The Older Nurse in the Workplace: Does Age Matter?

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The Older Nurse in the Workplace: Does Age Matter? Linda D. Norman; Karen Donelan; Peter I. Buerhaus; Georgianna Willis; Mamie Williams; Beth Ulrich; Robert Dittus Nurs Econ. 2005;23(6):282-289.

This six-part series on the state of the nursing workforce began with an examination of national survey data on registered nurses (RNs) to determine whether hospital-employed RNs perceived the nursing shortage was getting better or worse (Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2005a). In the second article of the series, we examined RNs' satisfaction with their present job and with nursing as a career (Buerhaus et al., 2005). In part three, our attention focused on assessing awareness and reactions of nursing students, RNs, and hospital chief nursing officers (CNOs) to the Johnson & Johnson Campaign for Nursing's Future that is aimed at resolving the current nursing shortage and preventing the development of a predicted future shortage of nurses (Donelan, Buerhaus, Ulrich, Norman, & Dittus, 2005). In part four, we examined RNs' and CNOs' perceptions of how the current nursing shortage is impacting care processes, RNs, and quality of care (Buerhaus et al., 2005c). In this article, we concentrate on a different but increasingly important component of the RN workforce — the growing proportion of older RNs. Awareness of the aging RN workforce began after a study published in 2000 (Buerhaus, Staiger, & Auerbach, 2000) identified the reasons for the increase in the average age of the RN workforce and described implications for the future age composition and supply of RNs through 2020. The study projected the average age of the RN workforce will continue to increase at a rapid rate, rising nearly 4 years between 2000 and 2010, reaching 45 years of age, and remaining at this level through 2020. Between 2010 and 2020, over 40% of the RN workforce will be over 50 years of age, and many RNs are expected to retire and withdraw from the workforce. Recent evidence suggests these projections are on target. An analysis of employment and earnings trends in the nurse labor market showed that of the 185,000 growth of RN employment in 2002 and 2003, nearly 130,000 was accounted for by re-entry of RNs over the age of 50 (Buerhaus, Staiger, & Auerbach, 2004). Between 1994 and 2001, RNs 50 and over grew at a rate of 4.7% per year, whereas beginning in 2001, the rate of growth exploded, rising 15.8% between 2002-2003. Meanwhile, the proportion of RNs under the age of 35 continues to decline, a 20-year trend reflecting the inability to attract younger people into the nursing profession. During the foreseeable future, the nursing workforce will be driven increasingly by the swelling number of older RNs and the forces that determine their decision to participate in the nursing workforce. Consequently, obtaining a better understanding of older-employed RNs relative to middle and younger-age RNs is critical to developing strategies to retain this rapidly growing segment of the workforce. Not only will the proportion of older RNs in the workforce grow in the years ahead, but older RNs possess a wealth of experience and knowledge that make them valuable resources to the nation's health care delivery system. At the same time, because the practice of nursing involves physically challenging work, these RNs will be increasingly susceptible to musculoskeletal injuries. In fact, older nurses report more job-related musculoskeletal and needlestick injuries than younger nurses, injuries that occur more frequently in hospitals (Levtak, 2005). Studies suggest there may be some important differences between older and younger RNs. Letvak (2002) reported older nurses are more likely to work in outpatient, community, and other non-acute care settings, and Buchan (1999) found the same in countries outside of the United States. There also is evidence that older nurses favor working 8 instead of 12-hour shifts (Hoffman & Scott, 2003). However, results are mixed with respect to whether older RNs compared to younger RNs are more satisfied with both their jobs and nursing as a career (Division of Nursing, 2000; Hoffman & Scott, 2003). In this study, we attempt to develop a comprehensive understanding of the personal characteristics, health, employment patterns, perceptions of the causes and resolution of the nursing shortage, and other traits and attitudes held by older RNs. Determining whether there are key differences relative to their younger age counterparts may offer clues to guide policymakers, employers, and others concerned with designing strategies aimed at retaining older RNs in the workforce for as long as possible. As in other studies reported in this six-part series, we use data from a recent national random sample survey of RNs. Analyses of the survey data were conducted as part of an ongoing collaboration among researchers at Vanderbilt University School of

