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Can Generation Y nurses supply areas of shortage? New graduate challenges in today's job market.

INTRODUCTION

Graduates wishing to register as a nurse in Australia will have completed a nursing course offered at a tertiary institution accredited by the Nursing and Midwifery Board of Australia (NMBA) (Australian Health Ministers' Advisory Council, 2006). On account of the predicted significant shortfall of nurses by the year 2025, the premise has been that these graduates will enter a job market eager to offer them a place in health care on successful completion of their course (Health Workforce Australia, 2012). However, currently these new graduates are reported to be experiencing difficulties obtaining employment in the Australian public health sector on graduation (Anderson 2013; Peters and Jackson 2013a; Uncut.com.au 2013).

To understand the new graduate employment experience is to acknowledge that generally today's job market is a difficult one for new graduate nurses to obtain positions. The literature and the media attribute several reasons for nursing graduates finding difficulties in sourcing employment. The 2007-2009 Global Financial Crisis delayed the predicted retirements of older experienced nurses who have been forced to work longer and thus retain potentially available positions (Peters and Jackson 2013b; O'Loughlin et al 2010). Perceptions by prospective employers that graduate nurses are unprepared for clinical roles, thus making them unsuitable applicants, is a subject of Internet blogging locally and internationally and is discussed in the academic literature (CINHC January 2014; Peters and Jackson 2013a; Uncut.com.au 2013; Cardillo 2011). As a result, applicants compete with each other for fewer positions; selecting areas that they feel prepared for, such as acute care nursing. However, acute care nursing is a specialised area of workforce that is currently experiencing lower demands for nurses (HWA, 2014).

Considering that new graduates experience multiple issues associated with their transition from education to work practice, a vulnerability already exists (El Haddad et al 2013; Boychuk 2008). New graduate nurses' preparedness for practice is extensively researched and well documented (El Haddad et al 2013). Transition shock and thought provoking situations during the early course of their nursing work are both documented causes of why some new graduates leave nursing after their first year of practice (Missen et al 2014; Drury et al 2009; Halfer and Graf 2006). Aware of potential future role hardship, final year students often elect to apply for a Graduate Transition Program (GTP) in general, acute and surgical nursing areas in large metropolitan hospitals.

An ideal solution both to address the inability of these new graduates to obtain positions and to address the specialty shortages would be to encourage new graduates to consider aged care and mental health nursing as career options. Universities and health care employers have attempted to foster favourable and positive attitudes to these specialties, but to date outcomes of innovative GTPs in aged care and mental health have not been overly successful. In this paper, we explore the following questions: Are we making aged care and mental health nursing unattractive as a result of unsubstantiated negative perceptions? Have nursing students and new graduates actually absorbed and experienced negative impressions from their clinical experience? Were these harmful and damaging exposures transmitted from experienced nurses and/or from educators?

There are complex reasons that may explain the difficulties in attracting new graduate nurses to specific areas of practice, particularly aged care and mental health nursing; areas at particular risk of shortages by 2025 (HWA, 2012). The aged care sector deals with a particular set of negative occupational stereotypes, such as a reputation for being boring and monotonous work, workplace violence and a wage disparity of 12% compared to other specialist nursing work (Currie and Carr Hill 2012; Palmer and Eveline 2012; Jackson et al 2003).

Similarly, mental health nursing appears to be an unattractive option for first year graduate nurses. Negative perceptions are propagated in professional literature and the media with both mental health and aged care nursing being described as 'the dark side' (Hazelton et al 2011, p.182), 'dirty' (Stannard 1973, p.329), 'basic' (Abbey et al 2006, p.14), 'repetitive' (Fussell et al 2009, p.220) and 'less exciting' (Happell and Cutcliffe 2011, p223).

Difficulties in recruiting new nurses to a career in mental health nursing have been highlighted. Problems in curriculum development in preparing undergraduate nurses to work in this field have meant that a 'diluted' content (McCloughen and O'Brien 2005, p.225) of mental health education is delivered in generic nursing programs. Additionally, limited exposure to mental health subjects and inadequate numbers of supervised mental health placements have led to a lack of motivation in choosing mental health as a nursing career. An Australian study evaluating a new graduate program in mental health (Cleary and Happell 2005) confirmed earlier findings: a combination of limited opportunities extended to the graduate nurse to practise their clinical mental health nursing skills and the absence of a supportive work environment do little to promote recruitment and retention in mental health. These factors were supported in an Australian literature review on promoting mental health positions for new graduates (Cleary et al 2012).

