Framing the issue

• In the next decade, job openings for RNs are expected to increase by nearly 20 percent. The Alliance for Health Reform predicts shortages of more than 90,000 physicians.

• The health care industry largely missed in attracting sufficient numbers of Gen Xers; it needs to attract Millennials to fill positions as boomers retire.

• Hospitals are looking at new ways to structure physician and nursing jobs as the health care landscape changes.

• With physician demand unmet, expect more of a demand for nurses and pharmacists to practice at the top of their licenses.

• Posting ads on social media is a start for recruiting younger medical professionals, but someone needs to answer responses swiftly.

At St. Luke's Medical Center in Boise, Idaho, the younger doctors and nurses texted each other continually — not to discuss where to meet up after work, but to deliver medical orders and patient updates.

Texting got the job done faster than a call or a page. Unfortunately, it wasn't secure and failed to meet HIPAA regulations.

Hospital leaders might have considered locking up the smartphones, a move that surely would have frustrated the Gen Xers and Yers. Using such devices is second nature to them and, after all, they were only trying to deliver patient care as expediently as possible.

Instead, they are working with an IT vendor to set up a secure texting system for the hospital.

"I've heard [officials of] other organizations say, 'We can't do that,'" says Jennifer Mensik, St. Luke's administrator of nursing and patient care services. "But when people are trying to do the best they can for the patient, they're going to try to find a workaround. That should be an alert to some of the older generation that this is a good idea. Let's not stop it. Let's figure out how we can do it legally and correctly."

Many hospital leaders have a hard time hearing, let alone embracing, the ideas of their younger staff. "What we're finding is [that] boomers don't like to give control away," says M.T. Meadows, R.N., the director of professional practice for the American Organization of Nurse Executives and herself a baby boomer.

That kind of inflexibility is no longer an option, Meadows and others warn. Boomers are retiring at a rapid pace, and putting up roadblocks for their successors will only hurt their organizations.

Openings for RNs are on pace to hit 3.2 million in 2018, a nearly 20 percent increase from 2.6 million in 2009, according to a survey from health care recruiting firm Bernard Hodes Group. Moreover, a 2012 study by the Alliance for Health Reform found that 45 percent of nurses are considering changing careers altogether in the next one to three years.

Up to a third of physicians are expected to retire in the next decade. The AHR predicts a shortage of more than 90,000 physicians by then, divided almost evenly among primary care doctors, surgeons and specialists.

Hospitals must reach out to Gen Xers and Gen Yers — also known as Millennials — in the medical workforce, while keeping boomers on the job as long as possible. That means rethinking recruitment strategies and figuring out what today's job hunters want, offering certain incentives that appeal to current employees and others that appeal to young professionals, adjusting management techniques to handle staff from multiple generations, and providing training to make up for gaps in experience or technological know-how.

"The hospital industry essentially missed with Generation X," says Chuck Underwood, a generational consultant for health care organizations. "That's why we have such a large nursing shortage in this country."

8 to 5 or 8 to ??

Gen Xers were the first latchkey kids, Underwood says. Their career-driven parents worked long hours, and the children spent a lot of time under the care and supervision of other adults. Now that they're grown with families of their own, they have different priorities. "They said, 'I'm going to work a regular shift,'" Underwood explains. "'I'm not going to be a workaholic. I'm going to have a personal life and fiercely protect my personal time.'"

When hospitals failed to offer an 8-to-5 workday, Gen Xers moved to industries with more appealing hours. "Hospitals absolutely have to nail the Millennial generation to make up for this shortage," says Underwood. "They must give concessions that they might prefer not to give."

At the same time, if baby boomers and "silent" (or preboomer) nurses need a work arrangement that will keep them on the job, "hospitals had damn well better offer it," he says.

Jim Diegel, president and CEO of St. Charles Health System in Bend, Ore., agrees that "there are huge physician and nursing shortages coming," and warns of "a leadership dearth out there that a lot of us are really worried about."

"Leaders are starting to exit at a pretty rapid rate. And there's not a steady pipeline of people to replace them," says Diegel, an American Hospital Association board member who chairs the Committee on Performance Improvement. The concern is great enough that for 2013, the committee plans to research the challenges hospitals face with having four generations of workers on staff at the same time.

Even as demand for doctors climbs, the number of available residency spots remains the same because of federal caps on spending. If that continues, Diegel says, support staff such as nurses with advanced degrees and pharmacists will need to practice more at the top of their license.

"A BSN-trained nurse has the ability to manage caseloads, manage care coordination," he says. "And a lot of the pharmacists are trained at the doctoral level to really manage the patient's pharmaceutical treatment."

