Hospitals & Health Networks magazine
March 2005

What Nurses Want

By Jan Greene
Different Generations, Different Expectations Gloria Boehm-Yu, former actress and fitness trainer, is working toward her bachelor of science degree in nursing at San Francisco State University. At 37, she's an idealistic member of Generation X who expects to become an active, vocal member of a patient care team, use an electronic patient record and be offered her choice of flexible shifts. She plans to love her job or leave it.

"I always place myself in an environment where I love what I do," she says. "You won't find me as one of those grouchy nurses, all they do is complain. If it got that bad, I'd move on."

But when Boehm-Yu gets her first full-time job as a hospital RN this summer, she will likely be in for a reality check. Some of the assumptions she makes about her job--that her work will be collaborative with other health professionals and that she can balance it with her personal life--are out of step with the way health care has worked for decades. Many hospital leaders are far behind the curve when it comes to acknowledging the changing expectations of a new generation of nurses and adapting the workplace to accommodate them--even as staffing shortages make it imperative that they do so.

Boehm-Yu and others new to the health care workforce may also find that their outlooks contrast sharply with those of the veteran nurses they work with. In many hospitals, for the first time four generations of RNs are working side by side and they often have quite different expectations for their lives and jobs. That can create serious tension among colleagues already highly stressed by the very nature of their work.

Even typically dry social science research describes the day-to-day friction among the different generations of nurses in vivid terms: "They bicker incessantly, complain of bad faith, and harp on each other's hypocrisy and propensity for betrayal when things go wrong," write Sandra Swearingen, continuing education coordinator at Florida Hospital in Orlando, and Aaron Liberman, a University of Central Florida professor, in a 2004 paper in the quarterly journal The Health Care Manager. "Generation Xers see their predecessors as self-indulgent, incompetent, morally bankrupt and ruthlessly exploitative of the weak. Baby Boomers portray their young detractors as shiftless slackers unwilling to pay their dues and as rebels who expect free rides to the good life."

Ouch.

Nurse leaders acknowledge a deep divide between the older generations and the younger ones. "I've never seen as much intergenerational friction as in the last three to four years," reports Jo Manion, R.N., who writes and consults on creating a positive health care workplace out of her office in Oviedo, Fla.

To the chagrin of hospital leaders, the conflict boils down to higher turnover rates. Young nurses who walk in with their BS degrees, comfortable shoes and backpacks full of idealism too often walk away within a year, disillusioned by the drudgery of their jobs and what they call the "eat their young" approach of a few older workers.

The implication for hospitals is clear: Recruitment and retention plans must be based on a clearly understood profile of the new nurse and what she or he wants from the workplace. If these nurses in their 20s or 30s aren't offered or can't negotiate work terms they consider satisfactory, they'll simply walk out the door and pursue another career that better meets their expectations.

And it's not just younger nurses whose needs must be accommodated. Hospital executives can ill-afford to alienate their highly experienced, longtime staff; indeed, as nurses age, certain changes in the workplace will be necessary to keep them happy and on the job for years to come.

Your Dismay is Beside the Pooint

Managers might consider Xers and Nexters (those in their teens to early 20s, also called Generation Y) lazy or uncommitted when they turn down a last-minute request to cover an extra shift--evidence of a kind of generationwide character flaw when compared with the workaholism of the so-called Boomers and Matures that has fueled hospitals for decades. Nonetheless, the fact is that younger nurses expect a lifestyle that balances work and home, and hospitals will have to deal with that reality.

"They've depended upon this over-the-top zealousness and dedication from another generation," says Ed O'Neil, director of the UCSF Center for the Health Professions. "They don't have a lot of that waiting in the wings."

Manion argues that younger workers are every bit as motivated to serve patients as their predecessors are--and may be even more so.

"In some ways, younger nurses are more committed than their counterparts 30 years ago, because they have a lot of other choices and they chose nursing," Manion says. "They really are interested in becoming competent, they just don't want to sell their souls to do it."

