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Retaining an aging nurse workforce: perceptions of human resource practices.

THE LARGE BABY-BOOM generation is slowly, yet steadily, aging and entering a time in which demand and utilization of health care typically increases (Garrett & Martini, 2007). The resources of health care organizations, including human resources (HR), will be strained as this large demographic cohort moves eventually into old age (Kovner, Jones, Zhan, Gergen, & Basu, 2002; Kovner, Mezey, & Harrington, 2002; Mion, 2003; Schofield, Page, Lyle, & Walker, 2006). Registered nurses are central to providing health care; thus, the retention of RNs, who are themselves aging, is a key policy imperative (Buerhaus, Staiger, & Auerbach, 2000b). This is particularly important in rural areas because of the heightened challenges of recruiting and retaining an adequate supply of rural nurses. Almost a quarter of the U.S. nurse workforce live and work in rural settings (Cramer, Nienaber, Helget, & Agrawal, 2006; University of Washington Rural Health Research Center, 2007).

To develop evidence-based older RN retention strategies, 583 RNs in 12 health care organizations that serve rural populations completed a survey entitled "Your Valuable Career Plans: Guidance for You and Your Employer." Policies and practices most important to nurses' decisions to remain in their organization and the extent to which their organizations currently engaged in these practices were identified. As such, this study provides an indicator of progress or lack of progress in addressing older nurse recruitment and retention and also offers guidance for differentiating policies and practices for younger and older nurses.

Background

The nursing shortage and an aging nurse workforce. Despite recent progress in attracting individuals into nursing careers, the expected retirement of the largest cohort of nurses will push the RN workforce below projected need by 2020 (Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2005; Buerhaus et al., 2000a; U.S. Department of Health and Human Resources, Health Resources and Services Administration [HRSA], and Bureau of Health Professions, 2002). In addition to concerns over shortage, never before have health care employers faced the challenges of managing a nursing workforce with the majority of nurses over 45 years of age (HRSA, 2007). Workplace changes, for a profession traditionally dominated by younger nurses, are now necessary.

Literature review. Research regarding older nurses has focused on their health, safety, stress level, preferred setting, schedule, intention to leave, and job satisfaction. One study done in the southeastern states found that over one-third of 308 hospital-employed older RNs reported jobrelated health problems (Letvak, 2005). Common injuries were needlesticks and back strains. A qualitative study of 11 older nurses found them confident in their abilities and capable of meeting the demands of hospital nursing (Letvak, 2002). This small sample reported stressors including inter generational conflict with younger nurses, less respect from patients and families, and inequity in pay. Santos et al. (2003) found significantly worse scores for stress and strain due to role overload, role insufficiency, role ambiguity, role boundary, and interpersonal strain in nurses born between 1946 and 1964 (Baby Boomers).

Some commonalities are emerging in regards to older nurses intention to stay and their preferred work setting. A statewide survey in a small rural state found the oldest cohort (age 61+) of a sample of 4,418, to be the most stable and unlikely to leave their position (McIntosh, Rambur, Palumbo, & Mongeon, 2003). These oldest nurses were more likely to work part-time and in settings of lesser acuity than the hospital. Findings regarding older nurses' work setting preference and intent to stay were similar in a study of 1,906 RNs from Metropolitan Statistical Areas in 29 states (Kovner, Brewer, Cheng, & Djukic, 2007) and in a national survey of 1,783 nurses conducted in 2004 (Norman et al., 2005).

The ability to delay retirement of a significant number of nurses or creating career paths that help facilitate a transition to a different work setting could help ease the shortage in the next decade. For example, an analysis on the loss rate of Australian nurses due to retirement at age 58 versus 65 concluded that later retirement could provide significant human resources not only in sheer numbers, but also in experience and expertise (O'Brien-Pallas, Duffield, & Alksnis, 2004). The attitude that older nurses are expendable and that an ample supply of new graduates will be available to replace retiring nurses in the next decade has been refuted by a growing chorus of concerned researchers around the world (Blakeley & Ribeiro, 2008; Camerino et al., 2006).

In the United States, evidence suggests that hospitals with AACN Magnet[R] hospital recognition, compared to non-Magnet hospitals, provided more support for their aging workforce. Hader, Saver, and Steltzer (2006) found there were increased efforts to reduce physical exertion, improve schedule flexibility, promote preventative care, establish succession planning, and offer educational/training opportunities. The authors urged nurse leaders to design more innovative solutions for retaining older nurses while paying attention to keeping their workforce in generational balance.

