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Growing Ambulatory Care Nurse Leaders in aMultigenerational WorkforceBeth Swan, PhD, CRNP, FAANThomas Jefferson University, bethannswan@gmail.com

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Recommended CitationSwan, PhD, CRNP, FAAN, Beth, "Growing Ambulatory Care Nurse Leaders in a MultigenerationalWorkforce" (2009). School of Nursing Faculty Papers & Presentations. Paper 24.http://jdc.jefferson.edu/nursfp/24

'k!!!k!Perspectivesin AmbulatoryCareI... ... .......Growing Ambulatory Care Nurse Leaders in aMultigenerational Workforce

r-. Ambulatory care faces challenges in sustaining anursing workforce in the future as newly licensednurses are heavily recruited to inpatient settings andretirements will impact ambulatory care sooner thanother areas.

r-. Building a diverse team by recruiting nurses of differ-ent ages (generations) and skills may result in a moresuccessful and robust organization.

:> Knowledge about generational characteristics andpreferences will aid nurse leaders and recruiters inattracting high-quality, talented nurses.

t'- Nurses of Generations X and Y can increase theirlikelihood of success in ambulatory care by betterunderstanding intergenerational issues.

STATISTICS RELATED TO THE

nUIsing shortage are wellknown. Despite the tempo-rary lull in shortages in

some areas that are fueled by thesagging economy, the fact remainsthat the nUIsing workforce is agingand insufficient numbers of newnUIses are being produced to meetfutUIe needs. While the averageage of all working nUIses isapproaching 44 years (Buerhaus,Auerbach, & Staiger, 2009), theaverage age of nUIses working inpublic health and ambulatory careaverages 49.5 years (Robert WoodJohnson Foundation, 2008).FUIther, a large portion of theambulatory care nUIsing work-force is predicted to retire in thenext few years (Buerhaus et al.,2009). This challenge is notinsignificant. According toKovner et al. (2007), of 3,266newly licensed RNs, over 84%

were employed in inpatient hospital settings versus

Janet P. Moye

Beth Ann Swan

JANET P. MOYE, PhD, RN, NEA-BC, is Assistant Professor,College of Nursing, and Clinical Assistant Professor, Departmentof Public Health, Robert Wood Johnson Foundation ExecutiveNurse Fellow, East Carolina University, Greenville, NC.

BETH ANN SWAN, PhD, CRNp, FAAN, is Professor and SeniorAssociate Dean for Academic Affairs, Robert Wood JohnsonFoundation Executive Nurse Fellow, Jefferson School of Nursing,Thomas Jefferson University, Philadelphia, PA.

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Janet P. MoyeBeth Ann Swan

only 3.8% in outpatient or ambulatory care. For a mul-titude of reasons, nUIses with limited experience havenot been encoUIaged to seek careers in ambulatory set-tings (Haas, 2009). A plan for recruitment and retentionof expert and engaged ambulatory care nUIses shouldbe carefully planned and executed. Such a plan needsto not only consider, but also capitalize upon the differ-ing characteristics of the generations in the nUIsingworkforce.

Over the past few years, much has been writtenabout the multigenerational workforce. In brief, foUIgenerations are employed side-by-side for the first timein history. A declining but still influential percentageof the oldest generation is still working. Aptly namedVeterans, they were born before 1944. A larger percent-age of workers are Baby Boomers, born between 1944and 1960. Generation X, born between 1961 and 1980,and Generation Y, born after 1980, are the two newestgenerations entering the workforce.

While stereotyping people is not helpful, under-standing how events have shaped the lives and influ-enced the preferences and values of current nUIses andfutUIe nUIses is important. For example, the GreatDepression and World War II impacted the Veterangeneration, shaping their views and values. The mem-bers are disciplined and pragmatic, having learned tolive with scarce reSOUIces. Similarly, Baby Boomers,known for their strong work ethic, optimism, anddesire for social change, were influenced by desegrega-tion and the Vietnam War. Generation X workers,affected by economic uncertainty, single-parent fami-lies, and man-made disasters, tend to be skeptical andinterested in transforming traditional corporate cultUI-al hierarchies to flexible, horizontal organizationalstructUIes. Generation Y, having always lived withtechnology, grew up with a different reality, as well aswith "helicopter" parents hovering to manage theirlives. They tend to desire autonomy, may lack loyalty,but make up for it with the value they place on rela-tionships with co-workers and managers.

