Rob Graham, R.R.T./N.R.C.P.

Throughout history, the contribution of elders to family and society has been both valued and invaluable. Both society and families have benefited from their leadership and governance, be it from cooler heads at the table, wisdom amassed over a lifetime of experience, or (sometimes unwanted!) advise on childrearing. While marked cultural differences exist regarding the value of older members of society and their contribution, the thread is common in all cultures.

Until relatively recently, older workers have been valued and respected in the workplace. Changing demographics and employment entry requirements have resulted in a loss of appreciation for what these workers bring to the table. Were many required to re-apply for their positions today, they would not be granted an interview. (Myself included).

“Baby boomers” in the workforce, while highly skilled and adept at their jobs, are often not as formally educated as their younger colleagues. Conversely, while highly educated, younger employees lack hands-on, real-world experience. Since senior roles have traditionally been filled by those with experience within an organization, newer, younger hires may see them as an impediment to their advancement while simultaneously considering them unqualified, at least on paper, and unable to “keep up with the times.” 

Younger workers’ perceptions of older workers coincided with an all too singular focus on the bottom line. As a result, senior staff were often let go, either through early retirement incentives or restructuring that was de facto constructive dismissal, to be replaced by new hires at less pay. While this may have worked at the time, it is now a flawed strategy since growth in the labour market has outstripped the supply of workers. (1) The traditional balance sheet has no column to reflect the value (outcomes in the case of healthcare) lost during this transition. Indeed, in a profit-driven system such as the American one, poorer outcomes, while a source of consternation on “the floor,” are cause for celebration in the executive suites since they drive revenue. As long as all are playing the same game, outcome rankings remain static, even in manufacturing. For instance, a washing machine that lasted 20 years is now designed to last just over 10. Profits are up, but since reliability ratings are relative, they have not been impacted. 

Healthcare is no exception to the ails facing the corporate world and may be facing more serious challenges. Staff shortages in the healthcare system predate the COVID-19 pandemic, and the pandemic has exacerbated the problem immensely. However, we cannot place the blame solely at the pandemic’s feet; the staffing crisis is multi-factorial. 

While staff burnout has and always will be an issue for healthcare workers, there has been a COVID-generated explosion in burnout. It has spurred an exodus from the field above and beyond those who have either succumbed to the disease or can no longer work. This crisis is the tip of the proverbial iceberg. (2) The Canadian experience is reflected in the U.S. and globally. (3) 

Since the 1970s, positions formerly open to high school and/or college graduates have increasingly required a university degree, and managerial positions now more often than not require a Master’s. While nurses were once trained in-house at hospital-based nursing schools or community colleges, this is no longer the case. Allied health professionals are also products of a degree program more often than not. (In Canada, respiratory therapy largely remains a diploma program, although many of those entering these programs have at least partial prior degrees). 

While a degree is undeniably useful, the cost thereof may be a barrier to those wishing to enter the field of allied health. The demanding nature of healthcare work, shift and weekend work and a lack of advancement opportunities may lead those who can afford university to shun a career in healthcare. Those who do pursue a career in healthcare expect (rightfully so) a wage commensurate to their investment. Even with good wages and benefits, many leave the field after a short time when work-life balance becomes anything but balanced. 

Everyone in this business knows that real learning begins on the job, especially in a field like neonatology; a few weeks rotation in a NICU in no way prepares one actually to work in one regardless of discipline. There is no substitute for an experienced clinical educator to guide new staff up the steep learning curve. The consensus amongst RTs in my workplace is that achieving a reasonable level of comfort and proficiency requires at least a full year on the job. That timeline is considerably longer if one is hired at less than full-time hours, an increasingly more common phenomenon. Call it the “summer vacation effect”: some of what is learned is forgotten between tours. 

One cannot learn from errors unless they are recognised, errors that are more likely to occur without input from those who have put their time in. Unfortunately, it is not uncommon for clinical educators to have spent a relatively short time at the bedside, degree preparedness notwithstanding. Compounding matters is newer unit designs featuring single-patient rooms, which effectively have clinicians operating in isolation. 

All these factors both lengthen the time required to ascend the learning curve and result in post-orientation hires assuming responsibility for their charges without the benefit of mentorship and with reduced oversight. The consequences are real. While senior physicians’ “quality of care” may not be better (4), the metrics used to measure their experience are unclear. (5) Poorer outcomes have been linked to weekend admission (when staffing levels are lower) and the number of senior attendings. (6,7) 

Following a change in physical location and directorship, the unit where I practice has seen a marked increase in staffing turnover for nurses and respiratory therapists. While anecdotal, we have experienced a significant decline in outcomes across the gestational spectrum in the past year for the first time in my 33+ years of employment there. While correlation does not equal causation, this has followed a slight but steady decrease in the number of senior staff at all levels. 