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Nursing, Massachusetts General Hospital, and Harris Interactive working to evaluate the Johnson & Johnson Campaign for Nursing's Future. Although detailed survey methodology is reported in part one of this series (Buerhaus et al., 2005a), briefly, the data analyzed in this study were from a national survey of 1,783 nurses conducted in 2004. The survey was sponsored by the Johnson & Johnson Campaign for Nursing's Future and by Nurseweek/Nursing Spectrum. We separated RNs' age into four groups: 18-29, 30-39, 40-49, and 50 years and over. The latter group compose roughly one-third of the total sample and, for convenience, are referred to as "older nurses." Data presented in this study were derived from mostly descriptive univariate and bivariate analyses by age group. We also conducted extensive multivariate logit analysis to more thoroughly examine observed significant bivariate relationships among age and RN satisfaction with work setting and career choice, perceptions of the nursing shortage in the nurses' community, and willingness to recommend a career in nursing to qualified students. Analyses were performed using SPSS version 13.0. All survey data were subject to sampling and nonsampling error. Sampling error arises from drawing a representative subset of the population rather than surveying each person in that population, and varies with the size of the subsample surveyed. The sampling error for this sample of RNs was with 96% confidence, plus or minus 2.3%. Sampling error increases, however, when examining smaller subsets of the data, and hence the sampling error associated with the subsample of older RNs was approximately 4%. Considerable efforts were made to minimize the most common sources of non-sampling error including non-response, response bias, and clarity of question wording. Selected demographic and work characteristics of working older and younger RNs included in the sample are shown in . Older RNs represent approximately 31% of RNs surveyed. As a group, they are more likely to have an associate degree as the highest nursing degree and less likely than younger RNs to have a baccalaureate degree. As a group, older RNs reported less earnings compared to younger RNs. Age, Education, and Employment Characteristics of Registered Nurses, 2004

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Participation in the labor market, type of employer, and positions held by RNs vary by age. Three quarters of older RNs were employed versus 93% of younger nurses. Among all employed RNs, a little less than half (46%) of older RNs provided direct patient care whereas much larger proportions of younger RNs worked in direct patient care (63% of RNs 40-49, 74% RNs 30-39, and 83% of RNs 18-29). Thirty-eight percent of older employed RNs worked in acute care settings, compared with 62% of younger RNs. Given older RNs' employment preference for non-acute care settings and providing proportionately less direct patient care, we explored the relationship between self-reported health status and age by work setting (see ). While older RNs were somewhat less likely than younger nurses to report their health as excellent, we found no significant differences in the proportion who reported being in very good, good, fair, or poor health. Similarly although work setting varies with the RN's age, there were no significant differences in self-reported health status of RNs by age within different work settings. Registered Nurses' Work Setting by Age and Health Status, 2004

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The relatively good health of the RN workforce may reflect a self-selection out of nursing by RNs who have health concerns. Among RNs not working, 60% were retired, 13% were not working for health reasons, 7% indicated they were burned out, and 4% cited family care responsibilities. About one-third of older RNs plan to leave their current nursing position in the next 3 years; however, older RNs are more likely than younger RNs to say they will remain in their current position. Moreover, of those older RNs planning to leave their current nursing position, nearly half (47%) intend to retire, 29% intend to take another position in nursing, 15% to change professions, and 15% to take time out for family or personal reasons. Figure 1 shows RNs' satisfaction with their current job and with being a nurse. Satisfaction with their job was asked only of RNs currently working, and career satisfaction was asked of all RNs surveyed. Across age groups, there is considerable satisfaction with nursing as a job and as a career. Consistently, in every age group, significantly more RNs were likely to say they were very satisfied with being a nurse than with their present job, although the difference among 18 to 29 year olds was not statistically significant. Older RNs also expressed greater satisfaction with their jobs and with nursing as a career choice.