Most authors addressing multigenerational work-force issues focus on improving workplace relation-ships, but do not address issues related to hiring, reten-tion, and leadership succession planning. In the

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NOTE: This column is written by members of the AmericanAcademy of Ambulatory Care Nursing and edited by Candia BakerLaughlin, MS, RN, C. For more information about the organization,contact: AAACN, East Holly Avenue, Box 56, Pitman, NJ 08071-0056; (856) 256-2300; (800) AMB-NURS; FAX (856) 589-7463; E-mail: aaacn@ajj.com; Web site: http://AAACN.org

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July/ August "Perspectives in Ambulatory Care" col-umn (Swan & Moye, 2009), we defined leadershipplanning and succession planning, acknowledged thesignificance of leadership succession planning,described the different pathways and approaches insuccession planning, identified leadership competen-cies, and discussed individual strategies and organiza-tional strategies that can be employed related to succes-sion planning. In this article, Part 2, the role multiplegenerations play in building talent and leadership suc-cession is described. Emphasis is placed on the gener-ational interaction and the impact of the multigenera-tional workforce in ambulatory care nursing. Strategiesare recommended both for nurse managers who wantto recruit and retain strong nursing staffs and for nurs-es who are identifying their own career opportunities.

Background and SignificanceHistorically, American workers have held the

belief that being loyal to their organizations wouldresult in benefits for them. While this held true for theVeteran nurses, many who have worked for the sameorganization for their entire career, Baby Boomers wereless likely to remain with the same employer for theduration of their career. Subsequent generations havehad even less loyalty to organizations, focusing insteadon their personal career and what the organization cangive them (Dychtwald, Erickson, & Morison, 2006).

While career and job mobility are advantages tobeing a nurse, the flexibility and ubiquitous nature ofnursing as a career are factors that draw many into theprofession. Studies are showing that many nurses near-ing retirement, the Baby Boomer generation, have beenso mobile throughout their careers that they have notstayed in one place long enough to qualify for retire-ment benefits (Hatcher et al., 2006). As a result, thesenurses are faced with uncertain financial security afterretiring, if they indeed can retire. In a recent survey ofRNs with an average age of 52, 62% responded thatthey did not have a clear idea of what their retirementfinancial needs would be (Osborne, 2009). Nurses earlyin their careers should be aware that, even thoughmany organizations have changed their benefit plans tobe more portable, the fact remains there are manyadvantages of achieving tenure in an organization.Prospective employers can highlight these advantagesduring the interview process.

Many nurses may not understand the benefits ofstaying in an organization: these may include seniori-ty-based job security, benefits increasing with years ofservice (e.g., paid time off), and opportunities foradvancement enhanced by knowledge of the workingsof the organization. The key is to choose well whenconsidering an organization to join.

Organizations are recognizing the high cost associ-ated with turnover, but also, as Collins (2001) states,placinggreateremphasisongettingthe rightpeople onthe bus, as well as gettingpeoplein the right seats.To

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Table 1.Hallmarks of the Professional Nursing

Practice Setting

1. Philosophyof clinicalcare

2. Executive nursing leadership

3. Recognitionof the value of nursing4. Collaboration

5.

6.

7.

8.

Advancement

Development

Participation in clinical decision making

Availability of technology

SOURCE: MCN, 2004

build a great. organization or team he recommendsleaders should:1. Begin with "who" rather than "what." Focus on

prospective candidates who are more interested inthe opportunity to work with a high-performanceteam than those who focus upon the convenientschedule or the short commute.