Unfortunately, the typical hospital remains the antithesis of what younger workers are looking for, O'Neil's research indicates. It is hierarchical, old-fashioned, lagging in information technology. By contrast, Xers and Nexters highly value a workplace that is service-oriented, flexible, diverse, high-tech and has a sense of community among employees, from executives to staff.

The economic and cultural pressures that keep hospitals from that ideal may be changing, albeit at what young nurses consider a glacial pace. However, hospital leaders can undertake some important tweaks right now to make their workplaces more attractive, from talking openly about generational differences to offering support groups for new recruits.


Communication

Reducing tension among workers with dramatically divergent outlooks on life begins with bringing their differences out in the open. If they can learn to laugh at those differences, so much the better.

"The first step is to be aware that there are differences," says Barbara Brown, R.N., vice president of the Virginia Hospital and Healthcare Association. "They're not related to personality defects, but to their experiences since they were 8 or 9 years old." Brown holds sessions for hospital staffs, most effectively at the unit level. "When I teach people about this, they all start to laugh, and it becomes fun. Then it's a willingness of staff to use it and try to problem solve. You can use generational differences as another tool to deal with conflicts."

It's also helpful to know that Xers and Nexters have different ways of taking in information. Instead of sitting through a daylong lecture, they learn better online, working at their own pace, explains Justin Lombardo, director of the NM Academy at Northwestern Memorial Hospital in Chicago. And they don't like to wait a week for an evaluation of their work. "They want immediate feedback, regularly and continuously," he says.

Nursing preceptors at Northwestern use generational differences to work more effectively with new hires. "We now require preceptors to go through significant training, focusing on how different generations learn and how they want to be coached," Lombardo says. "We talk to nurses, nurse leaders and preceptors about getting engaged with the employee, giving them a face to relate to."

Flexible Shifts

Some hospitals have already restructured shifts to make them flexible enough to meet the dissimilar demands of younger and older staff. Nurses in their 20s tend to prefer 12-hour shifts grouped together so leisure time comes in contiguous stretches. Nurses with young children at home may also like to concentrate their work hours on weekends, so a spouse with a weekday job can watch the kids.

Michigan nursing student Laura Perkins, 34, feels torn when asked to work overtime. She is sympathetic to the pressing needs of hospitals, but is unwilling to compromise her family life.

"I believe that once your assigned days are worked, your commitment is fulfilled," says Perkins, a student at Macomb Community College in Warren, Mich. "Most people plan their life around work. I believe you need to have a set schedule."

On the other end of the spectrum, shorter shifts will be needed for Baby Boomers as they age. "Twelve hours is a long time to be on your feet," Brown notes. Flexible arrangements, including part-time shifts, might even encourage seasoned staff to continue working past retirement age.

Revised scheduling arrangements can also help attract younger nurses to management jobs. At Children's Mercy in Kansas City, Mo., nurse executive Karen Cox split up the nurse manager duties between two full-time co-managers. The arrangement spreads the burden of 24/7 coverage and allows each manager to spend a shift every week working alongside the bedside nurses.

"This way we're able to keep women of childbearing age interested in being a nurse manager," a particularly demanding job, says Cox, senior vice president of patient care services.

Better yet, as Cox documented in an article in the September-October 2004 Nursing Economics, the arrangement saved money by reducing turnover in the unit, presumably because the managers improved their relationships with individual staff nurses.



True Teamwork

Conflict can actually be useful when approached the right way, say Swearingen and Liberman, the researchers who described intergenerational combat on the nursing floors. "Conflict is a natural part of the team environment," they write, "and teams that can manage conflict will bring out the best of the team environment by generating a more open, creative and ultimately more productive team."

