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Narrowing the Gap: considering gen-gagement
February 2017
Contents Foreword
Page 1
Acknowledgements
Page 2
Introduction
Page 3
Background
Page 4
Generational dimensions of job satisfaction
Page 5
Considering individuality
Page 7
Considering job satisfaction and retention
Page 7
Summary: considering gen-gagement
Page 11
How we conducted the project
Page 12
The project framework
Page 12
Outcomes
Page 17
What nurses and midwives told us: Generic themes
Page 17
A framework for enhancement
Page 32
Creating conditions for job satisfaction: generic
Page 32
Creating conditions for job satisfaction: gen-gagement
Page 36
Conclusion and Recomendations
Page 43
Appendices
Page 45
Appendix 1
Page 45
Appendix 2
Page 48
References
Page 49
Authors: Dr Kerry Jones, Magnet Programme Director, Nottingham University Hospitals NHS Trust Dr Heather Ingram, Lead Midwife for Education & Quality Lead for Nursing and Midwifery, Keele University Dr Nageen Mustafa, Research Assistant, Keele University
Foreword For the first time in history four different generations are working together in the same employment environment. The initial phase of this West Midlands hosted work stream resulted in the production of a report titled Mind the Gap: exploring the need of early career nurses and midwives in the workplace. Narrowing the Gap is the second phase of this piece of work that aims to better understand factors that influence different generations of nurses and midwives to remain working in the profession. It also explores ideas about how we design and support great nursing careers and retain and grow a resilient future workforce.
Professor Lisa Bayliss-Pratt Director of Nursing
With this in mind, our work has highlighted that there are generational concepts that require consideration if we are to appropriately support individuals in their careers. This report seeks to understand these differing motivational needs across generations to offer employers and education providers a real opportunity to better align support to meet individual needs and to enhance career development. It is with great pleasure we share the findings of this work with you to support our incredibly talented workforce and we would like to thank all those who have supported and contributed to this project.
Mandy Shanahan Local Director – West Midlands
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Acknowledgements We would like to thank all those who have supported and contributed to this project including: Directors of Nursing and staff from across Birmingham and Solihull; NHSI for their help with wider communication; and administrative staff at Birmingham Children’s Hospital and Keele University School of Nursing and Midwifery who have helped to co-ordinate a complex range of activities.
Most importantly, we would like to recognise and thank all the nurses and midwives that have contributed to the work. They demonstrated professionalism, courage, commitment and passion for their profession; even though they sometimes face challenges in enacting their role within the current healthcare system. They contributed valuable ideas, pragmatic solutions and shared their innovations, expressing a real desire to collaborate in designing and implementing future improvements.
Introduction Narrowing the Gap presents the findings of a project hosted in Birmingham, West Midlands. It was designed to identify opportunities to enhance job satisfaction and retention across four generations of nurses and midwives. This report does not aim to provide a definitive evidence base relating to nursing and midwifery job satisfaction and retention but represents the voices of nurses and midwives at the frontline (staff within bands 5 to 8), highlighting important conditions for job satisfaction as defined by them. Nurses and midwives views and job satisfaction concepts have been used to develop a guiding framework to enhance job satisfaction and retention. The framework aims to provide a guide for those developing strategies to enhance nursing and midwifery career development and
retention. Aligned to this framework, a selection of resources is provided which include: participant ideas, national mini case studies, and other useful information. Whilst this work initially focused on exploring differing generational perspectives, it soon became clear that essential conditions for job satisfaction were, in the main, generic. This said, generational nuances did emerge in relation to the areas different groups felt were most important them. Enhanced professional autonomy and flexibility to manage work-life balance emerged as critical determinants in job satisfaction for nurses and midwives in all generations, fields of practice and organisational settings. Whilst this project was conducted within an academic framework, this report has been structured in a broadly accessible format.
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Background During 2014 approximately 17,800 nurses left the NHS before retirement and another 7,500 retired (National Audit Office, 2016). The percentage of nurses and midwives leaving the NHS has risen every year since 2011/12, increasing from 7.7% to 8.6% by 2014/15 (Health Education England, 2015). Understanding why nurses and midwives are leaving the professions and selecting appropriate strategies to promote retention is critical; especially in the context of existing workforce supply shortages. The West Midlands (Birmingham locality) hosted a programme of work to better understand the factors that influence retention of nurses and midwives.The outcomes of the first phase of this work can be found in the report Mind the Gap: exploring the needs of early career nurses and midwives in the workplace (Jones, Warren & Davies, 2015). For the first time in history four different generations are working together in the same
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employment environment. There are generational concepts that require consideration if we are to appropriately support individuals in their careers. Generational nuances related to expectations, perceptions and motivations are highly relevant in terms of staff engagement, career progression and retention. Understanding differing motivational needs across generations offers employers and education providers a real opportunity to better align support to meet individual needs and to promote career development. Narrowing the Gap aimed to build on the Mind the Gap findings by working locally with chief nurses and key generational reference groups to identify high impact actions that could potentially enhance job satisfaction, career progression and retention. Related innovations and developments already initiated nationally and internationally were also scoped as part of this work.
Generational dimensions of job satisfaction There is a range of literature surrounding generational dimensions of job satisfaction, an overview of which can be found in appendix 1. Typically the literature highlights that the age of the individual may be a predicator as to whether or not they have job satisfaction and consequently stay in the profession (Currie and Hill, 2012). Equally it is highlighted that there may be differences among generations (baby boomers, generation X, and generation Y) in a number of areas that influence job satisfaction (Keepnews, Brewer, Kovner & Shin, 2010). Sherman (2006) asserts that nurse leaders must recognise and create a work environment that values generational differences; and supports the needs of each individual in their workforce. Further, it is said that nurse leaders should utilise the literature about generational cohorts in the nursing and midwifery workforce to create leadership strategies (Jones et al, 2015; Sherman, 2006). In terms of motivation, research demonstrates that as different generations have had different experiences, these help to shape preferences about how a generation wants to be coached and
motivated by those who lead them (Duchscher & Cowin, 2004). Facilitating the growth and development of staff is an important nursing leadership function. Yet in the presence of a generationally diverse workforce, this is not an easy task. Following are summary recommendations for nursing leaders who are leading a multigenerational workforce and enabling that workforce to thrive and to meet tomorrow’s healthcare challenges: • Seek to understand each generational cohort and accommodate generational differences in attitudes, values, and behaviours. • Develop generationally sensitive styles to effectively coach and motivate all members of the healthcare team. • Develop the ability to flex a communication style to accommodate generational differences. • Promote the resolution of generational conflict so as to build effective work teams. • Capitalise on generational differences, using these differences to enhance the work of the entire team.
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Generational traits in pictures A summary of key generational traits, taken from Mind the Gap: supporting the needs of early career nurses and midwives in the workplace (Jones et al, 2015).
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Considering individuality Broad descriptions of any generation can lead to stereotyping and hence their categories should be considered a general guide to understanding only (Lower, 2008). ‘Generational cohort’ assumes that a group of people have similar birth years, history, shared life experiences, have similar attitudes, emotions, beliefs, values and preferences towards work and career (Arsenault, 2004). Herrick and Hodgkin (2004) highlight that today’s workforce is more diverse in age than ever before and that unique characteristic differences are playing a major role in peoples experiences at work. Generations tend to understand each other and find greater comfort with each other. This said we must be cautious in presuming that everyone from a particular generation will have the same needs and motivations. Some consider that generational differences in the workplace are less marked, stating that whilst there are some distinctions among the generations there are also many commonalities in relation to what people want from their work and career. They also strongly warn that use of these categories too broadly could promote negative stereotyping in the workplace (Lester, Standifer, Schultz & Windsor, 2012; Heller Baird, 2015; Kriegal, 2016). This said, used discerningly, generational cohort typologies do offer a lens through which to consider potential differences in attitudes to work and career that may influence job satisfaction and retention. Whilst there are conflicting views in the literature in relation, to the influence generational differences have on job satisfaction and retention what is clear is that some groups, such as younger generations, are more likely to leave their jobs if job satisfaction is not achieved (Jones et al., 2015).
Considering job satisfaction and retention The literature review highlighted the complexity involved in understanding factors influencing job satisfaction and retention beyond generational dimensions. Effective retention strategies in the nursing and midwifery workforce can only be applied when the underlying causes for why nurses decide to leave are identified (Van der Heijden, Kummerling, Van Dam, Van der Schoot, Estryn-Behar & Hasselhorn, 2010). In terms of the nursing profession, Currie and Hill (2012) have highlighted that with the number of complex inter-related factors influencing a dynamic workforce, identifying one stand alone factor is difficult.
Used discerningly, generational cohort typologies do offer a lens through which to consider potential differences in attitudes to work and career that may influence job satisfaction and retention"
Research has found that job satisfaction is a predictor of staff retention (Cowin, Johnson, Craven & Marsh, 2008; Wilkins & Shields, 2009). However, job satisfaction can be related to a variety of factors and meanings relative to the individual, including: work environment, work load, management style, level of remuneration, career-specific factors, possibilities for career development and ethical climate of the organisation in which they work (Vandenberg & Nelson, 1999; Goldman and Tabak, 2010; Currie and Hill, 2012; Vandenberg and Nelson, 1999). Job satisfaction has been found as a predictor of employee’s performance, commitment and staff turnover in the workplace (Williams and Anderson, 1991; William, 1997; Dugguh & Dennis, 2014). Dugguh and Dennis (2014), 07
reported on the close link between organisational performance and productivity and psychologically balanced employees who are motivated and satisfied. In addition, they have found that the working environment needs to be able to not only attract but to retain staff in order to succeed (Dugguh & Dennis, 2014). In order to develop a framework for improvement further consideration was given to the key determinants of job satisfaction as described in the literature. The earlier job satisfaction literature proved most useful and helpful in terms of understanding our participant’s voices.