The importance of these issues is reinforced in the thorough review of the literature on older nurse retention (supplemented by surveys and interviews) undertaken by the Robert Wood Johnson Foundation (Hatcher et al., 2006) for their White Paper entitled "Wisdom at Work: The Importance of the Older and Experienced Nurse in the Workplace." The authors provide a baseline of best practices for retaining older nurses and encourage further research to explore and develop fresh approaches. This unprecedented compendium acknowledges successes to date and challenges health care organizations to make "necessary adjustments" for the future.

The current study was designed to identify "necessary adjustments" by replicating a significant Canadian study within a U.S. rural setting. Specifically, this current study uses the (Armstrong-Stassen, 2005) study of 361 nurses who were age 50 and over. In that Canadian study, a gap between what nurses want and what hospitals are actually doing was identified. Large discrepancies existed between what nurses identified as most important to their decision to remain in the workforce and what their organizations were currently doing in the areas of compensation, recognition and respect, pre and post-retirement options, and job design. The author concluded that some changes in HR policies might be costly, but most were not. Armstrong-Stassen (2005) also suggested that hospitals ignoring the input of older nurses on factors that will keep them in the workforce will face serious staffing problems in the years to come.

From a strategic perspective, the managerial policies and practices related to staffing, retention, development, and change management shape an organization's culture (Cascio, 2006). Collectively, these policies and practices communicate the value the organization places on the nurses which, in turn, directly influences their commitment and willingness to stay on the job. Since no American study of nurses in rural settings has sought to evaluate the practices that older nurses feel are most important along with what is actually being done in their respective organizations, this study seeks to fill that gap.

Purpose

The purpose of the study was to explore registered nurses' perception of (a) intention to stay in their current position, with their current employer, and employed as a nurse (as measured by self-report); (b) organizational and unit-level culture regarding older nurses in the workplace; (c) importance of specific HR practices/policies to their own intention to stay in the workplace; and (d) extent to which these HR practices/policies are currently done in their workplace. This research explores each of these HR policies and practices not only in terms of the importance to the nurse but also their perception of whether or not the organization currently addresses the issue.

Methods

This convenience sample study employed a modified Dillman mail design survey methodology (Dillman, 1978) to investigate perceptions of nurses in 12 institutions (four hospitals, seven home health agencies, and one nursing home). These organizations had agreed to participate in an open evaluation of their nurse retention initiatives as part of a HRSA career ladders project; the current investigation played an evaluative component. There were no ANCC Magnet hospitals in the sample.

The instrument replicated portions of the previously detailed Canadian Armstrong-Stassen study (2005). Permission to use the instrument was obtained from the author. The Armstrong-Stassen instrument was augmented with the organizational commitment scale (Meyer & Allen, 1997; Meyer, Allen, & Smith, 1993) consisting of 24 questions on a 5-point Likert scale. Meta-analysis of the three component model confirms that the three forms of commitment (affective, continuance, and normative) are all related negatively to withdrawal cognition and turnover (Meyer, Stanley, Herscovitch, & Topolnytsky, 2002). Demographic data, "intention to stay" questions, and a 14 centimeter line on which respondents indicated "your current place in your entire nursing career" were added. Validity of the final instrument was established by content experts' review, and pre-testing for readability and relevance by RNs employed in a range of settings that included hospitals, home health agencies, and nursing homes. Descriptive statistics are reported. ANOVA was used for the overall test of equality of means; if significant, pairwise group comparisons were made using Fisher's least significant difference procedure.

Results

The survey was returned by 583 RNs (53% response rate), and the demographic profile of respondents is detailed in Table 1. With the exception of racial diversity, the demographic profile of the respondents is very similar to both the participating state (Office of Nursing Workforce Research Planning and Development, 2005) and national nurse profiles (Spratley, Johnson, Sochalski, Fritz, & Spencer, 2000).

Intent to stay. Overall, respondents plan to stay in the workforce slightly longer than they plan to stay working as a nurse, and on average they do not intend to stay in the same position nor the same organization for the remainder of their careers (see Table 2). The majority (58%) either plans to or may work as a nurse after retirement. Only 19% of the sample indicated that they do not plan to continue working as a nurse. Conversely, 4% plan to work full time as a nurse after retirement.

Organizational culture. Issues regarding the aging nurse workforce were seen as moderately important (mean 3.7 on a 5-point scale) to all respondents. Individuals on nursing units were open to working with nurses age 50 to 59 (mean 4.3); however, organizations were perceived to be only modestly effective at recruiting these nurses (mean 2.5). Slightly less openness (mean 4.0) was perceived regarding working with nurses age 60+, and active work on retaining these nurses was minimal (mean 2.2) (see Table 3).

