change, and manage integration of theory and practice.
Unfortunately, many nurse managers have been unable to provide their nurses with the leadership and support that they need. Because turnover rates among nurse managers are comparable with those experienced among staff nurses, one could conclude that the nurse managers on whom the organization relies to address critical retention issues are at times ill equipped to meet that challenge (Andrews and Dziegielewski 2005). It is essential that upper management not neglect their responsibilities as leaders and provide nurse managers with their own systems of support. In light of this analysis, it is imperative that management not take the work environment of nurse managers for granted given the impact these managers have on nursing retention.
Some nurse managers may feel that they do not have the time to adequately support their employees and improve job satisfaction because of high supervision ratios and clinical workloads (Kimball and O’Neil 2002). As a result, concerns about employee job satisfaction may not constitute a high priority as nurse managers are forced to balance multiple job respon-
sibilities (Andrews and Dziegielewski 2005). Additionally, upper manage- ment may be neglecting the importance of the nurse manager’s job satisfaction responsibilities. According to a study by the National Healthcare Cost and Quality Association involving 100 major hospitals across the United States, 50 percent of hospitals hold managers accountable for retention and only approximately 25 percent actually tracked management performance on this issue (Martin 2001). Setting nurse retention goals and pegging performance bonuses to achievement of those goals would reinforce the importance of employee retention to nurse managers.
OPERATIONAL CHANGES Reineck and Furino (2005) report that 87 percent of nurse managers believe that their employers have not made changes to accommodate nurses over age 55. To enhance retention of older nurses, organizations should make use of information and ergonomic technologies (Reineck and Furino 2005). JCAHO (2002) asserts that hospital work environments can be improved through redesigned work processes; effective staffing and scheduling; adoption of information and ergonomic technologies; and workplace cultures that empower, value, and reward nurses.
One method for managing nursing workloads to accommodate staff aging is to offer nurses rotations through clinical areas in which the workload is lighter. Additionally, nurses who work in heavy-workload areas can be offered support or help with the physical
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workload, such as providing unlicensed personnel and more frequent or longer breaks (O’Brien-Pallas, Duffield, and Alksnis 2004). For night-shift nurses, making fresh fruit and healthy snacks available can help staff overcome the physical challenges of overnight work (Cooper 2003).
Shortages of ancillary personnel and other hospital workers have added supply chain, housekeeping, food service, and other responsibilities to nurses’ workloads, at times pulling them away from patient care (JCAHO 2002). This serves as a dissatisfier to nurses who enjoy greater job fulfillment by providing patient care, and it adds costs to hospitals that are now paying higher-waged employees to perform these functions. Employing equipment technicians who ensure that equipment is available, safe, and functional; patient service associates who resolve service issues and meet patient expectations regarding care; and admission nurses who can complete the admission database, start IVs, and initiate patient education would free up nurses to focus on bedside patient care (Kuhar et al. 2004).
HEALTH AND SAFETY According to a study by the American Nurses Association, 88 percent of nurses indicate that their health and safety concerns influence the type of work they do and their likelihood to continue to practice (ANA 2001). Sixty percent of nurses report experiencing threats of violence (ANA 2001), 40 percent report having been injured on the job, and 17 percent have experienced physical
assault while working (JCAHO 2002). Obviously, employee safety will need to be targeted to improve the work environment and retain aging staff.
Minimizing workplace stressors can be a significant element of job satisfaction (O’Brien-Pallas, Duffield, and Alksnis 2004). Because a perceived high workload can result in an increase in musculoskeletal symptoms (Bongers et aJ. 1993), healthcare organizations may find it necessary to acquire ergonomic technologies that reduce the risk of physical strain and injury during the care delivery process (JCAHO 2002). Additionally, organizations should restructure their patient care delivery areas to be more ergonomically sensitive. Examples include adjusting the height of charting tables, purchasing comfortable and supportive chairs, installing good lighting, providing supportive floors, and supplying rubber floor mats for charting areas. Healthcare providers should also evaluate the equipment that is used for efficiency and ease of use (Cooper 2003). Motorized beds and on-3 lift devices can assist in patient care while alleviating the current physical demands of nursing work (Kuhar et al. 2004).