Job satisfaction has been found as a predictor of employee’s performance, commitment and . staff turnover in the workplace."
Maslow’s (1954) Hierarchy of Needs There are a number of features that impact upon job satisfaction and a number of theories that have been developed to understand how people’s needs may be satisfied. One of the most influential is Maslow’s Hierarchy of Needs (1954). Maslow’s theory outlines how people satisfy various personal needs through their work and a general pattern of needs that people follow in generally the same sequence. This includes: 1. Biological and physiological needs - air, food, drink, shelter, warmth, sex, sleep. 2. Safety needs - protection from elements, security, order, law, stability, freedom from fear. 3. Love and belongingness needs - friendship, intimacy, trust and acceptance, receiving and giving affection and love. Affiliating, being part of a group (family, friends, work). 4. Esteem needs - achievement, mastery, independence, status, dominance, prestige, self-respect, respect from others. 5. Self-actulisation needs - realising personal potential, self-fulfillment, seeking personal growth and peak experiences. It has been asserted that an individual's desire to fulfil such needs will become stronger the longer they are not met and that lower level needs must be met before progressing to higher level needs (Benson & Dundis, 2003). Furthermore, it should be recognised that all levels of this model are dependent on the individual's needs and so may be defined differently depending on the individual (Benson & Dundis, 2003). Gawel (1997), suggests that when individuals do not correctly articulate what they want from a job, employers tell them what they want, based on what managers believe most people want under the circumstances. Alternatively, Herzberg, Mauser and Snyderman (1959), proposed that understanding an employee’s attitude towards work is the key in revealing motivation.
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Herzberg et al. (1959) Motivation-Hygiene Theory Herzberg et al.'s (1959) theory outlines the motivator-hygiene factors thought to explain satisfaction and motivation of employees working within an organisational setting. This theory focuses on outcomes of satisfaction (happy feelings or a good attitude within the worker and therefore motivation) and dissatisfaction (feelings of unhappiness or bad attitude not directly related to the job itself, but to the conditions that surrounded doing that job). Specifically, Herzberg et al. (1959) states that factors which lead to satisfaction and dissatisfaction are different, thus, the opposite of job satisfaction is not job dissatisfaction but instead no satisfaction or a lack of satisfaction and vice versa. Therefore, according to this model, factors that lead to job satisfaction and dissatisfaction come from different motivation and hygiene factors. Motivation factors can be viewed as those elements which satisfy individuals' wants to support their performance at work whereas hygiene factors reflect conditions within the working environment, e.g. organisational policies, that impact upon the individual (Gawel, 1997). Motivators (intrinsic within the work itself) described by Herzberg et al. (1959) include: • Achievement: Making sure employees know what their goals and strategies are, receive regular, timely feedback on performance and feel they are adequately challenged in their jobs. • Recognition: Refers to the honour, favourable note or attention given to an employee for a ‘job well done’ or an outstanding behaviour. The individual’s success does not have to be monumental before they deserve recognition. • Work itself: This involves helping employees believe that the task they are doing is important and meaningful. • Responsibility: Granting additional authority to employees in their activity, provide opportunities for added responsibility. • Opportunity for advancement or promotion: This involves electing employees from the present job or position to a higher one or level in the organization. If possible permit
and support them to acquire higher certificates so that they could become experts themselves and make them more valuable to the practice and more fulfilled individuals (Weir, 1976; Syptak, Marsland, Ulmer, 1999; Dugguh and Dennis, 2014). Hygiene factors (extrinsic entities which do not pertain to the worker’s actual job) by Herzberg et al. (1959) are: • Pay (salary): If an employee perceives that he is not fairly compensated, he will not be happy and so slow the pace of performance. Comparable salaries and benefits, clear policies relating to salaries, increments, bonuses and benefits must be clearly indicated to avoid dissatisfaction. • Supervision: Positive feedback and a set means of evaluating or appraising employees. • Working conditions: The provision of modern equipment and facilities, quality furniture, well ventilated offices, well spaced offices, secured, well spaced staff quarters. • Company policies, administration and procedures: Policies, administration and procedures should be clear. Policies may not make employees satisfied and motivated but one can decrease dissatisfaction by making policies fair and applicable to all. • Interpersonal relationships: Relating well with peers, managers and subordinates encourages job satisfaction. • Status: This is a person’s social rank in a group, which is often determined by a person’s characteristics, in addition to the person’s formal position. The issue of status should also be diluted to avoid a situation whereby those with higher status will not influence members having lower status. • Job security: When there is no job security, an employee’s needs for higher growth will be blocked. If he works hard but security does not return, he will seek to fulfil his needs elsewhere or burn out (Dugguh & Dennis, 2014).
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Herzberg et al.'s (1959) model has been linked to Maslow’s (1954) theory, in that motivators lead to positive job attitudes because they satisfy the worker’s need for self actualisation, which is the individual’s ultimate goal according to Maslow’s (1954) hierarchy model. Locke’s (1969, 1976) Range of Affect Theory Alternatively, Locke’s (1969, 1976) Range of Affect Theory purports that satisfaction is determined by a discrepancy between what an employee wants in a job and what he has in a job. Specifically, this theory suggests that the employee assigns different levels of value to different aspects of their work which, in turn, impacts upon levels of satisfaction or dissatisfaction felt by the employee dependant on the outcome of each aspect of their work. Locke’s theory (1969, 1976) indicates that satisfaction rating incorporates the judgment of importance and the range-of-affect hypothesis. Wu and Yao (2006), comment how this hypothesis involves two judgements involving firstly a discrepancy between the perception of what an individual has as opposed to what an individual wants, and secondly how this influences the individual's satisfaction. Items with high personal importance had the potential to produce a wide affective reaction ranging from great satisfaction to great 10
dissatisfaction and items with low personal importance, led to a restricted affective reaction to the neutral point of the satisfaction–dissatisfaction dimension. Therefore, dependant of the level of discrepancy the satisfaction rating on any given item is determined by the item importance. Therefore, the level of satisfaction for an item is determined by both the have–want discrepancy as well as the importance of the item. Both item importance and item discrepancy determine the level of item satisfaction (Wu & Yao, 2006). Hackman and Oldham (1976) Job Characteristic Theory In contrast, the Job Characteristic Theory (Hackman and Oldham, 1976) proposes a model that specifies the conditions under which individuals will become internally motivated in their jobs and therefore enrich an individual’s job role in an organisational setting. The model focuses on the interaction of three classes of variables: • (a) The psychological states of employees that must be present for internally motivated work behaviour to develop • (b) The characteristics of jobs that can create these psychological states • (c) The attributes of individuals that determine how positively a person will respond to a complex and challenging job. (Hackman & Oldham, 1976).
Further, this model outlines the core job characteristics that impact upon job outcomes. These include: • Skill Variety - the degree to which a job requires a variety of different activities in carrying out the work and involves the use of different skills and talents of the individual • Task Identity - the degree to which the job requires completion of a ‘whole’ and identifiable piece of work. That is, one that involves doing a job from beginning to end with a visible outcome • Task Significance - the degree to which the job has substantial impact on the lives or work of people in other departments in the organisation or in the external environment • Job Autonomy - the degree to which the job gives the employee substantial freedom, independence, and discretion in scheduling the work and in determining the procedures to be used in carrying it out • Job Feedback - the degree to which carrying out the work activities required by the job results in the individual obtaining direct and clear information on the results of his performance (Hackman & Oldham, 1976). This theory acknowledges that these core characteristics do not affect individuals in the same way, but are dependent on personal attributes. In particular, it is asserted that the core characteristics affect those who have a greater need to achieve a sense of psychological growth in their work (Dugguh & Dennis, 2014).
Summary: considering gen-gagement It is evident then, in order to develop and implement successful workforce development strategies it is important to identify the needs and workplace conditions that will support job satisfaction and retention for all generations; broadening our current thinking to consider how we develop strategies that promote successful workforce gen-gagement. To reflect this, the scope of the Narrowing the Gap work was broadened to enable us to differentiate and identify generic and generation-specific opportunities for improvement.
Recognising and addressing the needs of all generations in the workforce, creating an environment that supports them to: deliver in line with their potential; remain motivated; have a sense of wellbeing; and remain in the workforce"
Reviewing significant literature provided insights around differing approaches to satisfaction with work. Both Maslow’s (1954) Hierarchy of Needs and Herzberg et al.'s (1959) Motivation-Hygiene Theory proved most relevant when listening to and analysing the data.
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How we conducted the project The project framework
for longer. We identified areas of consensus and the most popular ideas for change and improvement.
Dick’s (1993), adaptation of Checkland’s soft systems methodology was used as a framework to identify potential high impact actions that would support career development and retention for all generations of nurses and midwives in the workforce. In this approach, Dick (1993), represents Checkland’s (Checkland, 1981; Checkland & Scholes, 1990), soft systems methodology as a system of inquiry using a series of dialectics. For each dialectic you alternate between two forms of activity, using one to refine the other (appendix 2). In phase (dialectic) 1 We asked nurses and midwives across Birmingham and Solihull to identify key actions that would encourage them to remain working in the profession
In phase (dialectic) 2 We used an adaptation of Maslow’s (1954), hierarchy of needs and Herzberg et al.’s (1959), job satisfaction model as a theoretical base to map themes for change and improvement into a framework for nursing and midwifery job enhancement. In phase (dialectic) 3 We further explored ideas and developments implemented nationally and internationally and matched these to the job enhancement framework, creating a resource for those considering on-going strategies to enhance nursing and midwifery job design, career development and retention.
Dialectical enquiry using Checkland’s systems methodology as a frame (Dick, 2009).
Immersion in reality
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action
Proposed Changes
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1
3
Define the Essence
2
Invent an Ideal
Overview of the project Crowdsourcing
Development of a guiding framework to enhance nursing and midwifery job satisfaction.