2. Recognize that the right people will be self-motivat-ed by their inner drive to produce the best results.

3. Appreciate that if they have the wrong people, theywill never have a great organization or department(Collins, 2001).Managers can use information about generational

preferences and characteristics to make more effectivedecisions about hiring, team assignments, workrequirements, and even policy and procedure develop-ment. Interviewers who tailor the interview based onthe characteristics of the prospective employee mayyield better decisions, resulting in achieving a better fitand reducing turnover; a win-win for organization andemployee.

A prospective employee nurse who approaches theinitial interview with a long-term view may find thather/his personal career goals mesh with the organiza-tion better than one might expect. The AmericanAssociation of Colleges of Nursing (AACN, 2004) pro-vides a guide to questions for new graduates to askwhen interviewing. Entitled "Hallmarks of theProfessional Nursing Practice Setting" (2004), thisguide would be helpful for even more seasoned nurseswho are seeking positions and want to maximize theinterview process. The eight key characteristics or hall-marks defined by AACN are detailed in Table 1.Interviewers can encourage new nurses to playa moreactive participatory role in the interview process. Thiswill increase their confidence in their skills and helpthem realistically and critically examine the organiza-tion as a fit for them.

Organizations, particularly those who rely on high-ly skilled "knowledge workers," are at risk when these

___, u____. __ II

people leave and take their vast knowledge and experi-ence with them. When gaps occur and essential rolesremain unfilled or existing staff "double up" and takeon additional responsibilities, organizations increasetheir exposure to risks and negative outcomes. In ahealth care organization, such negative outcomes arelikely to affect patients. The loss of history and knowl-edge, the "corporate wisdom," as well as the workloadand knowledge expectations of those who remain areconcerns for nursing and nursing leadership in healthcare organizations.

Impact of GenerationsDeveloping future leaders in ambulatory care is an

important role for nurse managers. In many ambulato-ry care settings, while a large contingent of staff arehighly competent, experienced, older nurses, managersshould calculate their anticipated longevity. In otherwords, using a sports analogy, the manager asks, "Howdeep is my bench?" and "Who do I have to step up tothe plate?" Hiring more staff with similar demograph-ics may not be the best way to strengthen the bench.

While nurse managers and administrators areexamining their bench strength, so should nurses inambulatory care staff roles be establishing their expertknowledge and specialty competencies related to theirshort and long-term career goals. In ambulatory care,where the specialized knowledge may be held by a fewindividuals in a given specialty, the need to passknowledge on is essential.

Recruiting and Retaining TalentGeneration X and Y nurses tend to be more career

loyal rather than organization loyal. Organizationsshould continue to focus upon hiring the right staffandputting them in the right positions, but also articulatingthe opportunities that may be available for nurses tomove within the organization for career advancement.

Both managers and staff should think broadlyabout opportunities for leadership experiences anddevelopment, rather than focus solely on formal man-agement positions. Most succession planning focuseson the upper levels of administration and is based onthe perspective of the organization identifying the rolesand talent needed. Additionally, the new or seasonedstaff nurse should accept equal responsibility in iden-tifying the potential opportunities that resonate withtheir career goals and interests. Unit-based activities orfunctions, such as developing a staffing work scheduleor peer review, give inexperienced nurses a chance toparticipate or observe activities to decide if leadershiproles are an area of potential interest. Attending a meet-ing of a professional organization, likewise, may sparkan interest.

Mentorship of nurses as potential leaders mayfacilitate their recognition of opportunities for growththey may otherwise miss. Managers and other mentorsmay find the following strategies helpful in supporting

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the career growth of their mentees.. Scan the organization to identify potential rolesthat match interest areas. These may include spe-cialized departments that support functions suchas staff development or quality improvement, ormay be unit-specific roles such assistant manageror patient educator.. Look for opportunities to educate them about some-thing that is of interest. Consider facilitating theirmembership on the unit-based quality improve-ment committee, participation in medical recordreviews, or assisting the mentor/manager with aproject such as evaluating new products or equip-ment.. Encourage their membership in a local chapter of aprofessional organization.