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Registered Nurses' Satisfaction with Nursing Career and Present Job by Age, 2004 Because satisfaction is a multidimensional construct, we explored the relationship between age and satisfaction with being a nurse using multivariate logistic regression analysis controlling for a number of factors, including race, marital status, education, wages, union membership, health status, work setting and position, earnings, and opportunities to influence decisions about patient care and work environment. Results showed that increasing age was a highly significant predictor of satisfaction with being a nurse. In part two of this series (Buerhaus et al., 2005b) we reported on hospital-employed RN ratings of relationships with other nurses, nurse managers, physician colleagues, support staff, and managers. Remarkably, in this analysis, we found no variation by age in RNs' assessment of the quality of these relationships, with the exception of the relationships between nurses and both nurse managers and hospital management: 48% of the older nurses rated their relationship with nurse managers as excellent or very good compared to 37% of the 18 to 29 year olds. Older RNs also rated their relationship with hospital management higher (31%) than the 18 to 29 year olds (18%). Both of these differences were statistically significant. Many older RNs have experienced prior nursing shortages in the United States. We reasoned, therefore, that they might view the current shortage differently than younger RNs with respect to the intensity of the shortage, reasons behind its development, solutions to the shortage, and where the shortage is likely to lead. shows that older and younger RNs differed in their perceptions of the main reasons for the shortage. RNs were presented with a list of possible reasons for the shortage and asked to indicate the two main reasons, with an option to write in other reasons if they desired. Among all RNs, the four most frequently cited reasons were (a) more career options for women, (b) salary and benefits, (c) undesirable hours, and (d) nursing not seen as a rewarding career. Although these four reasons predominate across all age groups, proportions vary significantly. For example, older RNs were far more likely to cite more career options for women whereas younger RNs were much more likely to report salary and benefits as the dominant reason.

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Registered Nurses' Views of How to Solve the Nursing Shortage, 2004

RNs also were asked to identify their agreement with the solutions to resolve the nursing shortage that are listed in . The reasons selected as helping a great deal to solve the shortage are consistent across all age groups. While virtually all RNs (96%) between the ages 18 to 29 said that increasing salary and benefits would help a great deal to solve the shortage, only 80% of older RNs indicated this strategy would help a great deal. Among other possible solutions, 55% of older nurses reported that increased capacity to train nurses would help, but only 43% of those 18 to 29 agreed with this solution. Regardless of age, more than 8 in 10 RNs agreed that improved working environments would help a great deal. As shown in Figure 2, higher satisfaction with a career in nursing does not mean RNs are willing to recommend a career in nursing to a qualified student. In all age groups, only about one-third reported they definitely would make this recommendation, although more than 70% in all age groups indicated they definitely or probably would recommend nursing. Older RNs were significantly more likely to say they definitely or probably would not recommend nursing. In either bivariate or multivariate analyses, age was not associated with willingness to definitely recommend nursing as a career. In multivariate logistic regression of predictors of willingness to recommend nursing, significant negative predictors included work in direct patient care, nurses earning lower hourly wages, and fair or poor opportunities to influence workplace decisions.