Following on from the five year Australian reform in mental health under the 1993 and 1998 National Mental Health Strategy, which saw a greater expansion of community based mental health services, little seems to have changed in perceptions of mental health nursing (Whiteford et al 2002). In an Australian scoping study by Hazelton et al (2011) of mental health education and new graduate preparation for practice, participants characterised mental health nursing as "arduous"(p.1), "uncaring" (pp.1,11,12), "mistreating" (pp.1,8) and "neglectful" (p.6).

DISCUSSION

Shortage of positions for new graduate nurses and oversupply of workforce in the acute care sector

Generation Y comprises a group of individuals who share the birth range from 1984 to 2002. This cohort is known to be technologically literate (LeDuc and Kotzer 2009) growing up in an era of information, social media, interconnectedness and globalisation. Generation Y nurses entered the workforce in times of industrial change: reduction in organised labour, shrinking unions and competition from international labour markets (Chung and Fitzsimmons 2013). International literature refers to this generation as globally vastly diverse--economically, ethnically and academically--from previous and subsequent generations (Bell 2013; Chung and Fitzsimmons 2013). Karl Mannheim's generational theory (1923) provides an insight into behaviours for this particular cohort. Mannheim posits that younger generations are "imperfectly socialised between ideals learned from older generations and the realities of the world they experience" (Codrington 2008, p3). Such a theoretical position might help to explain the generational differences between the four generations currently working side by side in nursing: The Matures (born before 1945), the largest cohort -the Baby Boomers (1946-1964), the smallest--Generation X (1965-1980) and Generation Y (1981- 1999). The youngest cohort, Generation Z (born 2000 to the present day), will enter the workforce in their numbers by the end of the decade.

The inability to obtain a first preference in an acute care generalist GTP has become a common experience for Generation Y graduating nurses. This is an area of concern for industry and workforce, employers and Generation Y nurses (Peters and Jackson 2013b; McCloughen and O'Brien 2005). Nursing graduates require a supportive, well-structured, learning environment to enable them to practise newly acquired skills safely and with confidence (Missen et al 2014).

The shortage of aged care and mental health nurses, due in part to an ageing workforce, is a matter of recorded concern. In 2012, 27% of the aged care workforce was aged 55 years or over, placing this cohort in the Baby Boomer generation (King et al 2012). The median age of a mental health nurse is 47 years and 46% are aged 50 years and over (Australian Institute of Health and Welfare 2012a, 2012b). Concerns over the Baby Boomers' departure from the workforce are expressed from a variety of industries (Australian Human Resources Institute 2012; Roberts 2012; Benson and Brown 2011; Long Dilworth and Kingsbury, 2005;). There is also awareness of the loss of expert knowledge and skills on the departure of Baby Boomer nurses. This departure of nursing knowledge is defined as the 'expertise gap' (Spector and Echternacht 2009; Orsolini-Hain and Malone 2007). This 'gap' is exacerbated by declining numbers of experienced nurses in the clinical setting, meaning that new and less experienced nurses miss out on learning skills from experienced peers in areas such as conflict resolution, prioritisation of care and initiative (Chenoweth et al 2010).

A survey of health employers conducted in 2012 by the Department of Education, Employment and Workplace Relations (DEEWR) revealed public and private health providers in metropolitan Sydney also find positions in mental health and aged care the most difficult to fill (Department of Education Employment and Workplace Relations 2012). Major Sydney hospitals do not experience the same recruitment difficulties in other areas of nursing, such as intensive care, emergency, acute care, surgical and ophthalmology, due to a pool of strong candidates. These areas generally attract younger, experienced nurses and Generation X nurses currently fill positions in leadership roles (Drury et al 2009). New graduates are eager to commence their career in high acuity areas of nursing where the pace is fast (Lavoie-Tremblay et al 2010). These new graduate nurses perceive that contemporary clinical education opportunities are available and there is greater scope to learn and grow in acute care environments (McCalla-Graham and De Gagne 2015).