Online conversation to scope high impact actions to enhance career development and retention. 110 participants across 4 generations. 1400 contributions and 42 unique ideas generated.
Generation specific workshops
Scoping of current developments / innovations already initiated to promote career development and retention in theme areas of job satisfaction model (national and international).
using consensus process framework to identify high impact actions for each generation Hosted in 6 diverse organisations 71 Participants.
Total 181 participants. Highest ranked ideas defined thematic analysis of narrative data. Cross cutting themes identified generic and generation specific.
Themes mapped to adaptation Herzberg et al. (1959) job satisfaction theory to create a model for nursing and midwifery job enhancement. Key themes for change and improvement defined.
Phase 1 About the crowdsourcing workshop The first phase of this project involved launching an online workshop (conversation) to seek views and ideas on how to support and encourage nurses and midwives across Birmingham and Solihull to stay working in the profession for longer. A purposive sampling matrix was used to ensure participation across generation baby boomer, X, Y and Z. Chief Nurses from each organisation provided names and contact details of potential participants and this group were invited to participate via e-mail (seven organisations including acute care, specialist adult, specialist women’s, specialist children’s, mental health and community providers). The potential participants were invited to join the on-line workshop and respond to the question: What can health organisations in Birmingham stop, start or do differently to encourage you to continue working as nurses and midwives for longer?
To enable participants to respond in their own time a simple, secure website, accessible from any device, at any time was utilised to collect this part of the data. Using this website participants were able to share ideas, comment on the ideas of others and vote the best to the top, collectively identifying and prioritising the responses. Participants were assured via the email that all contributions would be anonymous. The online workshop was open for a period of three weeks. In total 110 nurses and midwives engaged in the conversation making 1,400 individual contributions and creating 42 unique ideas. Ideas were ranked according to their popularity and the narrative data thematically analysed.
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About the face to face workshops Generational reference groups were established in six NHS provider organisations across Birmingham representing baby boomer, generation X and generations Y/Z nurses and midwives. A consensus process framework (Maine Government, 2009) was adopted to distil consensus on potential high impact actions that could enhance career development and retention for each generation. Potential participants were identified and invited by their employing organisation to attend a generation specific workshop. These were hosted by the employing organisation but independently facilitated by the project team. Using the same questions as the on-line crowdsourcing workshop, each member of the group was asked to note their individual perspectives and to then consider these, with others, in their generation-specific peer group. Areas of consensus and divergence were discussed and final consensus outcomes for the group agreed.
Phase 2 - Developing a framework for enhancement Collectively the project team re-read the lists of outcomes and decided to re-order them within the matrix – what was said (what was the world the participants described), what is the ideal (how/what would the participants like to be in operation to support them at work) and then what current initiatives exist elsewhere that could address the issues raised (this drew on the case studies arising from the last part of
the project). This process helped to refine the experiences, motivations and needs of the participants. Using the matrix, the original lists were translated into tables representing general comments and generational groupings. The tables were revisited after reviewing the literature surrounding motivation and satisfaction at work particularly Herzberg et al.'s (1959), useful theory on hygiene and motivation factors. The statements in the first column of each table (what was said) were divided into hygiene and motivation factors, as outlined in Herzberg et al.'s (1959), theory. Collectively, the project team began to question the meaning of the terms hygiene and motivation factors in relation to healthcare and explored different terminology which represented the views of the participants and which captured the essence of the theory. This led to the adapted terms – fundamental conditions which relates to hygiene factors and enhancement conditions which relates to motivators in Herzberg et al.'s (1959), theory. Fundamental conditions equate to those responses and statements which reflect factors that are key and central to working lives and which need to be in place to help workers stay at work. Enhancement conditions equate to those responses and statements which reflect factors that help workers develop and add value both for themselves and for the organisations in which they work. At this point Maslow’s (1954) hierarchy of needs married both Herzberg et al.'s (1959) and the participants voices. Enhancement conditions reflected those factors
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which promote and enhance self esteem and self actualisation and greater satisfaction with work and being at work – a sense of self value and being valued. The responses and statements identified clearly with fundamental and enhancement conditions for both general and generational typologies. The number of fundamental and enhancement conditions defined varied for each group and between groups, reflecting the emphasis they had placed upon what was most important to them.
To aid explanation, a visual depiction of how the participant’s comments aligned with the adapted Herzberg et al.'s (1959) theory was developed: a triangle with a flexible base to reflect the differences between groups and within a group between fundamental and enhancement conditions. The basic model is shown below. It is important to note that addressing fundamental conditions alone does not promote job satisfaction; it only helps to prevent job dissatisfaction. Job satisfaction is dependent on addressing enhancement conditions.
Adaptation of Herzberg et al.’s (1959) Motivation-Hygiene theory
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Outcomes What nurses and midwives told us: Generic themes Nurses and midwives, across all generational groups, identified six main areas for enhancement. In order to better understand why they consider these enhancements are needed it is important to have insight into the lived experiences of those who participated. Some of the description provided requires a sensitive and difficult conversation in relation to the impact external influences are having on the job of nurses and midwives on the ground. Participants were proud to work for some of the best organisations in the NHS however they were very clear that there were system wide challenges, outside of local control, that were having a negative impact on their professional role. In the pursuit of achieving meaningful improvement their perspectives are presented honestly and transparently. The following section gives voice to their reflections, structured around the fundamental and enhancement factors that contribute to job satisfaction. The six themes are represented below:
Supportive Working Conditions
Systems of Governance
Acceptable Pay Status and Security
Meaningful Recognition
Growth and Advancement
Professional Autonomy
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Fundamental conditions Supportive working conditions The nurses and midwives described their working conditions and collectively demonstrated similar experiences of not getting their breaks during shifts, working over their hours and attending meetings/mentorship sessions or completing work in their days off without recompense. One participant from the crowd sourcing commented: ’My daughter is training to be a general nurse. She is a really hard worker and I can’t believe the hours she works on general wards and be expected to function at a high level from 7am to 7.30pm and in the mix night duty thrown in between these shift patterns. She is completely exhausted when she gets home. Is this really what your life as a nurse will be until you retire? We are in a caring profession but who really cares about nurses' mental and physical health. It is no wonder nurses want to retire these days as soon as possible. Better off working in a supermarket to top up finances when retiring.’ From the workshops, participants, particularly younger generations, described how they could be moved from area to area sometimes without any input or explanation to compensate for low staffing levels which some participants expressed as ‘being treated like foot soldiers’. These experiences were described as ‘draining’, with baby boomers expressing sadness for younger generations stating that they had ‘no opportunity to enjoy the things we did’. Some participants commented:
The participants explained how these experiences contributed to burnout and concern about who is caring for the staff. There was a feeling that work-life balance for staff was secondary to meeting service needs. Most importantly all participants supported promoting the interests of safety and patient care and recognised this as central to their role and work. The consequence of the working conditions on the daily working day and job satisfaction was immense with little sense of who was acknowledging and realising how this lifestyle and working conditions impacted on them as individuals. Supporting patients was expressed as fundamental but this operated within a set of working conditions and expectations which did not support the individual practitioners’ wellbeing or job satisfaction. The nurses and midwives from each workshop offered suggestions and solutions to address this tension: wellness days, vouchers, child care support services which reflected shift patterns, ability to work from home, self e-rostering and the opportunity to tailor shift patterns during key phases in life. Specifically those participants representing baby boomers commented:
Open conversations about retirement plans without negative implications would be supportive. Introducing flexibility at the right time will help with balance of wellbeing"
We just do it, whatever we are told – no point in complaining" Loyalty was viewed as a quality that was expected but not received. Indeed, a comment from one workshop was: 'a football team does not need their captain playing for the other side’ 18
These suggestions were not popular with all participants but they do indicate that listening and responding to individualised worker needs across the working life may be an option in meeting the requirements for satisfying and supportive working conditions.
Organisational Governance This condition describes the influence of organisational governance on working lives through the use of policies, systems and processes. The nurses and midwives in the crowd sourcing and all the workshops commented on policies, systems and processes explaining that there is too much and the volume had risen sharply. Paperwork consumed their time and detracted from patient care:
Quite often we are given new documentation without any input prior to this. This often comes from the senior management team, quite often from people who do not work clinically. This often leads to many staff thinking they are becoming desk nurses ticking boxes"
Participants from one workshop agreed that complying with governance requests felt like ‘feeding the performance beast’.
Some participants queried whether the reality of clinical practice was understood and discussed how new developments were implemented without consultation and consideration of the practical implications. Participants overwhelmingly expressed frustration at the volume of ‘red tape’ that hinders them in their role. Some described these as ‘pointless activities’. They questioned who was challenging this and representing their feedback at higher level. They highlighted the volume of goodwill they contributed in terms of fulfilling hours and demands of the role. ‘I fill in what I believe to be unnecessary paperwork, complete audits, get patient feedback forms filled in etc. that are stipulated by them [commissioners and regulators] and if we don’t comply we get fined or finance is withheld. Are our managers putting forward an argument against these or their hands really tied to what the commissioners decide needs to be done? The staff are so frustrated by having to do so much on top of what they are supposed to be doing i.e. nursing care for their patients. Are managers aware that some of the things we are asked to do are completely redundant and mean nothing other than proving you can tick box. The nurses need to know that our managers are sticking up for their job.’
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Organisational governance processes were feared, expressed by some as ‘the whipping boys’ rather than a system supporting them to work more effectively. This comment is reflective of the phrasing used by participants to describe their feelings related to this. Others included ‘beating us’ and feeling like a ‘flogged horse’. One participant commented on the complexity of demands they faced and their feelings towards this: 'It would be a great job if we were allowed to care for our patients rather than worry about being sued, filling our duplicated notes, computer files with lack of admin support, emails to remind us we will lose our increment if we do not complete another repetitive set of educational, mandatory training hours/days... and why did they ever get rid of the beloved enrolled nurse, who was the mainstay of the ward, knew all the patients and staff and routine of the ward and could successfully support and mentor students and new staff and ensure the ward was run well, whilst the staff nurse/sister could manage the ward.'