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Registered Nurses' Willingness to Recommend Nursing Career to Qualified Students by Age, 2004 This study sought to determine whether and how older RNs differ from younger RNs in ways that might be important to help guide employers and policymakers develop actions to help retain this fastest growing segment of the nursing workforce. Surprisingly, however, we found remarkably few differences between older and younger RNs. In one area, however, important differences were noted. As age increases, the percentage of RNs working in acute care declines, from 72% of 18 to 29 year olds, 67% of 30 to 39 year olds, 56% of 40 to 49 year olds, to only 38% of RNs 50 and over. In a recent survey of student nurses, older students were as interested in acute care nursing positions as their younger counterparts (Norman, Buerhaus, Donelan, McCloskey, & Dittus, 2005). Thus, it may be that older new nursing graduates may choose to be employed in hospitals whereas older practicing RNs choose other care delivery settings where demands are less intense. Results indicated that one-third of older RNs plan to leave their current position in the next 3 years, with most retiring or leaving the nursing profession. Thus, because the average age of RNs employed in non-acute care settings is higher than acute care settings, in the years ahead shortages of nurses are likely to break out in specialty hospitals, subacute and long-term care, and home/community care organizations. Moreover, it is reasonable to anticipate that as older RNs retire, younger RNs employed in acute care settings will be recruited to replace them, thereby creating an even greater shortfall of RNs in the acute care environment than what already exists. Efforts are needed that specifically focus on retaining older RNs who are employed outside of hospital settings. If successful, the onset of the expected future shortage could be delayed. Throughout the world, many industries are trying to persuade older workers to remain in their positions past the time when they might otherwise retire. Some observers have even suggested the retirement age be increased to 70 (see, for example, "The Elderly Need to Be Redefined," 2005). A recent report of a global summit on the aging workforce proposed changes to help delay retirement, such as investing in health promotion activities for workers, reinventing the last third of life to instill the value of contributing to society instead of expecting retirement from work, retraining people as they age, and conducting more research aimed at determining what contributes best to healthy aging (Giorgianni, 2005). Health care employers should consider these approaches for their own aging workforce. Economic incentives to encourage older RNs to remain working also should be considered, particularly in light of the fact that

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we found in this study that salaries of older RNs were no different than younger nurses. New salary structures should be designed that encourage older RNs to remain in the workforce. Higher payments could be targeted to older RNs who provide direct patient care, or retirement benefits could be enriched but tied to longer years in the workforce. Such approaches would acknowledge the skills, knowledge, and experience, and hence, the value of older RNs. Policymakers and labor market economists could also investigate the possibility of using tax-based incentives or educational subsidies that would help lower the costs to employers to retain older RNs and retrain them then for new positions. In addition to economic approaches, the National Advisory Committee for Nursing Education and Practice (2004) recommended that strategies be developed and tested to capitalize on the experience of the older nurse in acute care settings and to lessen physical demands. Although decreased physical stamina and strength are cited as reasons for RNs leaving the hospital workforce, researchers focused on healthy aging find that, through regular exercise training, strength and stamina can be maintained as one ages (Fiatarone et al., 1990). In fact, health promotion activities that improve strength and increase stamina should be included in the workplace and available to all RNs regardless of age. However, incentives may be targeted to older RNs to increase their participation in this and other activities that could help preserve their physical strength and hence their ability to remain employed for years to come. Many RNs fear developing neck and back injuries from direct patient care, which may induce some RNs to leave the acute care environment (deCastro, 2004). These fears can be addressed by implementing improvements in the ergonomic environment of nurses as recommended by the 2003 American Nurses Association Position Statement on Elimination of Manual Patient Handling to Prevent Work-Related Musculoskeletal Disorders (American Nurses Association, 2003). Assistive devices for patient lifting and handling are available and are effective in preventing musculoskeletal injuries (Nelson, Lloyd, Menzel, & Gross, 2003; Trinkoff, Brady, & Nielsen, 2003). Unfortunately, however, the Center for American Nurses (2005) reports that few health care agencies have implemented these devices. Employers should survey their workforce and determine what ergonomic problems exist in their environment. This approach would allow employers to learn from nurses what can be done to improve their workplace in the near, mid, and long-term, as well as identify the least costly approaches to make these improvements happen. These surveys should be conducted over time to ascertain whether positive changes are being accomplished and what else could be done to address ergonomic problems affecting nurses. If nothing else, this strategy communicates to nurses that they are valued and that the organization cares about their well-being. Older nurses in this study had a more positive relationship with nurse managers and health care administrators than the youngest age group of RNs age 18 to 29. This finding supports redesigning new nurse orientation and preceptorship programs to augment the relationship between nurses and managers, as positive relationships help retain nurses (Shader, Broome, Broome, West, & Nash, 2001). For example, older RNs could serve as mentors to younger RNs during their first year of employment which could facilitate the integration of the new nurse into the clinical and administrative aspects of the hospital system (see, for example, Batcheller, Burkman, Armstrong, Chappell, & Carelock, 2004). Beyond focusing on retaining older RNs, it is important that employers initiate strategies to retain RNs who are approaching their 40s. Data in this survey showed that as RNs enter their 4th decade, there is a strong tendency to shift employment into non-acute care settings. Strategies should be developed and tested that encourage retention in direct patient care positions in acute care environments. Finally, nursing leadership and management curricula in undergraduate and graduate education programs should emphasize how graduates can effectively work with an aging workforce. Graduate nurses need to understand and appreciate the potential of older RNs, value their contributions, and, if nothing else, learn how they have adapted to a challenging work environment. In the January/February 2006 issue of Nursing Economic$, we conclude this series of articles describing the state of the nursing workforce in the United States. In part six, we provide new data on employment and earnings in the nurse labor market, pull together major findings of earlier articles, and offer recommendations to strengthen the current and future nursing workforce.