Anticipating physician and RN shortages, Sacred Heart Hospital in Eau Claire, Wis., is looking at new ways to structure jobs that open up, anticipating that in the future they'll have fewer inpatients and more outpatients, says Julie Manas, president and CEO. "There will be less need for that 24/7 clinician, but more for individuals to care for patients in new ways," she says.

For instance, Sacred Heart is placing more resources into discharge staffing, especially care coordinators — nurses who specialize in identifying the needs of patients at discharge and making sure they're at the right level of care. "It greatly reduces the readmission of those patients," Manas says.

She sees an increased need for hospitalists and nocturnists, and family and internal medicine practitioners. "More and more, we need physicians to work in ambulatory and primary care, and they're not necessarily interested in being on call," Manas notes.

Sacred Heart is constantly recruiting more physicians, advertising in the usual places like Linkedin, and medical journals. "If we don't try to recruit and retain doctors now," she says, "we'll be in trouble in five years."

Hospital leaders have noticed a particular generational issue: Millennials want an instant response to their applications. "One thing we're working on is trying to get feedback to the applicants much sooner," Manas says.

Michael Murphy, M.D., chief medical officer at Sharp Grossmont Hospital in La Mesa, Calif., says younger physicians vastly prefer working set shifts. When he worked at hospitals in Oregon and West Virginia, "we found we had to have that model just to get people employed," he says.

Sharp Grossmont uses a productivity model in which doctors can sign up for the shifts they want and work extra hours. The younger doctors who want to work longer and harder, though they're in the minority, like that model and it's actually helped with recruiting, Murphy says.

The first day, and beyond

To attract Gen Xers and Millennials, hospitals that can't claim Sharp's name recognition or enviable climate must be especially nimble with their recruiting, says Judith Russell, R.N., a vice president in the health care division at Bernard Hodes. Posting to Facebook, Linkedin and Twitter with links to static job ads isn't enough.

"If you tweet something out and someone does respond, you need to have somebody dedicated to answering their question right away," Russell advises.

Some of the most successful recruiting campaigns are being created by social media strategists working internally. They can specifically target new graduates, "which would more than likely be the Millennials," Russell says, with wording that would be "a higher incentive for that age group. Things like 'self-governance,' 'career advancement,' 'self-scheduling' or 'we have a career ladder.'"

However, that's time-consuming, she acknowledges, and a smaller hospital might not have enough resources to carry it out.

But even in the era of social media, employee referral programs remain the most successful recruiting source in health care. "There's never been just one strategy that works to fill positions," Russell says. "I even have some clients of late for whom direct mail may be an option. In our business, what's old is new. I'm an RN, and I look to see what I get in the mail. I have a client that has done pretty well with a combination of direct mail and a job fair."

A five-year plan

An unsettling reality for hospitals is that Millennials on average will have had seven different post-college employers by age 26, according to the Bureau of Labor Statistics. In practical terms, that means hospitals must begin the retention effort at the recruiting and hiring stage.

Millennials move so quickly that Underwood recommends assigning a buddy or "connection coach" to new hires, to help them settle in and feel comfortable in their jobs. "With Millennials, you can lose them during that interim," he says. "They will not necessarily not look for work elsewhere."

Unlike the typical mentor assigned to a newly hired staffer, a connection coach is closer in age and experience level to the new employee.

"They're probably from the same generation and share the same core values, so they can relate," Underwood explains. "And they can create time in their schedule to help, where a higher-up mentor can't be taken away from his or her high-level work."

Russell suggests human resources staff or the manager direct new hires to an onboarding website, send a "looking forward to working with you!" card signed by co-workers, and reach out by phone to see if they need anything as their first day approaches.

Having the recruiter keep in touch prior to the start date also can help because the new hire may feel more comfortable confiding in that individual than in the person who will be his or her boss.

Once Millennials have been hired, Russell says managers should work on keeping them on the job for the next five years because it's so expensive to replace them. For example, replacing a nurse can cost up to two times the individual's annual salary.

"Once you've got them five years, you've got 'em," she says.

Managers can benefit from specific training on how to talk to workers from different generations. Younger staff respond well to frequent recognition programs and more incremental opportunities for career advancement. New nurses often ask for specialized training; some hospitals offer it, but require them to sign a contract stipulating they'll work there for a set period.

Sacred Heart has tried such things as appointing Millennials and Gen Xers to supervisory panels, fast-tracking individuals interested in management, and giving younger hires supervisory roles even if they're just managing one or two people, Manas says.

The hospital also is open to flexible and part-time work schedules for physicians and nurses. To provide the frequent feedback Millennials tend to crave, the organization provides multiple channels for appraising their performance, from face-to-face evaluations to an online hub where managers can evaluate and guide them.