Mentoring and Developing Generation XDeveloping leadership from within the ranks is

possible, especially if the staff is capable and commit-ted. Thinking strategically with an eye on developingleadership should be part of ongoing performancereviews and goal setting with ambulatory care nurses.The following actions are recommended for recogniz-ing the characteristics and acknowledging the specificneeds of Generation X (Zemke, Raines, & Filipczak,2000).. Ask during the interview what is important to them

and what they are looking for in the position. Listento what you hear; expect to hear they want work-life balance and explain how that can be achievedin your organization.

. Stress the technology available and how they cancontribute to advancing technological knowledge.. Let them know that the environment is busy andmulti-tasking skills are an asset; stress the degree ofautonomy they can expect to enjoy.. Use technology as much as possible during orienta-tion. Show them the organization's Web site andwhere to find important information, and thenleave them alone to explore.· Give them resources and do not micromanage,trusting they are not afraid to ask questions. Letthem know you are the "point person" and theywill be free to do their job without the hassles, andwill be able to avoid politics, which they hate.. Form a committee that promotes an engaged andfun workplace. Generation X nurses will not want"warm and fuzzy," but like a workplace to berelaxed. Acknowledge those tasks that must bedone without trying to sugarcoat the message.While Generation X does not want micromanage-ment, these nurses know to expect a certainamount of drudgery, and will respect your honesty.· Encourage them to do some work independently.Generation X members view teams very differentlyfrom Baby Boomers and Veterans. Recognize whena Generation X employee has mastered the skills

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needed to do the job well. This will likely signalthat the individual is ready to look at advancementopportunities. Remember their loyalty is to theircareer, not the organization, so explore ways tomake it a win-win. Is it time to assign more respon-sibilities in the unit or assist in moving up the clin-icalladder? Perhaps there is a promotional oppor-tunity in another unit that would be a good fit.

Career Planning Tips for Generation X NursesNurses employed within a health care organization

who identify with Generation X characteristics mayfind the following strategies advantageous for develop-ing their personal leadership potential.· Do not be afraid to make suggestions. If you have an

idea that will improve the informatics support of thepractice setting or make the patient flow more effi-cient, let your supervisor and health care team lead-ers know. You are likely to be recognized for initia-tive and process improvement.· Explore opportunities in the whole organization,not just your department, when you realize you areno longer challenged or otherwise believe it is timeto "move on." Moving into another departmentwithin the same organization may offer you careermobility without losing your seniority and benefitlevel. Looking at internal openings that match yourinterests may provide a new learning opportunityand afford upward mobility.

· Find a mentor or career coach, someone who canhelp you assess your interest and evaluate options.A mentor can be someone in your workplace, aleader in a professional organization, or an advisoror instructor from your nursing educational pro-gram.

· Avoid burning professional bridges. If you decide toleave an organization for an opportunity elsewhere,leave on professional and mature terms. Often, situ-ations occur in which a nurse may want to return toa previous place of employment, need a profession-al reference, or seek employment with someonewithin the network of a previous employer. Yourreputation is one of the most valuable assets you canbuild.

Mentoring and Developing Generation Y

The traits of Generation Y are vastly different fromGeneration X.While Generation Y has the technologicalskills of Generation X, and then some, Generation Yhasan otherwise very different profile. Ambulatory carenurse leaders should consider the following tactics.· Understand that Generation Y nurses like and need

structure and attention; they were raised that wayand it is comfortable for them.

· Realize they are inexperienced as well as friendly,but may be easily intimidated by others. They mayhave trouble relating comfortably with bosses,patients, and peers who they perceive as difficult.

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· Be sensitive to potential conflicts Generation Ynurses may have with Generation X nurses. Whileolder Baby Boomers may lump the younger genera-tions together, in many ways their values and expec-tations differ.· Match Generation Y nurses with mentors, becausethey will value working with seasoned people, likeBaby Boomers.

· Motivate with inspirational messages; they areproducts of the terrorist attacks on America andhave a strong sense of patriotism. They want to con-tribute to better society.