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Of the additional 185,000 nurses that joined the workforce in 2002 and 2003, 70% were age 50 and over.

Part five of this series focuses on older RNs and characteristics of this growing cohort that impact the current and future nursing workforce such as employment patterns, attitudes, health, and perceptions of the nursing shortage relative to their younger counterparts.

While 46% of older nurses surveyed provide direct patient care, only 38% of older nurses work in acute care settings.

Older nurses are more satisfied with their current jobs and with nursing as a career than younger nurses; still, a third intend to leave their current position within 3 years with the likely intention to retire or change professions.

Given that older nurses are the fastest growing cohort of the workforce, the findings of this research deserve careful consideration by policymakers, health care leaders, and managers.

Efforts to retain older nurses with, for example, incentives to delay retirement may mitigate the shortages that are now likely to surface in non-acute care settings given the concentration of older nurses in these areas. Suggested Reading I

Buerhaus, P., Donelan, K., Norman, L., & Dittus, R. (2005). Nursing students perception of a career in nursing: Impact of a national campaign designed to attract people into the nursing profession. Journal of Professional Nursing, 21(2), 75-83. Buerhaus, P., Staiger, D., & Auerbach, D. (2003). Is the current shortage of hospital nurses ending? Health Affairs, 22(6), 191-198. Frontera, W., Hughes, V., Krivickas, L., Kim, S., Foldvan, M., & Roubenoff, R. (2003). Strength training in older women: Early and late changes in whole muscles and single cells. Muscle & Nerve, 28(5), 601-608. References

1. American Nurses Association. (2003). Position statement on elimination of manual patient handling to prevent work-related musculoskeletal disorders. Retrieved October 24, 2005, from http://nursingworld.org/readroom/position /workplac/pathand.htm 2. Batcheller J., Burkman K., Armstrong D., Chappell C., & Carelock J. (2004). A practice model for patient safety: The value of the experienced registered nurse. Journal of Nursing Administration, 34(4), 200-205. 3. Buchan, J. (1999). The 'greying' of the United Kingdom nursing workforce, implications for employment policy and practice. Health and Nursing Policy Issues, 30(4), 818-826. 4. Buerhaus, P., Donelan, K., Ulrich, B., Norman, L., & Dittus, R. (2005a). Part one: Is the shortage of hospital registered nurses getting better or worse? Findings from two recent national surveys of RNs. Nursing Economic$, 23(2), 61-71, 96. 5. Buerhaus, P., Donelan, K., Ulrich, B., Kirby, L., Norman, L., & Dittus, R. (2005b). Part two: Registered nurses' perceptions of nursing. Nursing Economic$, 23(3), 110-118, 143. 6. Buerhaus, P., Donelan, K., Ulrich, B., Norman, L., Williams, M., & Dittus, R. (2005c). Part four: Hospital registered nurses' and chief nursing officers' perceptions of the impact of the nursing shortage on the quality of care. Nursing