The top three HR practices (see Table 4) reported by respondents as important to their decision to remain in their organizations were (a) recognition and respect, (b) having a voice, and (c) receiving ongoing feedback regarding one's performance. Notably, these top three practices ranked above compensation and flexible work options. Again, as shown in Table 4, the HR practices most frequently reported as currently being done by the organization (mean response) included the categories of (a) employee health and safety, (b) performance evaluation, and (c) recognition and respect. The importance of retirement options and recruitment of older nurses was least important and least likely to be done. Even though similarities existed in the broad categories listed here, the greatest differences between importance and what was currently being done were all in specific areas of compensation. These practices included (a) offering incentives for continued employment, (b) increasing financial compensation, and (c) improving benefits, more vacation.

Age cohort differences. Cohorts for data analysis were defined in relationship to legal and government practices. Age 40 is the age when one is identified as an older worker under the Age Discrimination and Employment Act (ADEA). Age 55 is when many government programs start to cover "older workers." Thus, three age cohorts used for analysis were <40, 40-54, and >55 years. There were no significant differences between those age cohorts with respect to perceived organizational support, identification with their organization, and co-worker support and friendships (all/)>0.20). However, the perceived importance of HR practices did vary significantly in three areas. The oldest cohort (>55 years) was significantly more likely to report the following as important: recruiting nurses over 50 years (p=0.003), compensation (p=0.003), and retirement options (p<0.0001).

In addition, there were also significantly different perceptions among the age cohorts about HR practices currently being done. Younger nurses were more likely to perceive flexible work options as being done than the middle cohort (p=0.01) and more likely to perceive job design efforts as being done than both the middle and oldest cohort (p=0.0004). Conversely, the oldest cohort had a greater perception than the youngest cohort that pre/post-retirement options (p=0.01) and employee voice (p=0.03) were practiced; both the oldest and youngest cohort were more likely than the middle cohort to perceive performance evaluation initiatives (p=0.01) as currently being done. There were no differences among age cohort in the perception of recruitment, training and development, recognition and respect, compensation, and health and safety practices.

The age groups were significantly different regarding their feelings about recruitment and retention of older nurses. Nurses age >55 reported that their employers were more effective in recruiting nurses over age 50 than did the younger cohorts (p=0.0008). This oldest cohort also felt that their units were working on retaining nurses age >60 to a greater extent than did the younger cohorts (p=0.003). The middle cohort, age 40 to 54, felt individuais working on their units were less open to working with nurses age 50 to 59 than did nurses in the younger and older cohorts (p=0.03).

Intentions and careers. The nurses in this sample are intending to work well beyond age 55, which was once identified as "the traditional retirement age of hospital nurses" (Minnick, 2000). Moreover, the recent economic downturn will likely necessitate longer work years for many Americans. Clearly, the data in Table 2 show that the nurses in this study intend to work well into their 60s, with the average being almost 64, but they do not necessari] y plan to work in the same organization. This generational cohort ]ikely perceives their aging and work roles radically different] y than previous generations. Indeed, the popular press increasingly addresses ways to transition to encore careers and design a fulfilling "third act" in life. Popular books such as Leap! What Will We Do with the Rest of Our Lives?: Reflections from the Boomer Generation (Davidson, 2007) and Don't Retire: Rewire (Sedlar & Miners, 2003) reflect this emerging phenomenon. Our findings suggest three critically relevant points: (a) Nurses in this sample envision their work roles as not nearly complete, (b) Nurses are willing to extend work if the organization creates a responsive work environment, (c) Organizations that can respond in a thoughtful way will increasingly gain a competitive advantage.

Organization and unit responses. In terms of recruitment and retention of nurses over age 50, these findings may indicate some intergenerational tension that should be addressed with a c]ear message that nurses of all ages are needed and valued. Managers of all age cohorts may need support and assistance to make intergenerational respect and understanding an organizational norm. The imperative is clear: four generations of nurses are now working shoulder to shoulder with each generation bringing its own unique talents. The best way to avoid conflicts is for management to continuously promote intergenerational understanding and teamwork that utilizes the differing talents of all (Lancaster & Stillman, 2002; Raines, 2003).