Atlanta Veterans Affairs Medical Center implemented an intensive ergonomic education program to aid in its efforts to retain older nurses. The education programs include teaching proper body mechanics, team lifting, and slide techniques. Additionally, it has implemented a no-lift policy for its nurses. Instead, specialized equipment, such as stretchers with sliding devices
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and beds that convert to wheelchairs, is used (Cearon 2003).
One common misconception about older employees is that they are more likely to be involved in workplace accidents. Although older workers make up 13.6 percent ofthe labor force, they account for only 9.7 percent of workplace accidents (Cofer 1998). Older and younger workers also have similar absenteeism rates (Beatty and Burroughs 1999). Illness and injury rates for hospital workers are above average regardless of employee age: In 2004, the U.S. Bureau of Labor Statistics indicated that hospital workers experience job-related injury and illness at rates that are among the highest in the workforce (BLS 2004). According to the Institute of Medicine, nursing is a hazardous occupation and nurses are exposed to a wide variety of health and safety hazards (Sunderlich, Sloan, and Davis 1996).
Health and safety accommodations should be targeted for older employees. Older nurses have been shown to experience higher levels of stress and job strain (Santos et al. 2003). This finding is particularly important given that 70.5 percent of respondents to Hart’s 2001 survey identified acute and chronic effects of stress and overwork as one of their top-three health and safety concerns. Employee wellness and preventive programs should be evaluated as investments that can offset escalated spending later on—in the form of treatment of employees’ chronic medical conditions and lost productivity costs (Leopold 2005).
F L E X I B L E S C H E D U L I N G In Holtom and O’Neill’s (2004) study of nursing job embeddedness, one of the most frequently cited retention issues among nurses has to do with a desire for increased flexibility in work hours. As nurses approach retirement age, often their desire for flexible hours increases. Job sharing and flexible self-rostering enable nurses to balance work and family commitments. These arrangements can give staff autonomy to determine how they will split their shared position to accommodate their lifestyle as well as help older nurses deal with the emotional and physical demands of the job (O’Brien-Pallas, Duffield, and Alksnis 2004). Another incentive that organizations can offer is a seniority-based decrease in weekend and holiday assignments (Cooper 2003), altbough organizations must evaluate the corresponding effect on staff-recruitment efforts.
The goal of many aging workers is to ratchet back their work commitment and give up responsibility, yet stay involved and active in the organization (Morton, Foster, and Sedlar 2005). SSM Healthcare, based in St. Louis, Missouri, offers scheduling options of 4, 8, 10, and 12 hours; transfer opportunities across seven facilities within the health system; long-term care insurance; and spending accounts in which employees can set aside pretax dollars to pay for dependent care and healthcare expenses that insurance does not cover (Pennsylvania Department of Health 2004).
E D U C A T I O N As a result of shortages of experienced staff, senior nurses often have the
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greatest difficulty receiving paid time set aside for attending classes, seminars, or other educational pursuits. Consequently, older workers often fall behind in acquiring new skills because they are not given the same education opportunities as are younger workers. According to Olson, employees are given the most training opportunities at the age of 40 and the least after 55 (Olson 1996). As a result, the longer a worker remains in a job, the more likely he or she is to require additional training (Schooler, Caplan, and Oates 1998). It is in management’s best interest to make a concerted effort to encourage experienced nurses to continue their educational growth.
Management assumptions of older employees’ inability or unwillingness to learn may propagate the onset of employee boredom and indifference toward the job. Disengagement among all employees increases over time. However, it may be more prevalent among those nurses nearing retirement, particularly if they have been in the same position or organization for a long time. Yet, it is not age or time as a nurse that predicts job disengagement; job disengagement is most closely predicted by time in the same job and, to a lesser degree, in the same hospital (McNeese-Smith 2000). Therefore, to combat job disengagement, manage- ment should act to ensure that employ- ees who have significant tenure in the same position continue to feel chal- lenged and stimulated in their work.
O R I E N T I N G E X P E R I E N C E D N U R S E S In addition to retaining current em- ployees, organizations that recruit older
nurses need to make accommodations for their training and orientation. While these nurses may be new to the organization, they come with a deep knowledge and experience that should be handled in a manner different from new entrants to the field. Accordingly, training and orientation should be tailored to the experience level of the employee. Orientation and acclimation to a new team should not be one- size-fits-all (Aon Consulting 2004). Additionally, the American Hospital Association (2002) recommends that hospitals develop customized reentry programs for people who have left healthcare careers but wish to return.