Respect our role - have confidence in our profession - involve us in change"
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Suggestions to resolve the negative influence of organisational governance systems on job satisfaction included a competence passport and greater support from nursing leadership to carry out the work of caring by reducing bureaucracy and streamlining paperwork.
We need to encourage more mobile working. This encourages a paperlight system, stops staff having to travel back to base to update systems, mass collection of paperfiles at office (then on costs for storage) an up to date patient record all in one place"
There was a clear and consistent sense from all of the workshops a desire for joint working between those who implement and those who feel the impact of organisational governance. There was a consistent and loud message that to move forward a greater consideration of the practical nature of care and greater acknowledgement when creating and implementing governance approaches about how these may impact on everyday working lives and job satisfaction was required.
Acceptable Pay/Status/Security This condition centred on the financial remuneration for the role and status. All participants in the workshops recognised that other jobs provided greater financial reward but a significant retention factor was their personal internal value attached to being a nurse or midwife. Childcare was referred to in both the crowdsourcing and in several workshops. One example is:
I work 30 hours a week and the cost of childcare for my two kids is £1000 a month (I use childcare vouchers and get 15hours free for one of my kids). Seeing as I earn £1500, it really means 2/3 of my income goes to childcare. Some days I do think I would be no worse giving up work once petrol £250 a month and then car parking £50 a month is also paid."
'On site (if you have any sites left) creche facilities would be good. I know there is quite a bit of regulation etc... but this perhaps could be contracted out. The cost of childcare is often prohibitive. Subsidised childcare (not for/or for profit) would certainly have been useful for me. The tax benefits of work based childcare are said to compare favourably to childcare vouchers resulting in cheaper affordable childcare'
Their experiences highlighted other factors such as a ‘glass ceiling effect’. Despite significant experience, added value derived from additional training and development and the fact that their contribution to patient care underpinned the business of the service, pay was non-negotiable. Some key solution focused comments included:
Provide overtime payments or pay weekly for bank shifts. Reward and recognition together with ‘Invest in us'."
Acceptable pay/status/security as a condition in job satisfaction became important when other conditions were not similarly met. There was a tension between personal identity and self worth in being a nurse or midwife and working within a system which expects more and more without necessarily recognising or supporting the worth of the nurse or midwife through supportive working conditions. Herzberg et al. (1959) refers to this group of factors as external to the job however the participants connect how they feel about performing their job under the influence of the fundamental conditions. So rather than being external to the job there is a strong connection which contributes to their job satisfaction. This relates to working hard with low return (Duggah & Dennis, 2014).
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Enhancement conditions Conditions identified by local nurses and midwives as being critical to improving job satisfaction and retention were focussed in three main areas: enhanced professional autonomy; meaningful recognition; and opportunity for growth and development. All of these highlight the need to consider how we appropriately design and enrich the nursing and midwifery roles.
Enhanced professional autonomy-responsibility, authority and the work itself The need to have greater professional autonomy was one of the most stark and significant consensus themes across all generations of nurses and midwives who participated in the project. Participants, irrespective of the organisation they worked for, or their specialist field, expressed frustration at not being able to function at the level to which they were trained. Enhanced professional autonomy was expressed as a key determinant in job satisfaction. Nurses and midwives wanted to fulfil their role as a graduate level practitioner, accountable for assessing, planning, implementing and evaluating care and treatment and, more importantly, having responsibility and authority to provide that care in a flexible way in order to meet the individual needs of patients and clients. They indicated that working in a heavily bureaucratic and process-led system often hinders their ability to do this. They highlighted the need to balance clinical reasoning and professional judgement with the ritualistic following of a process. Whilst they absolutely recognised that some, evidence informed, processes were necessary and had made a significant impact on care quality outcomes, a more discerning approach to adopting these was needed. They described being ‘bound by process’, stating that if they did flex the process in line with the needs of the individual patient the ‘roof would potentially come down on them’. They questioned the impact of ‘box ticking’ on quality and safety highlighting that much of this related to delivering minimum standards rather than promoting care excellence. 22
Nurses and midwives recognised the ‘process driven culture’ was being influenced by the wider system, rather than the being an organisational or leadership issue. However, they consistently described the impact this was having on their role, often undermining their value as individual registered practitioners. The current approach left them frustrated as they were required to mechanistically complete components of a plethora of processes rather than being enabled to care for patients and their care journey holistically. They reflected that this sometimes made them feel like they were just part of a production line and not being utilised to the full extent of their ability. They expressed a desire for freedom to enact their professional role one group proclaiming ‘let nurses nurse’. They considered that this was having an impact on the image of nursing and for the individual nurse or midwife in the healthcare team. More junior staff described how clinicians would bypass them in favour of the nurse in charge when seeking information about a patient they were caring for. One nurse described that whilst she had responsibility, as the nurse in charge of her clinical area, others in positions of power frequently undermined her clinical management decisions.
This suggests sub-optimal job design in the way nurses and midwives work is currently organised. The essential characteristics for job satisfaction identified by Hackman and Oldham (1976) and Herzberg et al. (1959) are not being fully realised. In particular, conflicts can be seen in the areas of: task identity (the degree to which the job requires completion of a ‘whole’ and identifiable piece of work – that is, one that involves doing a job from beginning to end with a visible outcome); task significance (the degree to which the job has substantial impact on the lives or work of people in other departments in the organisation or in the external environment); and job autonomy (the degree to which the job gives the employee substantial freedom, independence, and discretion in scheduling the work and in determining the procedures to be used in carrying it out). Nurses recognised that in order to enable them to work to the ‘top of their licence’ new ways of working would be needed. They felt that they were currently being required to deliver at too many levels and at a pace that was unsustainable. They recognised that healthcare strategies that focus on prevention and promoting care closer to home would be essential to reduce demand in secondary care and that new roles such as that of the assistant practitioner were critical to enabling them to undertake activities more aligned to a graduate level practitioner. They considered this would be beneficial in terms of enhancing patient experience, patient care outcomes and improving productivity.
Respect my experience, listen to me and involve me" As previously highlighted nurses and midwives gave examples of how decisions were made to move them on a day-to-day basis without any discussion with them as individuals – making them feel as through they were merely ‘foot soldiers’. They agreed that there was generally a lack of involvement and consultation with them in matters that ultimately would impact on the way they work. They felt they were much better placed to evaluate options for change and improvement. The majority communicated their eagerness to be involved in leading change and innovation but reflected that they were not afforded the time to do this.
Shouldn’t we have at least the opportunity to undertake a review of ideas (changes) before it is forced upon us. This way nursing staff can have better input on ideas and fine tune the problems before releasing it to the rest of the hospital"
Professional Voice There was consensus across generations that nurses and midwives, at an individual and professional level, were not listened to as much as they should be. They recognised that that they had a valuable contribution to make in implementing successful change and improvement but were frequently overlooked.
Discuss and listen with clinical staff, not at clinical staff – don’t ignore us"
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Meaningful Recognition For the participants recognition in this context relates to nurses and midwives being valued, respected and celebrated in recognition of the unique professional contribution they make to healthcare and the healthcare team. Interestingly, nurses and midwives across a range of settings articulated how lack of professional autonomy was having an impact on the level to which they were valued and ultimately respected by others in the healthcare team and that this, in some instances, was eroding professional pride. There was an overwhelming sense of passion conveyed in relation to reclaiming control of
the profession, demonstrating and celebrating professional value and ultimately being consistently proud of their profession and role in society. The importance of enabling and enhancing professional autonomy cannot be underestimated. Equally, turning the tide on this issue within a heavily regulated and process heavy healthcare system will require focussed and system wide support. Nurses and midwives highlighted that they had been educated and developed to take responsibility and accountability. By having more local ownership of care quality outcomes and the flexibility to seek local solutions for improvement, they considered that the pace and scale of improvement and innovation would be escalated.
Re-esablish pride in the profession"
Value
Professional Autonomy
Pride
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Respect
Celebrating success Celebration events in the form of recognition awards and celebrations of achievement offer the opportunity to demonstrate how staff are valued and promote a sense of pride and motivation across the whole team (Li, Zheng, Harris, Liu, and Kirkman 2016). However, this theme related to more than awards. Nurses and midwives felt that they often worked in a culture where the focus was on the negative – when things go wrong and who and what was to blame. Whilst they recognised the value of learning lessons when things went wrong, they highlighted that there was more to celebrate in terms of what they do well and the difference they make to people's lives on a day to day basis.
I have worked in the NHS for over 40 years and I am a traditional nurse who deals with change looking at the benefits and team dynamics but it amazes me how the doers never get recognition but the talkers are met with warm smiles and well dones"
Our trust has introduced an IR2 system of reporting positive actions by staff... this has a ripple effect of taking time to acknowledge outstanding care when people have gone above and beyond to make a difference, unsung heroes and teams. This in turn encourages even more positive actions" Others noted that nurses and midwives needed to be more supportive of each other and not be cynical about the reasons why certain staff are nominated for awards etc.
I believe we can all support our peers on a daily basis and give warm smiles etc... I find that when staff are nominated, there is an air of suspicion... we need to have humility in our approach to each other, even when we don't think the people who receive the awards necessarily deserve it, this will build a better working environment" Participants stated that they sometimes felt ‘taken for granted’ and their efforts unappreciated. Generally, it was clear that most staff had never had any form of celebration for their commitment and continued good practice.