Differences by age cohort. The differences in the perceptions of HR practices by age cohort warrant closer examination. The majority of nurses were in similar settings (hospitals, 61%), and thus it is unlikely that the differences in perception by age cohort merely reflect different work settings. One explanation is that nurses are more likely to notice what they are interested in. Given that different age cohorts have legitimately different interests and work/life needs, they perceive the same reality differently. This could explain the greater perception of retirement options by the older group and the greater perception of flexible work options by the younger group. Other explanations are more troubling. Perhaps the designed flexibility is less apparent to the older groups because it does not meet their definitions for flexibility or offer the sort of flexibility useful to them, such as seasonal rather than shift or workday flexibility. Similarly, is it possible that older nurses are more likely to perceive having a voice as more important because they, indeed, have greater voice than younger nurses? These conjectures cannot be addressed within the confines of the current study, but offer fertile ground for future research and demonstration projects.

Specific human resource policies and practices. The top three HR practices that may affect a nurse's decision to remain in her/his respective organization are ones that nursing administrators can control. Recognition and respect, having a voice, and receiving ongoing feedback regarding one's performance, all rated higher than compensation for the survey respondents. Although the administrators who employed the sample could list ways that they were recognizing their nurses' accomplishments and dedication, those efforts were not sufficiently meeting the nurses' desire for recognition and respect. Moreover, the organizational meaning of recognition and respect may be incongruent with nurses' definitions and may vary by generational cohort. Efforts to increase the "voice" of every nurse are advocated by the Magnet Hospital recognition program. These data suggest that this goal is not being fully met in the study sample of small health care organizations serving rural areas.

It is noted that the practices that are most often reported as not being done are all in the general area of compensation. These results are only slightly different from findings in the Canadian study (Armstrong-Stassen, 2005). Compensation did not surface as having the highest importance for continued employment; however, it was an area perceived by this American rural sample as less that adequately addressed.

Financial incentives to retain older nurses. Retention of aging nurses is a fiscally responsible action for any organization to take. Replacement costs include the direct costs of advertising and interviewing, as well as the indirect costs associated with lost productivity during the replacement and orientation period and administrative paperwork. Turnover is an expensive burden for health care organizations, costing 1.2 to 1.3 times the yearly RN salary or up to 5% of the hospital budget (Jones, 2004).

Limitations. This study was conducted in one rural, largely homogenous U.S. state. This limits generalizability and excludes urban areas and large health systems. At the same time, a quarter of U.S. nurses work in settings similar to that in the study (Palazzo, Susan, & Hart, 2003) and the findings may indeed be applicable to them. A second limitation relates to the use of self-reported perceptions rather than analyses of existing human resource policies. Indeed, nurses' perceptions of organizational practices and policies may not be consistent with reality. Nevertheless, because behavior is driven by perception, perceptions matter and warrant investigation. Moreover, the study, by design, replicated a previous international study. Therefore, this second limitation is deemed acceptable. Finally, the opportunity to compare and contrast with research in a Canadian system, while interesting, must be viewed with caution, as the health care systems, social policies, and social mores are markedly different.

Recommendations. Areas to consider for improving recruitment and retention of older nurses are listed in Table 5. These should be tested empirically through further research and demonstration projects to create scientifically sound best practices.

The results presented in this article clearly suggest that perceptions about retirement are changing. Nurses are indicating a willingness to work longer, and they do not view themselves in the final stage of their careers. This is particularly important in the current economic climate, as nurses may "need" to continue to work to meet increasingly elusive financial goals. It is imperative that health care organizations design HR policies and practices that support the needs and expectations of a multi-generational workforce. Savvy organizations can position themselves as the "employer of choice" by showing respect for their most experienced nurses' unique contributions and integrating them successfully into a multi-generational workforce.

ACKNOWLEDGMENT: Support for this research was received from: HRSA # D65HP05247-01-00, Nurse Education, Practice and Retention: Career Ladders Grant, "Mission Essential: Ladders for a Lifetime."

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MARY VAL PALUMBO, DNP, GNP-BC, is a Gerontological Nurse Practitioner and Director, Office of Nursing Workforce, Research, Planning, and Development, University of Vermont, Burlington, VT.

BARBARA McINTOSH, PhD, SPHR, is a Professor, School of Business Administration, University of Vermont, Burlington, VT.

BETTY RAMBUR, PhD, RN, is a Professor of Nursing, University of Vermont College of Nursing and Health Sciences, Burlington, VT.

