Staff recruitment and retention is vital but different generations have different needs and expectations that require different strategies to address them
Every year increasing numbers of nurses and midwives leave the NHS. In the current climate of staff shortages it is crucial to understand why this is happening and try to resolve the problem; in Birmingham we have taken steps to do this. This article explores the different workforce generations, along with strategies that could enhance nursing and midwifery careers, ensuring they meet the needs of all generations, thereby encouraging practitioners to stay in their profession for longer.
Citation: Jones K et al (2016) Meeting the needs of four generations of nurses. Nursing Times; 112: 21/22/23, 12-15.
Authors: Kerry Jones is head of clinical workforce re-design; Michelle McLoughlin is chief nurse; Sara Brown is deputy chief officer for workforce/head of education and organisational development; all at Birmingham Children’s Hospital. Alison Warren is lecturer practitioner, clinical skills and simulation (child) at Birmingham City University and delivers practice education at Birmingham Children’s Hospital. Alison Davies is practice placement support sister, University Hospitals Birmingham Foundation Trust. Isabel Jamieson is principal lecturer – nursing, Ara Institute of Canterbury, Christchurch, New Zealand; Linda Crofts is head of learning and development, Sheffield Teaching Hospitals Foundation Trust.
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During 2014 7,500 nurses and midwives retired from the NHS and 17,800 left before retirement (National Audit Office, 2016). The percentage leaving has risen every year since 2011/12, when it stood at 7.7%; 8.6% left the service in 2014/15 (Health Education England, 2016). Understanding why these professionals leave, and selecting appropriate strategies to promote retention is crucial.
In 2014/15, in response to growing concerns about the turnover of early-career nurses and midwives, chief nurses and employers across Birmingham initiated a project to identify risks and opportunities to enhance retention. Supported by HEE, the project engaged 600 students and newly qualified nurses and midwives across the city and asked them what was important to them in their professional life. The results were published as Mind the Gap (Jones et al, 2015).
The report shows generational concepts need thought if we are to appropriately support nurses and midwives as they begin their careers. Four generations will be working in the same environment, so understanding their different motivational needs offers employers and education providers a chance to better align support to meet individual needs and improve recruitment and retention.
Four generational cohorts are either employed or in higher education undertaking practice placements: Baby Boomers, Generation X, Generation Y and Generation Z (Fig 1, attached). Baby Boomers and Generations X and Y dominate the NHS, while Generation Z is beginning to graduate from higher education. Jones et al (2015) stress that broad descriptions can lead to stereotyping so their categories should be considered a general guide to understanding only (Lower, 2008).
“Generational cohort” assumes that people with similar birth years have a shared history and life experiences, along with similar attitudes, beliefs, values and preferences about work and career (Arsenault, 2004). Hu et al (2004) highlighted that today’s workforce is more diverse in age than ever and the characteristic differences in age groups play a major role in people’s experiences at work. However, we must be cautious in presuming that everyone from a particular generation will have the same needs and motivations.
Some think generational differences in the workplace are less marked – that, while there are some distinctions, there are also many commonalities; they warn that using these categories too broadly could promote negative stereotyping at work (Kriegel, 2016; Heller Baird, 2015; Lester et al, 2012). Used discerningly, however, generational typologies can indicate possible nuances in attitudes that may influence engagement and retention at work.
Jones et al’s (2015) findings relate mainly to Generation Y. The career intentions of younger generations in the nursing workforce may differ from those of their predecessors. While passionate, highly committed and hard working, they may not feel tied to any one employer, role or profession. They value:
- Clear, structured career development and progression pathways;
- Care and support (personally and professionally) from leaders and teams;
- Feedback, guidance and developmental support;
- Team spiritedness – to be accepted and valued;
- Flexibility to achieve a work–life balance;
- Being supported and enabled to meet the expectations of patients and the public (by having the resources to deliver high-quality services).
Most employees might have similar needs and aspirations, but evidence suggests Generation Y is more likely to change employer, role or profession if these are not met. These findings resonate with much of the nursing and non-nursing literature – stark similarities can be seen in Jamieson’s (2012) work. It is therefore imperative that the nursing profession, employers and policy makers collaborate to design a workplace and conditions that motivate Generation Y nurses to stay in the profession for the long term.
Baby Boomers and Generation X
“What a shame my trust is letting me retire. I have a wealth of knowledge and skills that I am sure I can pass on in a different role that would support me later in my career rather than retire early.”
One year after the original work was completed we obtained a snapshot of nurses’ views by asking a small number of them from different generations their opinions on career progression. Of those with whom we spoke, there were three key types of response:
- Keen to continue working and “making a difference”;
- Looking forward to retiring from the NHS (but not averse to working in non-healthcare roles);
- Keen to continue to contribute but in different role, if possible.