Career Planning Tips for Generation YGeneration Y nurses may not be welcomed with

open arms in the ambulatory setting. Although the bar-riers to new graduates in most specialty areas of nursinghave been broken down, many ambulatory care organi-zations still look for experienced nurses. Generation Ynurses should be aware of this potential barrier, andconsider the following actions to overcome it.· Remember, organizations are more inclined to hire

someone who has had some experience on the unitas a student. If still in school, look for an opportuni-ty for a clinical placement in ambulatory. A summerexternship may be a possibility.· Underscore Generation Y attributes that are sharedwith the BabyBoomer generation. Characteristicsofbeing hard working, dedicated, responsible, andwilling to sacrifice for the collective good will val-ued by potential employers.

· Stress your desire to work as part of a team.Although inexperienced, you are a quick and eagerlearner and will value the input of more seasonedstaff.

· Do not become discouraged if your first effortsto getthe position you want are unsuccessful; try again.Ask for feedback, be optimistic and resilient.Remember that your generation will be the nurseswho care for the Baby Boomers as they age.

Implications

Ambulatory care is well positioned to benefit byincluding the new generations of nurses to the mix ofstrengths and attributes of team members. Organi-zations that currently consist largely of older, experi-enced nursing staffs that embrace an infusion of newblood will thrive. Nurses who embrace leadershipdevelopment and succession planning offera legacy tothe new generations of nurses. Failing to proactivelyanticipate the leadership needs for the future of ambu-latory care nurses poses a significant risk that mayresult in a weak bench, without enough time torespond adequately. Ambulatory nurses shouldstrengthen that bench with the nurses of tomorrow tocontinue to support the important nursing needs oftheir patients. $

continued on page 415

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out understanding what is happening with the nurs-ing workforce.

Buerhaus: Beyond the nursing workforce, whatare your other research interests?

Spetz: In addition to research on nursing and thequality of care and examining the relationship andimpact of health information technology in hospitals,I have done research on hospital mergers and growthof multi-hospital systems in California, with an inter-est in how those multi-hospital systems use theirpower to bargain more aggressively with insurancecompanies for higher reimbursements and how thoseorganizations could collude, which has labor marketimplications. I have also been doing cost-effective-ness analyses for a variety of projects, including astudy of rifampin compared to isoniazid amonginmates for tuberculosis prevention.

Buerhaus: Thank you Joanne for taking the timeto talk with me. And thank you for focusing much of

your research on the nursing workforce. You havealready made many important contributions and Iwish you every success for making many more. $

REFERENCESBolton, L.B., Aydin, C.E., Donaldson, N., Brown, D.S., Sandhu,

M., Fridman, M., et al. (2007). Mandated nurse staffing ratiosin California: A comparison of staffing and nursing-sensitiveoutcomes pre- and post-regulation. Policy, Politics, andNursing Practice, 8(4), 238-250.

Donaldson, N., Bolton, L.B., Aydin, C., Brown, D., Elashoff, J., &Sandhu, M. (2005). Impact of California's licensed nurse-patient ratios on unit-level nurse staffing and patient out-comes. Policy, Politics, &-Nursing Practice, 6(3), 1-12.

Spetz, J. (2008). Nurse satisfaction and the implementation ofminimum nurse staffing regulations. Policy, Politics, andNursing Practice, 9(1), 15-21.

Spetz, J.,Chapman, S., Herrera, C., Kaiser, J., Seago, J.A.,&Dower,C. (2009).Assessing the impact of California's nurse staffingratios on hospitals and patient care. Oakland, CA:CaliforniaHealthCare Foundation.

Economic Evaluation of Pressure UlcerCarecontinued from page 400

National Institute for Health and Clinical Excellence (NICE). (2003).Guideline on pressure ulcer risk management and prevention.Retrieved January 14th, 2008, from http://guidance.nice.org.uk/cG7/NiceGuidance/pdflEnglish

Oostenbrink, J.B., Koopmanschap, M.A., & Rutten, F.F. (2002).Standardisation of costs: The Dutch manual for costing in eco-nomic evaluations. Pha171lacoeconomics, 20, 443-545.