SHELLY NAUD, PhD, is a Biostatistician, Medical Biostatistics & Bioinformatics Facility, University of Vermont's College of Medicine, Burlington, VT.
Table 1.
Demographics

Gender
  95% female
Position
  76% reported their major activity
  was patient care
Hours
  53% worked full time
  Mean hours per week: 32 hours
Age
  Average 49.7 years
  55+ years                           33%
  40-54 years                         51%
  < 40 years                          16%
Education
  Highest nursing degree
    Diploma                           19%
    Associate's                       42%
    Bachelor's                        34%
    Master's                           5%
    Doctorate                        0.1%
  Highest-non-nursing degree
    Diploma                           10%
    Associate's                       11%
    Bachelor's                        17%
    Master's                           4%
    None                              57%
Employer
  Hospital                            61%
  Nursing home                         1%
  Home health                         38%
Mean years in organization     12.6 years
Mean years in position          8.8 years

Table 2.
Intent to Stay

Intention to stay working               13.9 years (Mean)
Intention to stay working as a nurse    12.4 years (Mean)
Intention to stay with present           8.8 years (Mean)
  organization
Intention to stay in current position    7.5 years (Mean)
Age of planned retirement               63.9 years (Mean)

Do you plan to continue working in nursing after retirement?

          Yes: 16%       Maybe: 42%      No: 19%    Don't know: 22%

If yes:   Full time 4%   Part time 86%   Paid 57%   Unpaid 16%

Table 3.
Organizational and Unit-Level Culture Regarding Older Nurses

(All questions answered on a 5-point Likert scale with (1) negative
to (5) positive, means are reported.)

1. How important is the issue of the aging of the nursing workforce
for your organization?

(Mean 3.72; 1 = Not at all important)

2. How effective do you feel your hospital/agency is in recruiting of
nurses over 50 years?

(Mean 2.458; 1 = Not at all effective)

3. Rate how well your hospital/agency is doing in retaining nurses
>50 years.

(Mean 3.161; 1 = Very poorly)

4. How active is your unit in recruiting/retaining nurses >50 years?

(Mean 2.547; 1 = Not at all)

5. How actively is your unit working to retain nurses age >60?
(Mean 2.236; 1 = Not at all)

6. How open are individuals in your unit to working with nurses age
50-59?

(Mean 4.316; 1 = Not at all open)

7. How open are individuals in your unit to working with nurses age
>60?

(Mean 3.973; 1 = Not at all open)

Table 4.
Nurses' Perceptions of Human Resource Practices and Policies

Importance to Your Decision to Remain
(Mean response on a 3-point Likert scale: 1 = Not at all,
2 = Some, 3 = Highly)

1. Recognition and Respeet (2.712)

2. EmployeeVoiee (2.710)

3. Performance Evaluation (2.60)

4. Compensation (2.57)

5. Employee Health and Safety (2.56)

6. Job Design (2.475)

7. Training and Development (2.41)

8. Flexible Work Options (2.31)

9. Retirement Options (2.13)

10. Recruitment of Older Nurses (1.68)

Practices Currently Being Done

(Mean response on a 3-point Likert scale: 1 = Not at all,
2 = Some, 3 = Highly)

1. Employee Health and Safety (2.30)

2. Performance Evaluation (2.25)

3. Recognition and Respect (2.18)

4. EmployeeVoice (2.17)

5. Training and Development (2.07)

6. Flexible Working Options (2.00)

7. Job Design (1.92)

8. Compensation (1.74)

9. Recruitment of Older Nurses (1.72)

10. Retirement Options (1.63)

Greatest Difference Between Importance and What Is Being Done
(All specific practices in the broad area of compensation.)

1. Offering incentives for continued employment (2.54/1.65)

2. Increasing financiai compensation (2.63/1.82)

3. Improving benefits: More vacation (2.53/1.65)

Table 5.
Areas to Consider for Improving Recruitment and Retention of Older
Nurses

* Staffing, Are older nurses actively brought into the
organization? Are older nurses actively being encouraged to stay?
Are staffing levels appropriate to reduce the stress on all nurses?

* Development. Are older nurses encouraged to not only update job
skills but also explore new areas? Are there opportunities to
advance or change specialties? Are nurses encouraged to make 5-year
career plans and set goals for accomplishing these plans?

* Work design. Are jobs designed for maximum effectiveness and
efficiency? Are nurses encouraged to examine their job
responsibilities and propose adjustments or redesign? Are flexible
working options available? Are pre and post-retirement options
available?

* Feedback/Recognition. Are nurses regularly told by administration
how they are performing on the job? Are they recognized for their
achievements?

* Compensation. Are reward systems competitive? Are benefits
regularly reviewed for attractiveness to different age cohorts?

* Culture. Are nurses given voice? Are experienced nurses
recognized? Do older nurses, in turn, demonstrably support the
unique contributes and values of their younger colleagues? Are
recognition and respect valued and reinforced in and throughout the
organization?
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Author:Val Palumbo, Mary; McIntosh, Barbara; Rambur, Betty; Naud, Shelly
Publication:Nursing Economics
Geographic Code:1USA
Date:Jul 1, 2009
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