Baby Boomers expressed how different the profession is compared with when they started. They expect a good pension but would consider retiring and returning to nursing if the role, pay and hours were agreeable. When entering nursing, they expected to make it their career. Those still in clinical practice explored opportunities in less-demanding “non-clinical” roles with less responsibility and more sociable hours. Most are due to retire within 10 years.
Generation X may have over 25 years’ experience and has witnessed several decades of change in the NHS. This is a self-reliant generation of pragmatic, independent, practical learners who provide a backbone of support. The loss of this generation will mean there is less expertise and support available for junior staff. Many are looking for supportive or educational roles with sociable hours, but some discussed retiring early and moving out of the NHS.
“I’ve been nursing for 25 years and I’m ready to take on a new challenge as a specialist educator. I could utilise all my skills and knowledge better than I do on the ward, although I am looking forward to retiring.”
Baby boomers and generation X were frustrated with how their autonomy, expertise and experience were being eroded by the “tick-box culture” of a process-driven and politically influenced healthcare system. They felt much of what they had to do did not add value or give them flexibility to prioritise and meet individual patient needs. This shows we must also consider the needs and opportunities for older, as well as younger, generations. We will lose both cohorts in the next decade so must ensure they work for longer if we are to grow and build a resilient future workforce.
“I am going to see how I do in my training and if I like being a nurse/midwife. Maybe I’ll see how I feel when I’ve finished.”
This generation will have a much broader outlook on nursing and midwifery. Current students are unsure about devoting their entire career to the profession; if they stay, they don’t want to be clinical nurses for too long before specialising and moving towards roles that will enable them to expand their careers. They find documentation and processes cumbersome and, as true digital natives, are acutely aware of how technology can help, of how information can be recorded, accessed and cascaded. They see NHS systems as disjointed and obstructive.
This generation will seek a role that is fulfilling, yet not too physically or emotionally demanding. Many said they only look at short-term options and not beyond a five-year plan. This could significantly affect workforce supply if role tenure shortens and mobility increases as these professionals search for the perfect role.
The findings discussed above stress the need to re-focus on how we support and encourage all generations of nurses to work in the profession for longer. Many organisations are starting to consider how they can enhance engagement and retention across a multigenerational workforce.
Sheffield Teaching Hospitals Foundation Trust
This large trust comprises five hospitals, 40 community locations, 16,000 staff, has an annual budget of £1bn and sees two million patients a year. Unregistered staff are predominantly local but it is also a popular destination for healthcare students. For many years the trust had high nurse retention and was spoilt for choice in recruiting newly qualified nurses from local universities.
The current workforce challenges in the NHS are now affecting Sheffield, albeit not to the same extent as other organisations. The trust is actively exploring what it can focus on to remain a destination of choice – this is an excellent opportunity to incorporate some of the themes from Jones et al’s (2015) report in several workstreams.
With its university partners, BCH is undertaking a “root and branch” review of practice placements, of which it can have 400 at any one time. Placement quality is high and feedback from students positive, but the analysis of Generation Z characteristics suggests STHFT should consider giving students on its database more personalised information and ensure they are notified and adequately supported when placements change at short notice due to service reconfiguration. A small team is exploring placements that follow patient pathways and other previously unconsidered areas that may support learning outcomes such as cardiac catheterisation labs and the metabolic bone unit. The first of these is now being piloted.
However, there is also a need to work with existing qualified staff, particularly Baby Boomers and Generation X, on the support and feedback needs of students on placement. Many such staff trained in an era when students were expected to “just get on with it” and may not realise that Generations Y and Z want a different experience and different feedback mechanisms. This is particularly important in light of the bursary changes – new students may see themselves as consumers and expect more placement choice. Generation Z students seek quicker gratification and real-time feedback. STHFT is exploring the use of apps so students can access information on their smartphones and tablets and provide real-time feedback.
The trust is looking to redesign preceptorship and the first few years of newly qualified practice. Currently it “matches” newly qualified nurses and their preferences with vacancies in the organisation. This has worked well to a point but there are now more vacancies than staff to fill them and recruitment is consistently easier in some areas. A transfer register was previously developed to facilitate nurses moving to equivalent-grade posts elsewhere in the trust – this shows that some areas still appear to be net gainers.
Generation Z wants varied experience in the early practice years, frequent feedback and more structure than previous generations so STHFT is developing a two-year newly qualified programme that rotates through clinical areas, including community care and those that may not have been part of pre-registration. The two years will incorporate preceptorship, clear learning objectives, specialist study days, teaching and assessing. The rotation opportunities should enhance staff satisfaction, helping to retain nurses in all specialties.