SALARY When determining a wage structure for nurses, it is important to balance the ability to recruit new staff with the desire to retain existing staff. Turnover costs should be considered when determining labor expenses at different wage rates. Assuming a turnover rate of 20 percent (the current average turnover rate among healthcare workers), a hospital that employs 600 nurses at $46,000 per nurse per year will spend $5.5 million per year in replacement costs (ICAHO 2002). Studies have shown that when organizations measure job satisfaction among nurses, they find that salary becomes an issue only if it is not competitive with that offered by other hospitals (AHA 2002).
One particularly important concern, given the aging of the RN workforce, is the timing of wage increases. The majority of wage growth tends to occur early in a nurse’s career. In 2000, full-time
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staff RNs viho graduated five years earlier had salaries 15 percent to 17 percent higher than that received by new nursing graduates with similar degrees. However, these same nurses were earning 1 percent to 3 percent less than nurses with 10 to 15 years more experience. This pattern that focuses on early-career wage growth, with low wage growth for experienced nurses, may factor into the decision of experienced nurses to leave patient care for careers outside of nursing (HHS 2002). Sixty-three percent of nurses reported in a study that they perceive not a lot of difference between the pay of RNs who have more experience and those with less experience, which leads them to think that “newness” is valued more than experience and retention (Reineck and Furino 2005). Compensation for an experienced RN, however, can change dramatically with a change in job position. As a result, pay ends up serving as a reward for changing jobs rather than increasing clinical competency or attainment of specialized clinical skills (Reineck and Furino 2005). Senior nurses, in turn, often feel that experience is not valued and that the only way to increase salary is to change their position, which removes them from providing direct patient care.
B E N E F I T S The American Hospital Association (2002) recommends that hospitals provide incentives to over-50 em- ployees for foregoing retirement and for continuing to work in their organizations. Offering benefits of interest to older workers—such as
long-term care insurance, preretire- ment planning, health and wellness programs, comprehensive medical coverage, health coverage for retirees and part-time workers, and prorated benefits for employees on flexible work schedules—will not only help retain aging but capable nurses, it will also help recruit experienced nurses from outside the organization (Morton, Foster, and Sedlar 2005).
A number of benefits and job elements are already being used to retain and recruit older nurses. These include benefit packages geared toward older employees, availability of eight-hour shifts when requested, reduced or part-time hours with either continuation of or prorated benefits, part-time hours and flexible shifts for older workers, eligibility to start retirement benefits to supplement part- time hours after age 60, appreciation gestures such as pins or stripes on a sleeve to recognize years of service, placement of older RNs in administrative positions when possible and using them to orient younger nurses, paid seminars for professional development, and scholarships for continuing education (Letvak 2002).
Bon Secours Health System in Richmond, Virginia, provides a discount on a quick-call monitoring service to its nurses who live with older adults and makes available a private-duty nurse at a subsidized rate to any employee with a spouse, parent, or parent-in-law requiring regular care (Pennsylvania Department of Health 2004). Baptist Health South Florida allows employees to take leaves of absence for as long as five years
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without losing seniority and permits workers over 59-and-a-half years of age to tap their retirement accounts while still working for the company (Shellenbarger 2005). Principal Financial Croup in Des Moines, Iowa, has a program through a temporary- help agency that enables employees to retire, begin drawing on their pensions, and return to work as temporary staff (Shellenbarger 2005).
CONCLUSION
Civen the challenges presented by projected nursing shortages and staff aging, healthcare organizations need to ensure that they are providing their nurses with job qualities, rewards, and work environments that increase their nurses’ job embeddedness and job satisfaction while accommodating their desires for work flexibility and reduced physical demands of providing care. The nurse manager plays an essential role in this effort. Organizations must ensure that their nurse managers are well equipped, available, and prepared to help support and retain the nursing staff. The cultural change that organizations may need to undergo to create an environment that recognizes, accommodates, and appreciates its older workers reaches far beyond enhancing a pension plan or providing elder care. It requires changes to the workflow, scheduling, facilities, and, perhaps most importantly, management style.
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