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In over 35 years I have never had a long service award as each time I went to apply for it was either stopped or the goal post was changed There is not enough done to recognise achievements on a ward/team level. Whether it be recognition from a clinical team, a certificate, a few cakes brought in or a night out. When we work hard morale is always boosted by a reward"
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Perhaps this (recognition) could be promoted from a management level to encourage more to be done. Healthcare is a difficult environment to work in. It would be great to work in a positive culture where it is the norm to recognise success and celebrate"
Growth and advancement Career and professional development Mind the Gap (Jones et al., 2015) highlighted the value that younger generations placed upon support from their employer in developing their career, seeing education as an essential component in this. However, the importance of high quality career development and support to access education and training was articulated by all generations. Early career nurses and midwives spoke of the need for clarity around career options and opportunities as well as the need for more structure around enabling progression within and across clinical, leadership, education and research career pathways. Variability and lack of equity in relation to the provision of opportunities was frequently cited. They highlighted an eagerness for access to high quality role models, senior staff and dedicated educators to support their learning and progression. They recognised the challenges faced by more senior nurses and midwives in providing support, having to balance the needs of staff, patients and families and other demands on their time.
Many highlighted they were willing to trade off the negatives for just a small amount of regular support, clinical supervision or feedback. A longer preceptorship period after registration and rotational opportunities were frequently suggested as ways to enhance support and career progression. What was clear for this group was the desire for variety and opportunity for change. Non-traditional development such as job swaps, attachments, fellowships and shadowing were seen as ways to achieve this. Generation X felt they were currently acting as ‘the glue in the system’ in terms of providing education and developmental support to learners and the high volume of novices. Similar to early career professionals this group considered that access to a high quality senior nurse/midwife role model was invaluable. Generation X felt that supporting others and prioritising their learning and development was often to the detriment of their own. They cite access to consistent funding for education as problematic and that they sometimes felt undervalued when comparing themselves to their medical colleagues. They considered that they were giving a lot of discretionary effort supporting others and the service, highlighting the potential return on investment if their development was more consistently supported.
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Interestingly baby boomers described how their learning and career development was often overlooked or neglected as they approached retirement age. Unfortunately, none of the participants had been party to any conversations about future career aspirations. Many highlighted the range of transferable skills they had that would enable career re-direction as an alternative to retirement. It appears very little was being done to encourage baby boomers to work longer. The main solution to working longer appeared to be retiring and returning part time at a lower pay band but, on the whole, participants considered this a less than successful strategy.
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The baby boomer participants fell into two broad groups. About 25% of them sat in the ‘wild horses would not keep me working in this job a minute longer than I need to’ group, indicating that no incentive or opportunity would persuade them to remain working in the profession. This was attributed to the quality of the working environment, level of autonomy, value and respect for them as well as the physical and emotional demands of perpetual ‘fire fighting’. Nursing for 32 years - In the latter years I feel I felt like a flogged horse. Stress is the worst I have ever known’
'Nursing assistant for 6 months before commencing training - on reflection these were the happiest times for me as a nurse. I am finishing my career as a ward manager, over the last few years they have come to be the worst times, every year brings more and more targets, and less and less patient contact - and zero job satisfaction' The majority however would be keen to explore opportunities to work longer. They did reflect that they would be looking for a new, or different, challenge that would be remunerated at a level reflective of their experience. Career re-direction and project-based or education-based roles were popular options. Equally, flexible and part time working options were considered to be key enablers to successful retention. ‘Nursing is physically and emotionally draining and with the pressures faced around capacity, shortages of nurses etc. is hands on nursing something that can be done full time for the lifetime of a career. I see many nurses reducing their hours because the work is too hard to sustain. If it isn’t doable as a full time job, what is the solution?’ Succession planning All generations highlighted the ‘glass ceiling’ effect of remaining in clinical practice. They were
of the view that the clinical nurse/midwife role should be the most esteemed and valued in the profession but in reality individuals had to move into management or other non-front-line roles to progress beyond a certain pay band. They consider more focus should be placed on valuing and rewarding clinical expertise and facilitating role design that enabled clinical experts to engage in education, research and leadership in an integrated way.
"
The clinical nurse/ midwife role should be the most esteemed and valued role in the profession"
Equally, all generations were looking for more structured development in terms of preparing them for more senior roles. Not only do senior staff want more time and opportunities to support knowledge transfer and share their experience with juniors, but those looking for progression also wanted different options to gain such knowledge and experience from seniors. Inclusive talent management at all levels requires focussed and innovative facilitation. The participants described a range of ideas to help with this such as job shares 29
for retirees, flexible working options and in-depth ‘career conversations’ at key points across the professional life span. 'I think one of the biggest mistakes made in nursing was the change in nurse banding under agenda for change. I think currently nurses are looking to progress onto a band 6 role too quickly – even just after a year of being qualified. When I qualified into the old band D role your aim was to progress onto a band E (senior nursing role) which meant you were still providing hands on care but it gave you the opportunity to continue to develop your knowledge and experience in managing the ward before becoming an F grade'. ‘I agree progression is too quick and the experience and skills required for managerial posts is not always available; should we consider a development programme from band 5 into band 6 and again band 6 into band 7?'
‘I believe retention may be helped if nurses who are unable to progress for one reason or another (part-time hours, no progression opportunities etc.) be allowed to take on extra responsibilities at their request. By this I mean if nurses wish to personally develop and have a full understanding that it is not expected in their current role but take it on, it should be allowed. For example nurse prescribing masters. There seems to be limited information [regarding this].’
A register of opportunities for those thinking of retirement that would offer new/different ways to use their knowledge, experience and skills (such as leading new projects, supporting
Nurses should have a 20/30 year review of their career and be asked how they would like to progress in terms of their career. It may well be that some staff would feel that this would be a good time to take on a leadership role or progress in other ways"
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education, coaching etc.). These would need to be adequately rewarded. Find a way to map service gaps to knowledge, skills and expertise of staff approaching retirement so that we know what talent we have in the system"
A Framework for Enhancement Based on these findings a generic model, reflecting the key components of a guiding framework for enhancing job satisfaction for nurses and midwives was developed. Within this framework enhanced autonomy and flexibility to manage work-life balance are shown as core to the structure. This reflects the weight of importance placed upon these by the nurses and midwives who participated in the project.
avoid burnout. The concept of the caring dilemma is described by Reverby (1987) and Bourgeault, Luce and MacDonald (2006). The caring dilemma recognises at the heart how the duty to care devalues the care being provided: ‘A tension between altruism and professional autonomy and by extension between the interests of the care provider and her client (patient)’ (Bourgeault, Luce and MacDonald, 2006, p390).
Creating conditions for job satisfaction: generic
One element in considering retention is a re-evaluation of models of working practices in order to hear and respond to the challenges twenty-four seven care model means on the individual practitioner and work-life balance. This is a strong theme emerging from all the participants; the difference is how the different generations have and will respond. As the participants have expressed, they want to be involved in creating or re-shaping a new approach whilst supporting the core reasons for having a health service, in much the same way as patients interests are foremost (Department of Health, 2013; National Institute for Clinical Excellence, 2012). The NHS Constitution (Department of Health, 2015), identifies staff rights and the NHS pledge to staff – the commitment is there.
Fundamental conditions The key aspect arising from the participant’s comments is the recognition that working practices to support the twenty-four seven care provision model come at a price for this group of health care professionals. The impact of working conditions required to sustain patient care and safety can be a factor in individual job satisfaction and work-life balance. Sandall (1997) discussed the significance of balancing the needs of staff against the needs of clients (patients) when identifying the need to implement flexibility to manage working hours in order to create a sustainable working practice and
Generic Outcomes
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Enhancement conditions Enhancement conditions described by our local nurses and midwives reflect the need to consider further how we enhance current job design to promote job satisfaction. This is described by Herzberg et al. (1959) and Hackman and Oldham (1976) as job enrichment. Job enrichment allows employees to have more control in planning their work and deciding how the work should be accomplished. It is considered one way to tap into the natural desire most employees have to do a good job, to be appreciated for their contributions to the organisation and to feel more a part of the team. There is a significant difference between job enlargement and job enrichment as shown below. Job enlargement is described by Herzberg et al. (1959) as a horizontal job loading where employees are given increased tasks without changing the level of challenge and such tasks are often repetitive in nature. Job enrichment, or vertical job loading enables employees to use a broader range of their abilities, completing tasks with increased freedom, independence and responsibility, receiving frequent feedback to assess their own performance and aligned development. This is clearly what nurses and midwives were describing in relation to how job satisfaction can be improved.