What is experienced? Someone once told a wise former manager of mine that they had ten years of experience. Her reply was, “Do you have ten years’ experience or one year’s experience ten times?” Without the continued guidance and mentorship of truly experienced clinicians, a new hire is more likely to experience the latter scenario. 

Staff turnover is a fact of life. Dealing with attrition was once a simple matter of posting a job opening; however, this is no longer the case. Management must replace the “people leave” mindset with “why are people leaving and what can we do to get them to stay?” 

Engagement is key and is closely tied to management and senior management. While seniority is arguably good for the patient, it is the worst metric for assessing managerial performance, (8) yet longevity is often the most common management trait, particularly at the senior level. “Suck it up buttercup” is all too often their response to grievances from younger staff since it typically reflects their own experience. This is not helpful. Many in hospital management have little former management training and may lack personality traits amenable to the task, which compounds the problem. 

Poor engagement is highly linked to employee retention. Employees who do not feel engaged are five times more likely to leave than those who are, and management plays a key role in that engagement. (9) 

Stamina, resilience, and overall energy levels naturally decrease as we age. The virtually universal adoption of 12-hour shifts and the all to common day-day-night-night schedule often do not fit the needs of older staff. Unfortunately, accommodations in scheduling and workload are often non-existent in hospitals or are offered long after burnout has set in. Failure to recognise the needs of older workers leads to earlier retirement or reduced hours that further increase staffing shortages. The European Union is far ahead of North America (particularly the U.S.) regarding work-life balance, but the problem exists there too. (10) Hospitals must be proactive, not reactive. 

Scheduling improvements can be good for older staff and can also benefit the organization by reducing overtime and absenteeism. (11) 

There are many ways to increase employee engagement. Autonomy, recognition, performance incentives, and scheduling flexibility are a few. While union contracts may limit (or forbid) pay for performance, there are other ways to reward staff. For older staff, value recognition is high on the list. (12) (Although irrelevant to older staff, the most egregious shortcoming of hospitals is the availability of childcare). 

Retaining older staff as long as possible benefits the entire organisation. Staff shortages increase workload, decrease employee satisfaction and lead to burnout. This results in older staff leaving and younger staff becoming disengaged and leaving. This creates a vicious circle that threatens to collapse the system. 

Costs associated with attrition are not trivial, but accounting systems that separate orientation budgets from staffing budgets obfuscate those costs. Systemic changes aimed at benefiting older staff can be universally beneficial. If newer hires see senior staff treated well, they may be more inclined to stay and experience higher job satisfaction. Win-win-win. 

“To further engage employees and win their commitment through your performance management programs, consider how to treat your organization’s most experienced employees. In many cases, these employees understand the intricacies of a job better than their supervisors or managers do. By virtue of long identification with your organization, they may be deeply committed to high-level goals. They use their expertise to contribute in ways that newer employees simply cannot match. But many of them also may be planning to retire soon, especially if they are from the “Baby Boomer” generation. How will you transfer their knowledge to younger workers? Design a performance management system that recognizes and rewards proactive sharing of knowledge and expertise among co-workers.” (12) 

In crisis, there is opportunity. One opportunity is in praise of older workers. 

(Full disclosure: I have just celebrated my 65th birthday (as much as COVID would allow, i.e., not!) and am in my 34th year of a wonderful career in the NICU). 

References:

1. https://www.forbes.com/sites/edwardsegal/2021/06/03/new-report-says-demographic-drought-will-worsen-labor-shortage-crisis/?sh=5d32c5f94686

2. https://healthydebate.ca/2021/10/topic/hospitals-nursing-shortage/

3. https://www.beckershospitalreview.com/pdfs/The%20Aging%20Workforce%20and%20Health%20Care%20.pdf

4. https://pubmed.ncbi.nlm.nih.gov/15710959/

5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7559170/

6. https://www.southampton.ac.uk/news/2015/12/medical-staff-and-hospital-mortality.page

7. http://www.med.mcgill.ca/epidemiology/hanley/c607/ch01/weekends.pdf

8. https://www.kevinmd.com/blog/2019/09/seniority-is-the-worst-metric-for-health-care-leadership.html

9. http://employeeengagementinstitute.com/wp-content/uploads/2013/06/EE-in-Healthcare.pdf

10. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-019-4655-3

11. https://www.longwoods.com/content/20285/nursing-leadership/a-case-study-the-initiative-to-improve-rn-scheduling-at-hamilton-health-sciences

12. https://www.shrm.org/hr-today/trends-and-forecasting/special-reports-and-expert-views/documents/employee-engagement-commitment.pdf