However, even in the acute sector, new graduates are reported to experience some difficulties in transitioning their practice from student to registered nurse. Negative reactions towards new graduates in acute care may also be attributed to generational differences. As much as new nurses from the Net Generation enjoy 'high tech' areas of nursing (Happell and Cutcliffe 2011, p.332), older experienced nurses may be sending the message to new graduates that "we are so specialised, you can't fit in here". Older nurses were found to be critical of their younger colleagues and considered what they perceived as younger nurses' lack of commitment and arrogance as a negative attitude to the work environment (Blythe et al 2008). Unfavourable work relationships in critical care and emergency care areas between novice and experienced nurses is reported in the nursing literature (Baumberger-Henry 2012). These attitudes and practices are reported as "tensions" (Nelsey and Brownie 2012, p.2) and "clash[es]" (Feng and Tsai 2012, p.2069) between nurses at different career stages.

Nursing education and workforce research reveal several influences impacting on future career and specialty choice for new nurses. Student nurses' are sensitive to educational experiences as well as the clinical contact offered, the ward milieu, and possess personal and generational motivational drivers. Based on positive work experiences, new graduate nurses will develop an intent to remain in nursing and follow a formalised post graduate area of practice, course of study and clinical ladder for a period of years (Zeller et al 2011). These combine to influence career paths. The figure below shows new graduate influences of career path as identified in the literature (Cleary et al 2013a; Haron et al 2013; Prentice 2012).

Lack of nurses in mental health and aged care

Ideally, there needs to be a focus on underserved areas to try to attract the surplus of new graduates into these positions. Mental health and aged care nursing specialties share characteristics that affect nurses' future career paths. In an effort to ameliorate the lack of nurses in these areas, research has focused on the role of universities in preparing new graduate nurses for work in aged care and mental health. Since educational experiences during course work or clinical placement are known to influence career paths (Pfaff et al 2014; McKenna et al 2010; Australian Health Ministers' Advisory Council, 2006; Waite 2006), some universities have attempted to expose students positively to these specialties by weaving mental health and aged care content throughout the pre-registration curriculum (Moxham et al 2011; Abbey et al 2006). The delivery of aged care and mental health subjects as electives is also proposed by others, with flexible content through the use of problem based programs (Haron et al 2013; Curtis, 2007).

Manipulating the learning environment by way of arousing interest and passion in the student is another way that universities have attempted to increase awareness of mental health and aged care nursing. Educators, clinical instructors and clinicians can act as mentors and role models displaying an enthusiastic and knowledgeable attitude when delivering nursing care (Cleary et al 2013b; Baumberger-Henry, 2012). There needs to be an awareness that the first contact with these specialties, whether in the classroom or in the clinical area, has a pivotal impact on the student. It is at this point that students start to develop ideas about a future career pathway (Browne et al 2013; Prentice 2012). This is a point of crucial knowledge to employers interested in addressing shortages. In addition, universities should inform new graduates throughout their course of study and upon graduation that there are shortages in aged care and mental health and this is where they should be applying. This proposition will have long term benefits to nurses in the development of a career and for nursing in addressing the predicted nursing shortfall by 2025. Plenty of post graduate education opportunities to encourage work engagement in mental health and aged care exist as well (King et al 2012). Aged care nurses respond positively to career progression and education opportunities but perceptions, shaped by ageist and paternalistic attitudes as student nurses, inhibit them to pursue a career in long term aged care once registered (Koh 2012; Chenoweth et al 2010; Fussell et al 2009).

Generation Y motivating factors

Individual characteristics also motivate the nurse to pursue a career in aged care or mental health. Positive attitudes take shape from past contact with elderly persons and personal experiences. An Israeli study surveying 486 final year nursing students found that promoting encouraging attitudes towards older people increased recruitment in aged care (Haron et al 2013). Encouraging nurses to make aged care or mental health a career choice can commence at a number of stages: in the formative school years, as pre registration undergraduate students and through post graduate education for registered nurses (Chenoweth et al 2013; Knight et al 2011; Stevens 2011; Drury et al 2009).