It is clear from the findings that the bureaucratic burden alongside lack of professional autonomy, is making the ‘job on the ground’ increasingly unattractive and far removed from the one nurses and midwives felt they should be doing"
Adaptation of Herzberg et al.’s (1959) and Hackman and Oldham’s (1976) role enrichment theories
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It is clear from the findings that bureaucratic burden alongside lack of professional autonomy, is making the ‘job on the ground’ increasingly unattractive and far removed from the one nurses and midwives felt they should be doing. This aligns with the notion of job loading, rather than job enriching, leading to job dissatisfaction. A re-focus then on job enrichment offers the potential to enhance job satisfaction for nurses and midwives. Herzberg et al. (1959) recommends using the following seven principles to review the options for job enrichment. Increased professional autonomy • Removing some controls while retaining accountability • Increasing the accountability of individuals for own work • Giving a person a complete, natural unit of work • Granting additional authority to employees in their activity Self – managed teams - local use of data/ evidence based practice, regular feedback • Granting additional authority to employees in their activity • Making periodic reports directly available to the workers themselves rather than to supervisors Education, training, flexible career development • Introducing new and more difficult tasks not previously handled • Assigning individuals specific or specialised tasks; enabling them to become experts Interestingly the findings of this work align to work undertaken in the United States of America (USA) published in the early 1983’s by McClure, Poulin, Sovie and Wandelt (1983). McClure (2011), describes how the study identified 41 organisations across the USA that successfully attracted and retained – like a magnet - professional nursing staff during a time of national nursing shortages. The study found that these organisations had re-designed the work environment that included: a practice setting with congruence of values at
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all levels of the organisation; a clear vision and actualisation of the roles of the professional nurse; and consistent administrative support regarding the value of staff and patients. McClure (2011) describes 14 characteristics that were found to be consistent across these magnet hospitals that, interestingly, starkly align with what local nurses and midwives told us. They include: • Quality of nursing leadership • Organisational structures – decentralised with active nursing representation on decisionmaking committees and groups • Management style – participatory style with staff input being fundamental to decision making and open communication • Personnel polices and programmes – salaries and benefits were competitive, every effort was made to involve staff in the creation of flexible staffing models and careful attention was paid to working hours • Professional models of care – giving nurses both responsibility and authority for the provision of care to their patients. Nurses were viewed as true professionals, expected to be accountable for their practice and coordinators of the total care their patients received • Autonomy – nurses sense of autonomy was reflected in their concern for standard setting and monitoring of care at unit and organisational levels • Quality of care – nurses considered whole organisation was committed to standards of excellence and gave credit to their nurse leaders for actively creating an environment where excellence was valued • Quality improvement – nurses active participation in assessing and improving care. • Consultation and resources – specialised clinical resources available to nurses and physicians • Community and the healthcare organisation – strong community presence with nurses involved in outreach programmes • Image of nursing – very positive across organisation with nurses viewed as being competent and credible, resulting in them feeling valued and respected • Professional development – strong emphasis on personal and professional growth and staff development
• Teaching – valued their own development as well as their role in supporting the education of others. • Interdisciplinary relationships – shared decision-making and mutual respect. Over time this work was used as the basis for development of a national, evidence based, programme to promote excellence in nursing services and provide recognition to organisations that excelled in creating work environments that imbedded the philosophy, practices and leadership to support exemplary nursing practice and quality patient care. Staff nurse involvement was the cornerstone of the programme as recruitment and retention of nurses was of paramount concern (Floyd & Mulvey, 2011). Floyd and Mulvey (2011), describe how further work undertaken by Kramer and Schmalenberg (1988, 1993, 2002), led to the identification of the following essentials of ‘magnetism’: • Working with other nurses who are clinically competent • Good nurse-physician relationships and communication • Nurse autonomy and accountability • A supportive nurse manager or supervisor • Control over nursing practice and practice environment • Support for education • Adequate nurse staffing
are congruent with the components identified as being critical to job satisfaction for our local nurses and midwives. Exploration of Magnet® and its transferability to the NHS context is one of the recommendations featured in Raising the Bar- Shape of Caring: A Review of the Future Education and Training of Registered Nurses and Care Assistants (Health Education England, 2015), chaired by Lord Willis. The report (Health Education England, 2015), recommends establishing an expert group to consider Magnet® as this is viewed as instrumental in improving both the workforce and outcomes for patients. This is currently being explored by a number of organisations across England working collaboratively through the UK Magnet® Alliance group. Equally, the underpinning principles and philosophy of the newly launched Chief Nursing Officer for England’s strategy Leading Change, Adding Value: A framework for the nursing, midwifery and care staff (National Health Service England, 2016), aligns to key conditions in the job enrichment model.
This recognition programme continued to develop in line with an emerging evidence base and continues today. The American Nurse Credentialing Centre (ANCC) manages the Magnet Recognition Programme® on behalf of the American Nurses Association (Drenkard, Wolf & Morgan, 2011). There have been many critiques of this programme and its transferability to the UK setting. This said, key elements found to be consistent in organisations in the US who were successfully retaining staff
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Creating conditions for job satisfaction: gen-gagement Whilst the generic model forms the basis of the essential components to enhance job satisfaction there are generational nuances in relation to the emphasis, or weight of importance, placed on each condition by different generational groups. The following section provides a visual representation of these differences and an overview of the generational perspective. Baby Boomer As previously highlighted for a minority of nurses and midwives approaching retirement no incentive or flexible option would tempt them to work beyond eligible retirement age. Reasons for this were, in the main, system wide including perpetual fire fighting; staffing challenges; resource constraints and systems of governance.The majority of nurses and midwives said they would consider working longer in the right
Baby Boomer
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circumstances. To enable this a range of ideas were suggested. These included: better pension advice in order to explore financial implications of working longer; more flexible working hours; remuneration at an appropriate level for their experience; options for working in less physically demanding roles (as shift work and the pace and demands of contemporary environments were considered a barrier to working longer); opportunities to take on new and different roles; and innovative transition arrangements such as skill-mix model of job sharing with someone of a lower band who could be supported to develop and then apply for their role when they retired fully.
In light of the current workforce demographic, and significant supply challenges, we need to explore every opportunity to encourage and support baby boomers to work longer. Retaining their professional knowledge, skills and experience in the system, even if not in their current role, could be pivotal in turning the tide on retention for other generations. Considering retirement – baby boomer perspectives 'There are a number of midwives who retire because they do not feel able to continue with the physical challenges of the role. For those that this affects who would otherwise continue in employment would it be possible to offer them some of their time in a non clinical role I think there are a number of midwives who would continue to work if they were able to take pension and return on less hours but with their grade protected. They still have the knowledge and expertise they had before retirement but we lose a great deal of this if you have to take a lesser grade to remain at work’ ‘No one has even asked what other skills I have or if I would be interested in a different role rather than retire’ ‘I did not want to end my career feeling bitter, I asked of the possibility of returning to nursing assistant role for the final year before retirement, thus retaining my pension and finishing with a high level of personal wellbeing - in my trust this was an impossibility, almost felt like I was asking for the moon. NMC were happy for me to relinquish my pin and had no problem with my suggestion... their concern was I may not work to the job description Heck - I’ve been working to Job descriptions for the past 33 years - so I guess I will retire miserable… after all’
‘For those who have remained clinically for many years up to retirement age I would argue do so because they came into nursing to be at the frontline of clinical care with the patient in front of them - education and management was not how they viewed nursing. There is a point in all our lives when we develop a level of mental and physical tiredness/fatigue and the relentless clinical workload activity can contribute to this. However the passion, knowledge, expertise and experience is still there. So if there was an opportunity to gain the reward of receiving one’s pension in good time but continuing to work less hours to continue to contribute to health care sharing personal and professional attributes - this could benefit the nurse and the health service.’
Collaborative retirement planning with your employer would mean that you could explore the options that may be available to you and your employer will know of your intentions to retire and what you would like to do after retirement. Most nurses don't want to retire completely and often want to explore options that may suit them"
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Enhancement conditions Wise owl or dinosaur: a matter of perception Listening to the voices of baby boomers in relation to job enrichment was fascinating and, at times, emotional as they described situations that could lead to them questioning their self–worth or value as an individual in the system. Baby boomers recognised that they had much to offer the NHS, utilising their experience to inform future planning and decision-making; and did their best to do this. They had witnessed many things ‘go full circle’ and sometimes had to express concerns when strategies were proposed that had been tried and been unsuccessful before. They recognised their input in these circumstances was not welcomed by some with less experience; being perceived as being resistant to change or being ‘grumpy’, ‘bitter’ or ‘a nuisance’. Some had been marginalised because of this and some had uninvited to meetings. This was personally frustrating, making them feel their knowledge, expertise and experience were not valued. In response some had made the decision to withdraw and ‘just count the days to retirement’.
Those that contribute to the health and wellbeing of this nation should be respected and honoured more that they are currently. Would love to continue to mentor the new future leaders. Respect and use our experience"
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Baby boomers wanted to be valued and respected for the years of experience and expertise they had as well a their contribution to society as a whole. In societal terms, they described this as their ‘silent service’ that was rarely celebrated or recognised in the same way as others in public service. The majority wanted to continue to share their experience and to be recognised as a ‘wise owl’ rather than ‘a dinosaur’; supporting younger generations and offering expertise to the system as a whole. Some baby boomers talked of feeling vulnerable in their role, describing experiences where roles were constantly being reviewed and opportunities explored to find cheaper solutions requiring less experience. They described how their real value and potential contribution was often only recognised by those who they worked most closely with. ‘In my experience it is unfortunate that once it is mentioned that someone in a senior nursing leadership post is approaching/considering retirement the discussion is whether the post is retained or becomes a cost saving, rather than a recognition of the skill, competency and knowledge that will be lost and any exploration of how this can be retained through other means such as part time, flexible working, consultancy etc. The value and appreciation of the individual is often recognised by those we work with rather than senior managers.'
Continuing professional development and life-long learning Baby boomers highlighted their desire to continue to learn and develop their careers in new directions. They wanted to transition into roles that enabled them to have balance between work and social life but that would give them a new challenge and ‘re-energise’ them. However, they recognised that once they were ‘of a certain age’ they were often overlook in terms of professional development. They considered it important to have frank and open career conversations with them to identify future opportunities that could benefit them and the NHS. They also highlighted that managers may be anxious about having such conversations, worrying they may be considered discriminatory. ‘Chronological age should be no barrier to still wanting and being able to give one's best to a profession that is all about helping people through experiences that lead to changes in their lives for good or bad. Nurses should be able to have a personal and professional self-assessment of how they feel at key timeframes in their career;
to take stock of what they have done; where they are at, and how they see their future. This should be heard and taken notice of. It should be done in-line with how they feel as a ‘whole’ person as nursing does infiltrate home and family life and general wellbeing.’ Creating a register of short-term opportunities across the local system was suggested as a way to re-direct and retain the skills of those at retirement age. They considered this would provide a cost effective alternative to project consultants and enable nurses and midwives to continue to develop and grow and achieve their full potential across the professional life span. Generation X Both fundamental and enhancement conditions were important to generation X nurses and midwives.