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Economic$, 23(4), 214-221. 7. Buerhaus, P., Staiger, D., & Auerbach, D. (2000). Implications of an aging registered nurse workforce. Journal of American Medical Association, 283(22), 2948-2954. 8. Buerhaus, P., Staiger, D., & Auerbach, D. (2004, November 17). Web exclusive. New signs of a strengthening nurse labor market? Health Affairs, W4-526-W4. 9. Center for American Nurses. (2005). The center provides recommendations to the White House conference on aging. The American Nurse, 37(5), 10. 10. deCastro, A. (2004). Actively preventing injury: Avoiding back injuries and other musculoskeletal disorders among nurses. American Journal of Nursing, 104(1), 104. 11. Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration (DHHS). (2000). The registered nurse population findings from the national sample survey of registered nurses. Retrieved October 24, 2005, from http:/bhpr.hrsa.gov/healthworkforce.rnsurvey 12. Donelan, K., Buerhaus, P., Ulrich, B., Norman, L., & Dittus, R. (2005). Part three: Awareness and perceptions of the Johnson & Johnson campaign for nursing's future: Views of nursing students, RNs, and CNOs. Nursing Economic$, 23(4), 150-156, 180. 13. Fiatarone, M., Marks, E., Ryan, N., Meredith, C., Lipsitz, L., & Evans, W. (1990). High intensity strength training in nonagenarians: Effects on skeletal muscle. Journal of American Medical Association, 262(22), 3029-3034. 14. Giorgianni, S. (2005). Global summit on the aging workforce. The Pfizer Journal, 9(3), 4-38. 15. Hoffman, A., & Scott, L. (2003). Role stress and career satisfaction among registered nurses by work shift patterns. Journal of Nursing Administration, 33(6), 337-342. 16. Levtak, S. (2002). Retaining the older nurse. Journal of Nursing Admin istration, 32(7/8), 387-392. 17. Levtak, S. (2005). Health and safety of older nurses. Nursing Outlook, 53(2), 66-72. 18. National Advisory Committee for Nursing Education and Practice. (2004). Minutes, November 2004 meeting. Rockville, MD: U.S. Department of Health and Human Services. 19. Nelson, A., Lloyd, J., Menzel, N., & Gross, C. (2003). Presenting nursing back injuries: Redesigning patient handling tasks. American Association of Occupational Health Nursing Journal, 51(93), 126-134. 20. Norman, L., Buerhaus, P., Donelan, K., McCloskey, B., & Dittus, R. (2005). Nursing students assess nursing education. Journal of Professional Nursing, 21(3), 150-158. 21. Shader, K., Broome, M., Broome, C., West, M. & Nash, M. (2001). Factors influencing satisfaction and anticipated turnover for nurses in an academic medical center. Journal of Nursing Administration, 31(4), 210- 216. 22. The elderly need to be redefined. (2005, September 19). Yomiuri Shim bun, 4. 23. Trinkoff, A., Brady, B., & Nielson, K. (2003). Workplace prevention and musculoskeletal injuries. Journal of Nursing Administration, 33(3), 153-158. Acknowledgments The authors appreciate Sandra Applebaum and David Sandman who led the fieldwork team from Harris Interactive and provided assistance in survey design. We thank Johanna Mailhot for her assistance in preparing the data and performing descriptive and statistical analysis.

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Funding information The study was funded by a grant from Johnson & Johnson and Nursing Spectrum. Johnson & Johnson played no role in the design and conduct of the study, analysis and interpretation of results, and preparation or approval of this manuscript. Nurs Econ. 2005;23(6):282-289. © 2005 Jannetti Publications, Inc. This website uses cookies to deliver its services as described in our Cookie Policy. By using this website, you agree to the use of cookies. close

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