Generation Y possess numerous professional motivational drivers. As the new and largest nursing workforce, Generation Y undergraduate and new graduate nurses have identified that they are committed to the philosophy of nursing and the ideals of the caring profession (Jirwe and Rudman 2012; Mooney et al 2008). Care giving is considered an important component of their work ethic and this is shared by generations of nurses before them. Price (2009) conducted a meta study of career choices in nursing and identified influencing factors, many of which are also shared by older nurses: caring ideals, the role of significant others and the caring paradox. Identifying factors of attraction and retention for Generation Y nurses in order to integrate them into retention practices have also been the subject of recent research (Clendon and Walker 2012; Hutchinson et al 2012; Tourangeau et al 2012; Cubit, 2011; Lavoie-Tremblay et al 2010).

Flexibility in the work place is a major factor in attaining work satisfaction for Generation Y (Carver and Candela 2008). A work schedule that enables life and work balance is a professional driver for Generation Y; thus workplaces that are shrouded by out-dated policies, practices and lack of access to technology do not make for an attractive career choice. Generation Y undergraduates also express their wish to choose what they study and where they work (Cleary et al 2013b). Lack of choice results in frustration and may precipitate their intention to leave nursing. Other professional motivators and drivers for Generation Y include acknowledgement of a job well done by supportive and nurturing leaders (McCalla-Graham and De Gagne 2015).

Creating work opportunities for new graduates should take into account their work requirements. Generation

Y like to be stimulated at work and work towards consolidating newly learned professional skills (Hutchinson et al 2012; Lower 2008). Provision of education, working with technology and career progression may improve their organisational commitment to their employer. Mostly, Generation Y graduates are usually free from financial and other responsibilities such as family, child minding or caring for elderly relatives due to their time of life (Ng et al 2010). They want to work to afford the lifestyle they most enjoy and this is potentially a motivator to employers to recruit these new nurses and focus on keeping them.

Generation Y distracting factors

This new generation of nurses is also a vulnerable workforce (Hutchinson et al 2012). Generation Y has expressed concern over workplace issues such as less pay for work and work conditions. A dominant theme in new graduate aged care nursing research is the effort/reward imbalance (Lavoie-Tremblay et al 2010). There is current dialogue between industry and government over the lack of monetary incentives provided to aged care nurses. Concern stems from nursing positions being replaced by less qualified, cheaper auxiliary staff (Happell and Gough 2007). The attrition of Generation Y nurses due to job dissatisfaction, negative work environment and lack of job motivation is foreshadowed. Disillusioned, unemployed new graduate nurses have the choice to consider leaving nursing, study further at postgraduate levels or retrain with a view to "side step" from nursing. These choices impact on national turnover and retention rates, already weakened by an ageing workforce, health budget cuts and the GFC. Health related areas, such as pathology, pharmaceutical sales and research, become innovative work fields where Generation Y are made welcome, supported and offered greater possibilities for career advancement. These are substantial distractions to the long term Gen Y engagement that is required for the nursing workforce. Another aspect of fragility for this new workforce is the possibility of applying for jobs that leave them open to exploitation such as working as Registered Nurses for lower rates of pay or performing non-nursing duties such as cleaning (Stevens 2011; Duffield et al 2008; Holmes 2006).

PREDICTED NURSING SHORTFALL TO 2025

The findings of HWA 2025 through its retention modelling scenario, outlined the urgency to retain the nursing workforce by at least 20% in "meeting the demand for nurses" (HWA 2012, p.49). In the case of a 'do nothing' comparison scenario, where currently nursing loses up to one in five of its nurses, the estimated shortfall signifies it will be necessary to increase supply by 27% (or 109,000 nurses) by 2025 (HWA, 2012, p120). Focus should be placed "on the retention of the current nursing workforce" (Mason, 2013, p. 259) to which new graduates belong. Frustration is evidenced by protests, campaigns and research about the lack of jobs for new nursing graduates (Parker et al 2012; Thomas 2012). With an ageing population of consumers and health workers, new graduate nurses are part of the solution to a growing workforce problem.

CONCLUSION

A range of local and international nursing specialty and workforce literature has been reviewed to highlight the sentiments expressed by new graduate nurses unable to source employment opportunities. This paper also identifies the responsibilities of universities and employers in the recruitment and eventual retention of Generation Y nurses.