Generation X
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Fundamental conditions Generation X nurses and midwives highlighted the impact changes in the NHS pension scheme and retirement age might have on them as a cohort. They felt strongly that there was a need to consider financial remuneration for nurses and midwives in relation to reward and recognition and level of pay. They highlighted that they were a very reliable group in the workforce who provided much discretionary effort supporting others; often to the detriment of their own. They suggested ways to recognise and reward this loyalty should be considered. Support to manage work-life balance, especially childcare, was highly valued. They were also the group most focussed on the need to have appropriate staffing levels that were frequently reviewed and that reflected actual acuity of the caseload and wider workplace demands, as they were often the ones with responsibility of ensuring rotas were covered. They particularly highlighted the amount of discretionary effort they personally gave in terms of working extraunpaid hours. Many indicated that this had now become habitual and expected; leaving on time could often be met with disapproval or subtle suggestions that they lacked commitment. Many gave examples of coming in on their days off to attend meetings or to complete student documentation. They were happy to be flexible to meet the needs of the organisation, to be loyal and to ‘go the extra mile’ but would like organisations to demonstrate their loyalty to them in return by ‘investing in us’. Enhancement conditions In this area generation X nurses and midwives highlighted similar needs to other generations. Respect in the form of enhanced autonomy and recognition of their skills and experience; wanting to be recognised and used in line with their particular strengths in problem solving and pragmatism. As with other generations the notion of ‘professional voice’ was important, again involving them and other front-line clinicians in decision-making featured strongly. They, like generation Y and Z, considered further work to create conditions that would build a strong sense of community and mutual respect across teams was essential.
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In terms of growth and development they suggested more focus is needed on succession planning, finding new and innovative ways to expose people to higher-level skills and senior mentors, coaches and role models. They were concerned in relation to the level of investment available for education and training and the variability in access to these funds across the workforce. They considered a re-think was needed in relation to education and training due to ‘competency overload’ and the repetitive nature of some assessment. They suggested the idea that a ‘nurses passport’ could support the nurses and midwives as they transitioned across roles and organisations, stating this would be more efficient and productive. This aligned with the notion of having more professional autonomy generally; with responsibility being placed on the individual, and the line manager, to decide their personal development needs rather than the current 'one size fits all’ and ‘must do’ policy.
s
Think personal training budget is a very good idea - nurses however need to be made aware of training which is available and be encouraged to prevent boredom and low motivation which easily sets in when working in job roles for a number of years"
Generation Y/Z
In line with findings in the mind the gap report the main priority areas for generation Y and Z were enhancement conditions. In this report (Jones et al.,2015) participants highlighted the following areas as being important to them: • 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, valued and appreciated • To be engaged in meaningful work – to make a difference • Flexibility to achieve work-life balance • To be supported and enabled to meet the expectations of the patients and public (to have the resources to deliver quality care) Fundamental conditions Two key fundamental conditions were of most concern to this group. The first was support and flexibility to achieve work-life balance. This centred on the need to provide enhanced flexibility in terms of job design but also the need for equity in approach. Many felt that there was still an inconsistency in how rosters were completed and signed off claiming that, even with e-roster, the system was open to favouritism. Inequity in relation
to how flexible working and part time policies were applied locally was discussed. It was interesting to hear generation Y nurses and midwives, especially those in their thirties, describe the approaches they had used to secure part-time and day time only contracts after they had had their first child. Some shared positive experience but others described how they were offered no alternative and had resorted to giving notice – some were then offered alternative options, others had found jobs in other areas such as clinics and outpatients. There was much talk of the level of disposable income left in their monthly salary after paying for childcare and travel costs; for some this amounted to approximately £300. The same participants highlighted that this was a sum that they could, with some budget management, live without. They stated that the reason they continued to work was because they enjoyed their job rather than for significant financial gain. Flexibility for this group included the ability to manage childcare. They indicated that childcare facilities that opened ahead of the day shift and into the evening were scarce; and finding child care open during public holidays was a near impossibility. Very few knew of any on-site childcare facilities aligned to shift work patterns and considered this would be particularly helpful.
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I know nurses who have left the profession due to childcare responsibilities" The second area that this group considered a priority for action was being frequently moved at short notice to cover staffing gaps in other clinical areas; this being associated with being a more junior member of staff. Whilst they recognised employers needed flexibility to cover the service it was the manner in which the moves take place that was the source of frustration. They communicated that sometimes they had been moved to areas where no one knew their name, referring to them merely as ‘the band 5’. This made them feel they were ‘just a number on a rota’. A good example was provided where one organisation had put systems in place to ensure all staff moved received a formal and structured welcome and orientation to the new area, overseen by a senior nurse. Enhancement conditions As previously described there was greater emphasis on solutions to address job enhancement with: increased professional autonomy; valuing staff; growth and development and celebrating success featuring strongly. Enhanced professional autonomy was articulated
as having respect for their role and confidence in the profession. It was considered important to them to recognise their value and to involve them in decision-making, especially when such decisions would impact on them directly with one group stating that there should be ‘no decision about me
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without me’. They suggested employers explore ways to support and enable them in their role, empowering them as professionals to lead at all levels. In relation to staff feeling valued the main solution provided was to put more focus on building a sense of community at work, expressing this as wanting a ‘work family’. Career and professional development featured strongly, highlighting the need for this to be holistic and ‘in situ’, not just based in the classroom. Transitional support in the early career period was highly valued by those who had received it. They indicated more emphasis be placed on providing access to high quality role models and senior staff who could coach and mentor them. It was clear that this group were looking for more structured career development as well as opportunity for variety and change, including rotational posts, attachments, job swaps etc. ‘Guaranteed career pathway development for all qualified nurses. I hear about a lot of nurses getting into ruts and becoming frustrated about lack of career development opportunities, unlike medics who have structured pathways.’ ‘I have previously experienced newly qualified nurses bring offered an 18 month rotation to enable the nurse to experience working alongside more experienced staff in different specialities with a permanent contract on one of the wards taking part in rotation. This was successful as it reduces staff vacancies and increased morale.’
Conclusion Participants were enthusiastic and keen to explain their experiences and provide solutions, expressing views signposting towards a cluster of factors that contributed towards job dissatisfaction and factors that would add job satisfaction. The cluster of factors highlighted common themes across the different generational typologies and some generational specificity. Overall it is clear that challenges in role fulfilment and job satisfaction arise from the impact of factors beyond the control of the individual nurse or midwife. What is under each individuals control is how each responds to the challenges. Promoting the interest of patients and patient safety places expectations and a set of working conditions which impact on the lifestyle of the practitioner. Systems developed to establish how patients are cared for detracts and steals time and mental space from staff who wish to care for patients. Participants valued being nurses and midwives – being a nurse or midwife is central to their identity and self esteem. Nurses and midwives want to be able to function at the level to which they have been trained but describe how the job itself seems to have become increasingly process led, leaving less flexibility to provide individualised care. This has left practitioners wanting to, but sometimes unable to, give that individualised care. Equally, current role design impacts in their ability to work ‘at top of their licence’ due to current demands requiring them to deliver at too many levels.
practitioners who prefer to remain in clinical practice and care for patients. Current NHS policy context is framed by The Five Year Forward View (NHS England 2014). This sets out a vision for the future of the health system. This vision is focused on achieving the triple aim of improved population health, quality of care and cost-control, this needed to be matched by triple integration, removing the boundaries between mental and physical health, primary and specialist services, health and social care. A healthy, happy and engaged workforce will be key to delivering the transformation required to deliver the triple aim. In this context it has been suggested that this vision should now be a quadruple aim; adding an aim to improve the experience of providing care (Sikka et al., 2015). Sikka et al (2015) describe how this acknowledges the importance of staff finding joy and meaning in the work of healthcare or having a sense of importance of their daily work and the feeling of success and fulfillment that results from engaging in meaningful work. This clearly aligns with the need to create conditions that support job satisfaction as described in the guiding framework. Recommendations There is scope for a more proactive and creative approach to be adopted which encourages leaders and clinical practitioners to work together and find joint solutions to the issues identified. This requires taking a position that recognises that clinical staff want to and are able to find solutions to enhance care provision. Exploring new governance models that promote ‘bottom up’ leadership of clinical care and care quality outcomes should be considered. This will require a gradual evolution, building capacity and capability to lead evidence based practice; facilitate change and manage care quality outcomes locally.
There is a sense that the participants do not feel their contribution to that which is the heart of the business of healthcare is recognised or that they, as practitioners delivering services, are not valued and recognised. This has rendered many voiceless despite the importance their contribution makes to There is a need to re-examine and improve the systems which enable the nurse and midwife to the business. work the hours required to support the provision of care around the clock and which support All participants valued the opportunity for practitioner life balance. Exploring solutions pathways that support their professional outside of the English NHS as well as promoting development and progression. However, a glass team self-management should be considered. ceiling in clinical practice exists for those
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Local ownership by teams of roster patterns within critical parameters of quality, safety and productivity offers the opportunity to better align individual and organisational needs. Equally, workforce re-design methodologies should be explored to ensure new ways of working deliver clear role design and a more resilient care workforce. There is a need to implement a more proactive approach to individual job pathways/learning plans so that an individual’s career is tailored to personal and professional aspirations and role responsibilities – inclusive talent management. Prompt action to scope career ambitions of those approaching retirement to maximise opportunities for them to work longer is strongly recommended.
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Policy intentions such as Shape of Caring (HEE, 2015) and Leading Change, Adding Value (NHS England, 2016) provide an opportunity to liberate nurses and midwives to lead care and realise their full potential in the workplace as well as build fulfilling future careers. Through this project a guiding framework to enhance nursing and midwifery job satisfaction has been developed. This framework can be used by employers, nursing and midwifery leaders to assess local opportunities for improvement. To support this an annex document has been produced, providing a high level summary of the project as well as a selection of resources aligned to initiating improvement.