A “career elevator” has been established. It includes bands 1-4, identifies different entry points for the myriad of clinical careers that are evolving and maps into the Talent for Care framework (HEE, 2014). It is constantly reviewed so there is something to meet the needs of all four generations in the workforce. It also includes all apprentices aged 16-18, who must give a high level of commitment and professionalism. By ensuring they have regular access to a workplace tutor, time in college with their peers, a clear structure and regular feedback, STHFT hopes to continue building on its excellent track record of converting apprentices into clinical support workers.
Birmingham Children’s Hospital
Birmingham Children’s Hospital (BCH) Foundation Trust provides a wide range of health services and has over 270,000 patient visits every year. BCH is a nationally designated specialist centre in several areas – it has one of the largest child and adolescent mental health services in England with an eating disorder unit and acute assessment unit for regional referrals of young people with the most serious problems.
BCH has been working with all staff to build great teams and promote an environment focused on caring for staff and promoting their wellbeing. Getting it right for staff ultimately means getting it right for the children, young people and families for whom it cares.
The trust had been doing significant work on staff support but when it shared findings from the generations project, it found people had suddenly understood the need to recognise what all generations across the workforce wanted. This resulted in richer conversations between staff, allowing them to explore solutions together. The importance of considering how to support all staff was recognised, leveraging differences across the generations to enhance team working and retention.
Although at an early stage of implementing developments, BCH has already:
- Introduced pre-registration student nurse scholarships, which has promoted a sense of belonging and enhanced student social integration;
- Introduced a student wellbeing champion to enhance care and support, and build a social community for students;
- Designed a new career framework that signposts development needs and multiple pathways open to nurses at all stages of their career;
- Introduced a transition and early career programme to support the move from student to newly qualified practitioner;
- Started work to introduce new options for staff rotation and a “beyond newly qualified” development programme to equip people for the next stage of their career;
- Begun to explore the use of shared governance to aid greater involvement in decision making and empower staff to lead change at all levels;
- Considered and begun facilitating, early career engagement in research, improvement work and health policy. Through this it aims to promote a sense of progression and challenge, and provide greater understanding of how individuals’ work contributes to the wider healthcare system;
- Begun reviewing senior roles and age profiles to help those nearing the “autumn” of their career to look at other opportunities and work for longer;
- Introduced a range of wellbeing interventions to support practitioners at all career stages.
Supported by HEE, BCH’s chief nurse is working with local universities and other chief nurses across Birmingham to identify potential high-impact actions that will promote retention across the generations. It is hoped the outputs of this work can be used to further develop its attraction, engagement, development and retention strategies.
Conclusion and next steps
Many of the foundation stones for effective attraction, engagement and retention apply to all staff but it is important to acknowledge that generational nuances may influence individual motivations and choices across the workforce , and to adapt strategies accordingly. With this in mind a second phase of work has recently started. Hosted by Birmingham chief nurses and supported by HEE, Narrowing the Gap aims to work with key generational reference groups to identify practical, high-impact actions that could enhance “gen-gagement” and retention across the workforce. This will also scope national/international developments initiated in this area to create a shared repository that can be used by employers as a retention toolkit.
As described by Lester et al (2012), if nothing else, it is important that we embrace the differences between generations. By recognising them as strengths, rather than challenges, and establishing common ground and a clearer understanding of what colleagues really value, we can work together in a more positive and productive way.
Box 1. New Zealand: attitudes of Generation Y nurses
During 2009/10 an online national survey of 358 Generation Y New Zealand registered nurses aged <30 years was undertaken to elicit their views about nursing, work and career. They were driven by traditional values of altruism, the desire to care for others, the ability to work closely with people and being able to contribute to society. They sought interesting, challenging, exciting work. Job security, the ongoing demand for nurses, the ability to leave and return, and the ability to combine work and family, were also factors that helped them to decide to become nurses.
They were satisfied with their decision but very clear that nursing does not define them. They appeared set to remain in the profession for at least five years, with many wanting to increase their clinical skills and undertake postgraduate study. However, while they demonstrated a high level of affective commitment towards nursing, they did not show a high level of continuance or normative commitment. It is questionable whether they plan to stay in nursing long term.
These nurses found nursing more stressful and challenging than anticipated and expressed concern about salaries, bullying, how shift work would affect their private lives, older peers not being supportive, managers’ and management’s apparent lack of recognition of nurses’ contribution to patient care, and the public’s lack of understanding about their role.
Most young New Zealanders who decided to become nurses did not regret the decision. Some wanted promotion, most wanted to stay in a clinical role at the bedside but, on the whole, they did not appear committed to the profession.
Source: Jamieson (2012)
- Staff shortages are a common problem in the NHS
- It is vital that trusts improve their ability to recruit and retain high-quality staff
- The needs and expectations of staff may vary depending on the generation to which they belong
- Only by recognising what different groups are looking for, can improved recruitment and retention be achieved
- Differences between generations should be viewed as strengths not challenges
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