The ageing nursing workforce: a global challenge

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Today, nurse leaders in most developed countries are confronting the reality of a nursing workforce that is rapidly ageing at a time when healthcare demands are increasing. McIntosh et al. (2010) suggest that the shift toward an aging nursing workforce has significant implications. Organisations will need to consider ways to build supportive cultures, teach the workforce about generational diversity, rethink the way that work is done and pay closer attention to ergonomics and job engineering. Yet, Hill (2011) points out that myths persist about ageing and that research and evidence-based practices are noticeably absent from the nursing literature. Finding solutions to complex workforce problems requires that nurse leaders adopt more of a worldview as they look for best practices and creative strategies (Clark 2011). This issue of the Journal of Nursing Management is very timely. Nurse experts and researchers with a special interest in the ageing nursing workforce have contributed evidence-based work and innovative ideas to support nurse leaders in their strategic planning.

The workforce challenges ahead

There are currently 57 countries considered by the World Health Organization to be in a crisis relative to their work force (WHO, 2010). It is widely understood and accepted that across developed countries, health care systems are also facing major challenges due to changes in ageing demographics. An ageing population and the consequent rise in chronic and long-term conditions will be key drivers of change increasing demand for health services and requiring new forms of treatment and delivery systems tailored to the needs of older persons. At the same time, the graying of the nursing workforce mirrors the trend towards population ageing. Although many countries are considering workforce policy changes that could delay the retirement of nurses, it is unlikely that these policies will take effect early enough to substantively change the current projected losses.

A recent RN4CAST project (Filkins 2011) funded by the European commission projected a shortage of 600 000 nurses across Europe by 2020. Large numbers of nurses are expected to leave the workforce in developed countries during the next two decades, just when geriatric competence will be in higher demand due to unprecedented acceleration in population ageing (EU Commission, 2012). Indeed, the scarcity of qualified health personnel including nurses has been highlighted as one of the biggest obstacles globally to achieving health system effectiveness and this problem is expected to intensify over time (Buchan & Aiken 2008). In developed countries, a primary force behind population ageing has been the transition from high to low fertility rates. Falling fertility and increases in life expectancy have serious implications for the labor force. In most Organization for Economic Co-operation and Development (OECD) member countries, a declining ratio of young and working-age people to retirees will place significant stress on public budgets and pension systems. The OECD estimates that by 2015, the number of people retiring will outnumber entrants to the workforce (Warmuth 2008).

The problem is equally serious in the United States where the average age of a nurse is 47 (U.S. Department of Health & Human Services, HRSA 2010). Future workforce projections indicate that there could be a shortage of up to 250 000 nurses by 2025 (Buerhaus et al. 2009). Although the recent economic downturn has postponed the early retirement of many nurses, more than one third of the RN workforce are between the ages of 50 and 64 (Buerhaus et al. 2013). Confronting these problems will require strong nursing leadership but this group is also ageing, and succession planning is proving to be challenging. Westphal (2012) analysed the ages of nurse leaders as reported in the US National Nursing Sample from 1992–2008 and found a progressive increase in age over time. Wendler et al. (2009) have predicted that up to 75% of the nurse leaders in the United States workforce will retire by 2020. Their loss threatens the smooth continuity of healthcare delivery.

Traditional methods to address the nursing shortages such as increasing educational capacity, improving RN productivity and international recruitment may not be adequate considering the long-term prospects of a declining population with fewer entrants into the workforce. To minimize workforce shortages and meet the increasing demands for healthcare of an ageing population, employers will be required to develop new employment strategies to induce older nurses to extend their working life. The challenges involved with leading an ageing nursing workforce require careful strategic planning. The articles in this issue address three key issues. These include retaining the ageing nurse in the workforce, building healthy environments to accommodate an ageing workforce and succession planning for the future.

Retention of the ageing workforce

Though it is clear that proactive initiatives are needed to build a future workforce, there is also a need to focus on retaining nurses longer in the workforce so their expertise can be shared and their knowledge transferred. Some organisations have already begun the work of making changes which may encourage the older nurse to stay. In the United States AARP (N.D) annually awards those organisations recognized to be the top 50 best employers for employees over the age of 50. Healthcare organisations such as Atlantic Health System, Mercy Health System, Massachusetts General Hospital and Kaiser Permanente, as well as others qualified for this honor in 2011. Common threads in the selection of these organisations include evidence of considerable respect for their employees, active recruitment of employees over the age of 50, recognition of employee work, encouraging voice in decision making and providing meaningful feedback.

There are tools that can be helpful in planning. The Older Worker Lure Scale (OWL) (McIntosh et al. 2010) can be utilised to assess priorities and employee needs so realistic interventions can be planned. The OWL asks employees about their interest in continuous development, career opportunities, formal career ladder, succession planning, tuition reimbursement, in-service education support, age diversity training and recruitment of older nurses. It also allows the employees to rate their organisation's efforts in the implementation of best practices to accommodate an ageing workforce. The scale provides good direction for strategic planning but many of the factors such as flexibility of hours and shifts continue to be problematic in today's healthcare environment and impact retention.