Oostenbrink, J.B., Koopmanschap, M.A., & Rutten, F.P. (2003).Handleiding voor kostenonderzoek. (Guideline on costresearch].Diemen:Collegevoor zorgverzekeringen.

Oostenbrink, J.B., Buijs-Van der Woude, T., van Agthoven, M.,Koopmanschap, M.A., & Rutten, F.F. (2003). Unit costs of inpa-tient hospital days. Phannacoeconomics, 21(4), 263-271.

Schoonhoven, L., Haalboom, J.R, Bousema, M.T., Algra, A., Grobbee,D.E., Grypdonck, MH., & Buskens, E. (2002). Prognostic cohortstudy of routine use of risk assessment scales for prediction ofpressure ulcers. British Medical Journal, 325(7368), 797-800.

Schoonhoven, L., Grobbee, D.E., Donders, A.R, Algra, A., Grypdonck,M.H., Bousema, M.T., et al. (2006). Prediction of pressure ulcerdevelopment in hospitalised patients: A tool for risk assessment.Quality and Safety in Health Care, 15(1),65-70.

Schoonhoven, 1., Bousema, M.T., & Buskens, E. (2007). The preva-lence and incidence of pressure ulcers in hospitalised patients inthe Netherlands. A prospective inception cohort study.International Journal of Nursing Studies, 44(6), 927-935.

Severens, J.1., Habraken, J.M, Duivenvoorden, S., & Frederiks, C.M.(2002). The cost of illness of pressure ulcers in The Netherlands.Advances in Sldn and Wound Care, 15(2), 72-77.

Vanderwee, K., Grypdonck, M, &Defloor, T. (2005). Effectiveness ofan alternating pressure air mattress for the prevention of pres-sure ulcers. Age and Ageing, 34(3), 261-267.

Vanderwee, K., Grypdonck, M., &Defloor, T. (2007). Non-blanchableerythema as an indicator for the need for pressure ulcer preven-tion: A randomized-controlled trial. Journal of Clinical Nursing,16(2), 325-335.

\-NURSING ECONOMIC$/November-December 2009Nol. 27/No. 6

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Perpectives in Ambulatory Carecontinued from page 411

REFERENCESAmerican Association of Colleges of Nursing (AACN). (2004).

Hallmarks of the professional nursing practice setting.Retrieved from http://www.aacn.nche.edu/PNN/hallmarks-brochure.htm

Buerhaus, P.,Auerbach, D., &Staiger,D. (2009)The recent surge innurse employment: Causes and implications. Health Affairs,28(4) 657-668.

Collins, J. (2001). Good to great. New York: Collins Business.Dychtwald, K., Erickson, T., & Morison, R (2006). Workforce crisis.

Boston: Harvard Business School Publishing.Haas, S.A. (2009). Priming the pipeline: Creating aspirations for

new graduate nurses to enter ambulatory nursing roles.Nursing Economic$, 27(1), 58-60.

Hatcher, B., Bleich, M., Connolly, C., Davis, K., Hewlett, P., & Hill,K. (2006). Wisdom at work: The importance of the older andexperienced nurse in the workplace. Robert Wood JohnsonFoundation. Retrieved from www.rwjf.org/files/publica-tions/ other/wisdomatwork. pdf

Kovner, C., Brewer, C., Fairchild, S., Poornima, S., Kim, H., &Djukic, M. (2007). Newly licensed RNs' characteristics, workattitudes, and intentions to work. American Journal ofNursing, 107(9) 58-70.

Osborne, J. (2009). Final report nurse investor education survey.Center for American Nurses. Retrieved from http://www.can.affiniscape.com/ associations/91 02/files/WISER_NIEPSurveyReport9-4-09FINALV2. pdf

Robert Wood Johnson Foundation. (2008). Charting nursing's future.Retrieved from http://www.rwjf.org/files/research/20081010chartingissue7. pdf

Swan, B.A., &Moye, J. (2009). Growing new ambulatory care nurseleaders: Building talent from the primed pipeline. NursingEconomic$, 27(4), 251-254.

Zemke, R, Raines, C., & Filipczak, B. (2000). Generations at work.New York: American Management Association.

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