True teamwork allows younger workers to contribute ideas despite their low rank or lack of experience. "You can't expect to have all the answers," says Brown. "You solve it by working with others. You use the different groups to bring up the possibility of trying something new. I tell leaders, 'Take heart, you don't have to know all the answers, but you do have to provide a pathway for ideas to get to you.' "

That kind of openness is certainly what Boehm-Yu expects in her career. "I love team building and that environment, where you have incentives and motivations to participate as a team, and you share communication strategies," the nursing student says. "It seems like it's so easy to strategize through team leadership to be more efficient and make fewer errors and function more efficiently."

Younger nurses expect to be listened to as part of the clinical team, and to be treated respectfully by all team members--including physicians. Whereas nurses have traditionally deferred to doctors, even doctors who were rude and abusive, new generations are far less apt to do so. "They're more likely to walk," Manion says. "Although I don't think the younger generation is necessarily more assertive, I do think they are willing to tolerate less. They will just leave and move on."

That's a big heads-up for hospitals. "Your new nurses are smart, they have choices, and they want to be in an environment where they can self-govern and participate in decision-making around care choices," says Catherine Gilliss, dean of the Duke University School of Nursing. "And they'll migrate to the places where they can find it."

Technology

Hospitals may be inching their way into the 21st century with new electronic medical record systems, but probably not fast enough for the Xers and Nexters, who grew up with computers and rely on them day in and day out in their personal lives and education. They demand no less at work. "The Xers expect that technology will be the answer and resent writing the same thing in two or three places," Brown says. Where young recruits see basic, essential technology tools, too many hospital administrators see overpriced and unnecessary bells and whistles. "Right away you've got a setup for high turnover," Brown says.

One medical center invited a group of nursing grads to a job fair and couldn't entice a single one to work there. The snag: the hospital didn't have electronic health records, a major turnoff to the tech-savvy recruits. "Access to technology had become an expectation and they're looking at a workplace where they feel like they're back in the Stone Age," Manion says.

Mentoring And On-The-Job Training

It's common to hear veteran nurses complain that new graduates are unprepared for the realities of the hospital. Workplace experts say the same complaint has been heard over the years about every generation of young nurses. Given the ever-expanding amount of health care knowledge and deepening complexity of nursing specialties, it's hard to imagine that anyone could be prepared to walk right into a modern ICU ready to go, Manion says. "It's foolish to expect anything but that these new grads coming out will need extensive workplace training, mentoring and support," she says.

While these needs are intensifying at a time when hospitals have fewer resources available to meet them, experts say mentoring and clinical training are now musts, not options. "I do not recommend a hospital [to a new graduate] that does not give a good residency or some kind of preceptorship for at least six weeks, or a few more months," says Mary Ann van Dam, nursing student adviser at San Francisco State University.

In addition to showing a recruit the particular work processes at a hospital, a mentor can help explain the politics of working well with others. "The successful places are dealing with this by having mentors who teach them about communication patterns and behaviors," Brown says. That works best when the mentor and the new nurse are of the same generation.

While it's true that some nurses will leave and take their on-the-job training with them, Brown contends it's a worthwhile investment nevertheless. Because young nurses move around so much, they might very well return to their original employer eventually. "Hospitals need to look at things that make it easy for people to come back, to be really good employers because people will be in the workforce for a long time," she says.

Boehm-Yu, like many nursing students her age, has already been through a couple of careers before choosing to become an RN. And while she hopes to stay in the hospital environment for many years, she recognizes that the job is likely to take a physical and mental toll over time. Plenty of other fields beckon: disease prevention, health care policy, lobbying on behalf of nurses, for a few examples. She's already envisioning her first project to improve conditions wherever she gets a full-time job: a place where nurses can lie on mats and take stretching breaks midshift. "It's great for your feet and your back," says the former fitness specialist. And while that's something an employee might appreciate at whatever age, it's the kind of perk younger nurses will just assume hospitals will provide. "I hope the hospital industry will recognize the needs of the new generation of nurses," says Boehm-Yu.

Jan Greene is a freelance writer based in Alameda, Calif.

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This article 1st appeared in the March 2005 issue of HHN Magazine.