Appendix 1. Generational dimensions of job satisfaction: overview of literature There is a range of literature surrounding generational dimensions of job satisfaction. Wilson, Squires, Widger, Cranley and Tourangeau (2008), reported generational differences in relation to what constituted job satisfaction. They found that effective retention strategies are required to alleviate the international nursing shortage and that in order to understand better generationspecific retention approaches there is a need to understand generational differences related to job satisfaction. Overall, baby boomers were found to be more satisfied with their job than generations X and Y. Those who may be looking to start a family, have family commitments or have young children may consider factors outside of their employment as to whether to stay or leave their post (Antonazzo, Scott, Skatun and Elliott, 2003; Shields and Wooden, 2003). For example, Health Services National Partnership Forum and Irish Nurses’ Organisation (2003), reported that 44% of nurses leaving the profession stated family commitments as the reason for doing so. Currie and Hill (2012), identified the following key factors related to nurse shortages and high turnover across international literature: Work and the nature of the work environment: • unit size and safety concerns; • leadership style; • other managerial/organisational factors; • workplace stress; • workplace location. ‘Personal’ reasons: • home and family; • age and generation related; • values and ethics; • reasons more specifically related to personal career; • opportunities/professional development.
In relation to nurses, Currie and Hill (2012), reported that the age of the individual may be a predicator as to whether or not they have job satisfaction and consequently stay in the profession. They reported that high job satisfaction was related to older generations as opposed to their younger counterparts. This finding has been supported amongst the international community ( Wieck, Dols and Landrum, 2010). In the UK, Storey, Cheater, Ford and Leese (2009), found that older generations of primary and community care nurses identified the following important as factors for staying in the profession: feeling valued, being consulted when change was implemented, pension considerations, reduced working hours near retirement and enhanced pay (specifically for those qualified to degree level). In a study conducted in the USA, Keepnews et al. (2010), revealed significant differences among generations (baby boomers, generation X, and generation Y) in a number of areas: job satisfaction, organisational commitment, work motivation, work-to-family conflict, family-to-work conflict, distributive justice, promotional opportunities, supervisory support, mentor support, procedural justice, and perceptions of local job opportunities. In terms of generational differences, baby boomers were less likely to have had formal orientation into the role and less likely to have gone through an internship or paid externship. However, baby boomers were more likely to have head nurse positions during their first year of practice. Indicating that employers assumed that baby boomers may be less in need of formal orientation and are better prepared to move rapidly into management positions due to their age and work experience before entering nursing (Keepnews et al. 2010). They also found that generation Y and X nurses were much more likely than baby boomers to work in an Intensive Care Unit and for longer shifts (10-12 hours), indicating their greater ease with technology and potentially the need for baby boomers to have shorter less ‘taxing’ shifts.
Economic reasons: • level of remuneration, including pensions. 45
In a study conducted in New Zealand, Clendon and Walker (2016), examined why some nurses cope well with continuing to work as they age and others do not. Results showed that there were a range of challenges associated with ageing in the workplace. Some of these were linked to the physical challenges being a nurse can bring (Heiden, Weigl, Angerer and Muller, 2013; Stichler, 2013). Though results showed that performance, productivity and absenteeism remained the same for both older and younger nurses despite the age difference. Additional factors that impacted upon ageing nurses staying in the profession was guilt (not being able to do the job properly and letting colleagues down – linking to the characteristics of their generation including their loyalty to the organisation and their colleagues) and reluctance to engage in ongoing education (participants recognised the need to maintain skills and identified ways they achieved this, but they did not wish to invest financially in obtaining new qualifications). In order to cope with the challenges of ageing in the workplace nurses reported maintaining health and fitness, self-care, using external memory aids, working in familiar and supportive settings and changing their work hours to accommodate changing needs were all important (Clendon & Walker, 2016). In order to help retain our nursing workforce the needs of older nurses must not be forgotten. ‘the juxtaposition of ageing and nursing demonstrates nurses who continue to work while they age face a range of challenges associated with the ageing process but develop effective coping strategies that help build their resilience in the workplace. Workplaces can support nurses to manage the challenges of ageing by addressing ageism, assessing their organisational approach to older workers and providing a supportive environment where nurses of all ages can flourish’ (Clendon & Walker, 2016, p9). Sherman (2006), asserts that nurse leaders must recognise and create a work environment that values generational differences; and supports the needs of each individual in their workforce. Further, it is said that nurse leaders should utilise the literature about generational cohorts in the nursing workforce to create leadership strategies (Sherman, 2006; Jones et al, 2015). Nevertheless, it should be acknowledged that within each generational cohort there can be diversity and so generational stereotyping should be 46
done with some caution (Duchscher & Cowin, 2004). In a Canadian study conducted by Lavoie-Tremblay, O’Connor, Lavigne, Briand, Biron, Baillargeon, MacGibbon, Ringer and Cyr (2015),cross-sectional data from 727 registered nurses, via an online questionnaire, was collected to assess the impact of abusive leadership practices on the quality of care in novice nurses and the intention of nurses to quit the profession. Results showed that leadership practices of nurse managers were effective in increasing the retention of new nurses and improving patient care. Moreover, Cummings, MacGregor, Davey, Lee, Wong, Muise and Stafford (2010), found that various forms of leadership have different effects on the nursing workforce and work environments. They suggest that organisations need to develop transformational and relational leadership styles to enhance: nurse satisfaction, recruitment, retention, and healthy work environment in the nursing profession. In order to identify which leadership style is correct for the workforce, Halfer (2004) suggests that age profiling, and the irrational issues on the team should be documented so that individual employee needs and generational differences can be considered. Moreover, Hart (2006) has reported that by incorporating generational preferences in areas such as coaching and motivating, communicating, and resolving conflicts it will help to promote staff retention. In terms of motivation, research demonstrates that as different generations have had different experiences these help to shape preferences about how a generation wants to be coached and motivated by those who lead them (Duchscher & Cowin, 2004). For example, baby boomer nurses are said to prefer being coached in peer-to-peer situations and value lifelong learning as a way of improving their performance (Duchscher & Cowin, 2004). They find perks, such as employee parking spaces, newsletter recognition, and professional award nominations to be motivating (Greene, 2005). In contrast, generation X staff have been found to prefer opportunities to demonstrate their expertise in the learning environment and without the feeling of being micromanaged (Lahiri, 2001). Generation Y value internships, formalized clinical coaching, mentoring programs,
personal feedback, opportunities for selfdevelopment and flexible scheduling (Halfer, 2004).
that workforce to thrive and to meet tomorrow’s health care challenges:
For communication and conflict resolution, baby boomers prefer communication that is open, direct, and less formal such as staff meetings that provide opportunity for discussion (Zemke, Raines & Filipczak, 1999). Generation X prefers communication that involves technology. Generation Y favour immediate feedback (Sacks, 2006), whilst also enjoying team meetings as a forum for communication. Carlson (2005), suggests that as this group reads less lengthy documents, policies and procedures may not be as effective as emails.
• Seek to understand each generational cohort and accommodate generational differences in attitudes, values, and behaviours. • Develop generationally sensitive styles to effectively coach and motivate all members of the health care team. • Develop the ability to flex a communication style to accommodate generational differences. • Promote the resolution of generational conflict so as to build effective work teams. • Capitalize on generational differences, using these differences to enhance the work of the entire team.
Sherman (2006), outlines the value of each of the generational groups found in the nursing population. Baby boomer nurses should be valued for their clinical and organisational experience. Utilising them to coach and mentor younger nurses will be important to insure that the intellectual capital or knowledge of organisations will not be lost when large numbers of this generational cohort begin to retire (Ulrich, 2001; Weston, 2001; Halfer, 2004). Generation X nurses should be valued for their innovative ideas and creative approaches to unit issues and problems. They can be instrumental in helping organisations design new approaches to nursing care delivery. Millennial nurses should be valued for their understanding of technology and insights as to how it can be used in practice. Although novices to nursing, they can be instrumental in helping organisations implement computerised systems and other forms of technology. They can also serve as technology coaches to older generational cohorts (Carlson, 2005). Understanding how to maximise the talents of each individual nursing staff member by addressing both their individual and generational needs is critical to good leadership. When each generation is appreciated for the strengths they bring to the team, generational diversity will lead to a synergy that brings the team to a much higher level of performance (Hobbs, Hostvedt, White, Benavente, Brooks and Poghosyan, 2005).
Greene (2005) has noted that the dismay many nurse leaders express in terms of the changes they see in the workforce today is beside the point in today’s competitive recruitment market. Leadership strategies that have worked well for a less age-diverse nursing workforce may not be as effective in today’s environment. Rather learning to flex one’s style will be critical for both leadership and organisational success.
Facilitating the growth and development of staff is an important nursing leadership function. Yet in the presence of a generationally diverse workforce, this is not an easy task. The following points are summary recommendations for nursing leaders who are leading a multigenerational workforce and enabling
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Appendix 2. Dialectical enquiry using Checkland’s (1981) and Checkland and Scholes (1990) systems methodology as a frame (Dick, 1993) Dick (1993) represents Checkland’s (1981), and 2. You then forget about reality, and work from your description of its essential functions. You devise Checkland and Scholes (1990), soft systems the ideal system or systems to achieve the system’s methodology as a system of inquiry using actual or intended achievements. Moving to and fro a series of dialectics. For each dialectic you between essence and ideal, you eventually decide alternate between two forms of activity, you have developed an effective way for the system using one to refine the other. Dick describes to operate.
each of these dialectics below: 3. 1. First you immerse yourself in the system, soaking up what is happening. From time to time you stand back from the situation. You reflect on your immersion, trying to make sense of it. At these points you might ask: what is the system achieving or trying to achieve? When you return to 4. immersion you can check if your attributed meaning adequately captures the essentials. This continues until you are content with your description of the essential functions.
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The third step is to compare ideal and actual. Comparisons may identify missing pieces of the ideal, or better ways of doing things. The better ways are added to a list of improvements. Finally, the feasible and worthwhile improvements are acted on, forming the fourth dialectic.
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