Ageing nurses frequently complain about leadership rigidity in shift scheduling. In the United States, it is not uncommon for nurses to be given no option but to work 12 hour tours. Any discussion of their elimination or reduction evokes passionate arguments on both sides of the issue. Yet the evidence for the negative impact of 12 hour tours which includes staff fatigue, medical errors and patient dissatisfaction continues to grow (Stimpfel et al. 2012, Geiger-Brown & Trinkoff 2010). In this issue, authors Clendon and Walker (pp. 903–913) explore the impact of shiftwork in their research with nurses in New Zealand. They found that nurses report a decreasing tolerance for working night shift as they age and poor scheduling practices that did not allow for adequate rest were particularly detrimental to older nurses. Letvak, Gupta and Ruhm (pp. 914–921) were interested in whether there were differences between older and younger nurses in their overall health, productivity and quality of care delivered. Their research includes an analysis of data from over 1000 nurses working in North Carolina. They found no differences in the quality of care; but that nurses over 50 had higher BMIs (body mass index), better mental health scores yet reported higher pain scores and a 12% higher prevalence of having health problems that resulted in lost productivity. They ask intriguing questions about whether the complex patients care assignments often given to older nurses should be reconsidered to retain them in the workforce. Finally, Frank (pp. 922–926) explores another dimension of the ageing workforce, the ageing of nursing faculty. Her commentary is about her own experience in a phased retirement program which could be a promising solution for educational institutions confronting faculty shortages.

Creating healthy work environments for older nurses

There is growing evidence in the nursing literature about the positive impact of healthy work environments on staff satisfaction, retention, improved patient outcomes and organisational performance. Building on work begun by the American Association of Critical-Care Nurses (2005), many organisations have launched efforts to improve their work environments in an effort to retain staff. Magnet designation which has now been achieved by more than 390 hospitals globally (ANCC, 2013) is an example of an important initiative for organisations that seek to build professional practice environments that are healthy and support the work of nurses.

In a review of research looking at the nursing shortage and intent to leave, Chan et al. (2013) identified that work environment, culture, commitment, work demands and social support were key organisational predictive factors. There has been little written in the literature that specifically addresses older nurses and retention. In this issue, our authors present some creative strategies to retain the ageing workforce which include initiatives such as improving work engagement, reducing bullying, and environmental design to better accommodate older nurses. Havens, Warshawsky and Vasey (pp. 927–940) report on their research done in five rural US hospitals where they found no statistically significant differences in the level of engagement across generations but confirmed that professional practice environments are associated with higher levels of work engagement in all generational groups. Bishop (pp. 941–949) presents promising program evaluation research on a caring-based initiative that was specifically designed to re-engage staff by revitalizing the internal motivation and self-reward that brought them into nursing. Longo tackles the important issue of bullying. Most of the nursing literature on bullying explores the impact on new graduates. Longo (pp. 950–955) points out that nurses of all ages can be bullied and it does impact the retention of older nurses. Finally, Stichler (pp. 956–964) did a synthesis of the current literature and describes the physical challenges that ageing nurses experience and how facility design features can help to reduce these challenges. She makes a strong case that design features that promote healthier work environments can motivate nurses to continue working.

Succession planning

The looming retirements of significant numbers of baby-boomer nurses and nurse leaders during the next 10 years is usually presented in the literature within the context of anticipated nursing shortage vacancies and replacement costs. Less discussed is what the impact of lost knowledge that these nurses have gained through years of experience and will take with them could have on patient care, healthcare organisations and the profession of nursing. Hatcher et al. (2006) authors of the Robert Wood Johnson Foundation report on Wisdom at Work observed that while the retention of older nurses in the workforce for as long as possible is an important goal, inevitably they will begin to retire. They are concerned that with a large number of retirements occurring in a short period of time, younger nurses are likely to get pushed into jobs that they are not prepared to do in a very complex healthcare environment.

The knowledge and expertise of nurses can be difficult to articulate because it is often abstract and dynamic and reflects a set of complex interdependencies and experiences. Patricia Benner (2000) recognised this in her work on how nurses move from being novices to experts. Benner's model is widely used in nursing today as a framework for understanding how the knowledge, skills and abilities that nurses developed over time in their work impacts their practice. In this issue, Cathcart and Greenspan (pp. 964–970) beautifully illustrate one creative way to capture this wisdom in their work with nurse managers using narratives. This is why succession planning at all levels of the organisation is important. Titzer, Phillips, Tooley, Hall and Shirey (pp. 971–979) present a comprehensive synthesis of the evidence on nurse manager succession planning. Based on their review, they recommend that nurse manager succession planning needs to be deliberate because new managers take months to adapt to their new positions. Trepanier and Crenshaw (pp. 980–985) examine succession planning in acute care hospital settings. They present a business case for the importance of succession planning and provide practical strategies for nurse executives to consider in designing programs.

Conclusion

There are no easy answers to this global challenge confronting nurse leaders. The editors would like to thank all of the authors for their thoughtful work on this important topic. We hope the readers will find these articles both thought provoking and helpful in designing strategies to proactively manage the global challenge of the ageing nursing workforce.

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