Residencies for new nurses

Sharp HealthCare in California has nursing residency programs in five of its hospitals, ranging from six months to two years, says Caroline Etland, director of education, research and professional practice at Sharp Chula Vista Medical Center. Each new nurse is assigned a preceptor — an experienced nurse who connects with them regularly for the first 90 days. The preceptor's job is to teach the new employee procedures, skills, policies and guidelines and help to establish a workflow.

During the residency, the nurses rotate to different areas of the hospital so they can decide where they ultimately want to work. Then supervisors try to place them in their chosen areas. Openings occur fairly regularly because nurses and other staff members often come from the large number of local military families who are relocated periodically.

Generational gearbox?

Managers must balance giving younger workers the perks they need without alienating experienced staff. St. Luke's Mensik hears grumbling around the holidays because senior nursesresent that they don't get scheduling priority — everyone is either in Group A or Group B and staff rotate holidays over a two-year period.

"We have a lot of nurses who've been in the organization 25 to 35 years who definitely think they've earned the right to not work weekends, not work holidays, or to work a preferred shift," Mensik says. "And we have younger nurses who really don't want to work weekends and holidays. When we had a seniority-based system, we found that it was really hard to recruit and retain younger nurses, who thought it was unfair that they had to work their way up."

One thing that helps is a consistent policy. "We've maintained a pretty straight line of no seniority-based decision-making," she says.

Underwood says that everyone in a hospital supervisory position should be trained to develop what he calls a "generational gearbox." That's the technique of "shifting smoothly and strategically from dealing with an employee from one generation to another from the next and from the next."

"Management can't just go to each generation and give them whatever they want," he says. So for Millennials, that might mean taking extra time to explain that training is mandatory, not optional, and that they have to come to work on time.

"Millennials are not a generation that is trying to insult the boss," he says. "If hospital leaders possess that generational gearbox, they can soften the blow and the resentment that exists between the generations in the workplace."

Science of generational studies

Meadows admits to struggling with understanding her younger colleagues. "I make sure that I'm responsible for my own attitude," she says. Pertaining to dissatisfaction issues in the workplace, "Millennials, especially, [think], 'It isn't my fault, it's external control.' And that's a significant difference."

AONE includes a section on generational differences in its training for nurse managers, bringing in a well-known nurse leader to talk about generational differences and how they contribute to conflict. Students then share their own experiences, look at case studies and do some role-playing.

Among the things that come up in those sessions: younger nurses can't understand physical issues older nurses sometimes have; boomers' comfort with hierarchical leadership butts up against the younger generations' expectation of shared leadership; and older nurses wonder how to handle workers constant cellphone calls and texting.

Generational studies "are not a pop-culture thing," Meadows says. "It may have started out that way, but it's become a very legitimate area of science and theory with a lot of research and evidence behind it." A nurse manager could very well be responsible for a staff that includes boomers, Gen Xers and Millennials.

"Managing three different viewpoints all on the same shift can be pretty complex and, because of the differences, creates some levels of conflict," Meadows says. "So the nurse leader needs to be fairly astute in managing conflict, regardless of its origins."

— Laura Putre is a freelance writer in Cleveland.

Executive Corner

Kathleen Nelson, chief nursing officer of Eastern Idaho Regional Medical Center in Idaho Falls, has seen her share of generational friction among the 900 employees she oversees. " Here are some things she recommends to ease generational tensions:

Problem | New nurses get antsy because they're not in the unit they prefer.

How they handled it: Because of the high cost of orientation, the hospital requires new nurses to spend six months in the unit where they start out. "We've had to relax that policy a bit," Nelson says. "We've done it more on a case-by-case basis rather than a general rule. Rather than just saying hard and fast, 'Well, you can't go until you have six months of med-surg,' we ask, 'Are you ready?' And if they're not, then we explain to them, 'We need you to have these skills because these are what are going to make you successful in the ICU.' Younger generations want the whys."

Problem | Millennials don't feel they're getting enough personal attention.

How they handled it: "What we've learned is we have to go to almost individual rounding on staff. It's not as effective to have all-out general staff meetings. Better to spend 15 minutes individually talking to a staff member. And we try to do it by saying, 'We appreciate this, you've done this, these are your strengths. What concerns do you have? What things can we fix to make your job better?'

"It's amazing — it's the small things sometimes. They're into making sure that they have the tools they need. So it could be as small as, 'This computer doesn't boot up the way it needs to.' Maybe nobody notified IT. If the computer's just old and slow, replacing a computer is much cheaper than replacing a nurse because of her frustration with it."

Problem | Boomer nurses can't understand why younger nurses "can't just live by the rules."

How they handled it: "With my nursing managers and directors, I have done some presentations on generational diversity and how we have to expound on the attributes of each generation rather than becoming frustrated.