The message that universities and employers are not preparing new graduate nurses to work where they are most wanted is not new. The idea that nursing graduates should supply areas of need is not enough to motivate and attract nurses to these areas. Generational theory alone does not answer why there are gaps unable to be filled in aged care and mental health. However, the theory is useful to guide and alert workforce planners to certain behaviours, especially in terms of work commitment and engagement with work environments. Unfortunately, generational stereotypes are often used to negatively categorise Generation Y as disloyal, unmotivated and interested only in work flexibility (Department of Education Employment and Workplace Relations, 2013; Baumberger-Henry 2012).

RECOMMENDATIONS

The discussion presented aims to alert those concerned about the challenges faced by graduating nurses and suggests that their impending employment should be addressed at the time of entry as students at university. Coupled with workforce and employers' needs, new nurses will play an important role in addressing the predicted shortfall of nurses by 2025. As a young, vibrant and knowledgeable workforce, there need to be processes in place at regular stages of Generation Y's early careers. This generation needs to be informed of workforce needs as students and again as graduate nurses when they begin their nursing career. Developing an awareness of 'where nurses are needed' in the early stages of their career has the potential to inform future career choice and fill workforce gaps where education and health might cooperate to find solutions.

Creative ways to educate nurses and provide a career pathway are suggested. Proposing electives in aged care and mental health nursing in pre-registration programs is one way to develop early interest and passion in these fields, provided they are positive and nurturing experiences. Generation Y nurses want to choose where they would like to work and initial contact with the clinical arena can have a major impact in their chosen field. Workforce and education providers should make new graduates aware through their course of study and on graduation that there are shortages in aged care and mental health care and suggest that this is where they should be applying. Some specialist aged care and mental health GTPs are offered to successful applicants in private and public health facilities, but retention of new graduate nurses remains low (Rush et al 2013). It is recommended that strategies targeting under graduate students in the classroom and clinical areas would be of benefit to nurses and employers. Presenting the state of nursing recruitment needs early, in a transparent and coordinated manner to 'new' nurses, would facilitate their preparation into the industry.

Industry representatives such as the Australian Nursing and Midwifery Federation (ANMF) have done much to raise public awareness of the employment plight of new graduates. Campaigns such as "stop passing the buck: Australia's nursing grads need jobs", mobilise the nurses concerned, employers, health care consumers and education providers in a united and solid front (Thomas 2012). The aim of the ANMF and its factions is to motivate governments to introduce commitment and economic investment in recruiting and retaining new graduates. Participating in public dialogue such as the Aged Care Workforce Strategy (Aged Care Insite 2014) place the needs of the aged care workforce high on the health workforce agenda.

Generational theories such as Mannheim's 1923 Theory of Generations (Parry and Unwin 2011; Codrington 2008) may be applied to redress the imbalance experienced in these three areas of nursing workforce: the shortage of suitable positions for new graduates; the predicted nursing shortfall; and the lack of specialist nurses in mental health and aged care. Applying a sociological approach provides the foundation for shared action facilitating the transition from the Baby Boomer to the Generation Y workforce.

Bringing these issues together may form a potential solution: graduate nurses filling attractive positions in mental health and aged care would in return increase prospective retention.

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AUTHORS

Sybele Anne Christopher

RN, MN (Sydney), MPH (UNSW), Ortho Cert CN PhD Candidate, Lecturer, M02--Sydney Nursing School, The University of Sydney, NSW, Australia

sybele.christopher@sydney.edu.au

Professor Elizabeth Mary Chiarella

RN, RM LLB (Hons), DipNEd, PhD, FCN, FRCNA Professor of Nursing, M02--Sydney Nursing School, The University of Sydney, NSW, Australia

mary.chiarella@sydney.edu.au

Professor Donna Waters

RN, PhD MPH (Sydney) BA (Macquarie), Paed Cert FCN Dean, Faculty of Nursing and Midwifery M02--Sydney Nursing School, The University of Sydney, NSW, Australia

donna.waters@sydney.edu.au
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Title Annotation:SCHOLARLY PAPER
Author:Christopher, Sybele Anne; Chiarella, Elizabeth Mary; Waters, Donna
Publication:Australian Journal of Advanced Nursing
Article Type:Report
Geographic Code:8AUST
Date:Dec 1, 2015
Words:6044
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