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Never before have so many generations worked side by side in hospitals. With four distinct generations of employees who bring different expectations and behaviors to their jobs, hospitals must find creative ways to meet their needs. To discuss strategies for managing a generationally diverse workforce, Health Forum convened a panel of hospital executives and industry experts July 26 in San Diego. The group explored the unique traits of the different age groups and their implications on recruitment and retention. The panel also explored the challenges and opportunities associated with a multigenerational workforce and how organizations can foster communication among the generations. Health Forum would like to thank all of the participants for the open and candid discussion, as well as B. E. Smith for sponsoring this event.

JOHN COMBES, M.D. (Moderator): We are in a unique time in that we have four generations' populating our workforce. That can lead to some conflict and misunderstanding given some of the expectations, backgrounds and perspectives of the different generations. We have the traditionalists, which include almost everybody born during or before World War II; the baby boomers — many of us in this room are in that generation and are moving toward retirement; the Gen Xers, who are mostly our children; and then Generation Y, or the millennials, people born in the '80s and '90s who have grown up in a technologically advanced world and have a different way of approaching work and each other. So, it is a challenge for organizations, yet it has a potential to enrich the organization as well by incorporating diverse perspectives and keeping in touch with patients and the community. What's the status of your workforce today? What does it look like?

ANN MADDEN RICE (University of California Davis Medical Center): The traditionalists — or those born before 1945 — comprise about 1 percent of our workforce. We've seen many retirements in the last couple of years from that generation. The biggest group for us is Gen X, followed by the baby boomers. We're now starting to see more Gen Y, which is 1981 to 2000. We're not really seeing the baby boomers dominate the way that we did five to 10 years ago.

CAROLYN CALDWELL (Desert Regional Medical Center): The biggest spread that we tend to see is really with our medical staff, where we do have more traditionalists, many of whom were going to retire but stayed on because of the recession. We run into problems recruiting millennials because they have different job expectations. They don't want to work 15-hour days, seven days a week. The traditionalists don't care about taking time off, while the new doctors coming in want lots of vacation. So, we have difficulties trying to recruit younger physicians to join some of our more senior physicians' practices, which creates a problem because we have to have succession planning.

LARRY MULLINS (Samaritan Health Services): Our baby boomer population has noticeably postponed retirement. So, what we're seeing are boomers continuing to grow in terms of their proportionate representation in the workforce. And then we fast-forward right to Generation Y, the millennials, probably because we're in a university town. But, in our case, we've seen a real connectivity between the boomers and the millennials, especially with some mentorship programs that we've tried. There has been a stronger connection there.

MODERATOR: That's very interesting. Are others seeing that, where we're sort of skipping that generation in relationships?

SCOTT MALANEY (Blanchard Valley Health System): That basically describes our situation at Blanchard Valley. It seems to be playing out that way.

CAROLYN SCANLAN (Lancaster General Health): It seems that Generation Y really wants and seeks mentorship and boomers feel as though they have a wealth of knowledge to impart. Generation X doesn't seek that knowledge from the boomers or anyone older. Building a formal mentorship program is a satisfier for both the boomers and for the younger workers.

MULLINS: The converse is true as well. For example, most of us have gone through a significant information technology transformation. It's fair to say that my generation was a bit more challenged by it than millennials, who were very comfortable with it. As we went through that transition, we saw millennials stepping up and working with the baby boomers to help them with the new technology. The millennials essentially became coaches. It was interesting to watch.

DOUG SMITH (B. E. Smith): Our executive search efforts — on the permanent side — are mostly dominated by baby boomers. We have a small sliver of traditionalists that we place. The Generation Xers, not so much. We just don't see a lot of candidates coming from that generation. We're anxious for the millennials to come up. Over on the interim side, we're seeing a number of traditionalists and baby boomers move into interim placement at this point in their careers. It's really what they want to do. They still have lots of energy and they want to work. They like to work. They have been intellectually challenged their whole career and this is a good option for them to stay involved, but also to enjoy some of the perks of retirement.

MODERATOR: I would like to explore Generation X for a moment because they are a large percentage of the workforce right now. In most of our organizations, they are the middle management. So what does this mean for them? Are they being skipped over in terms of relationship-building within the workforce?

JIM SHEETS (Intermountain LDS Hospital): I'm a Gen Xer and I feel that a lot of Gen Xers have a different view on organizations. The expectation is to move up quickly within the ranks without putting in the work. They are looking for a quick promotion and do not have a lot of organizational loyalty. And they're not as flexible as the millennials; the millennials are very flexible. Millennials will think outside the box while Gen Xers are not as career-focused. Instead, Gen Xers are very focused on lifestyle, but they want their cake and want to eat it as well. I believe that's what Doug was saying; some Gen Xers will get stuck in middle management. They are not willing to put in that extra time because they focus on their lifestyles. To move up in an organization, you often have to put in the extra time and take on the extra projects.

SMITH: I believe that Gen Xers have watched baby boomers in their careers and seen the sacrifices they have made and they don't want to do the same.

LEE DOMANICO (Marin Healthcare District): Marin County is the oldest county in the state of California, population-wise. It's also the healthiest county. Our workforce is aging in place. We have very little turnover. When we do bring people into the organization, it's mostly baby boomers in the middle-management level. The few Gen Xers that we've seen do have different career expectations. They don't want to see as many patients and they have a different income expectation. They are willing to work less and earn less and have more of a work-life balance.

CALDWELL: I mentor a young man who is a millennial. He's like a sponge. He's wonderful, respectful and eager to learn. I see that among most millennials. They respect our knowledge. They are coachable and teachable. Those traits make you want to spend time coaching them and working with them. Generation X, on the other hand, is less willing to listen. They already feel they know it all.

SCANLAN: It's a feel-good opportunity for boomers. They like being sought after for their knowledge after the investment they've made in their own careers. Unlike most boomers, my children are actually millennials — I was a late mother. They are more at ease talking to older adults than those who are a decade older. It's an interesting phenomenon. Combined, Generation X and Generation Y outnumber the baby boomers. They could really create a powerful coalition of workers that would be pretty remarkable. But there are barriers. And it's going to be a challenge for organizations that have to make management decisions between the two generations.

SHEETS: Health care organizations often struggle with employee engagement and alignment. And given all of the changes under way, the hospital five years from now will be very different from the hospital today. And that's where flexibility comes into play. Millennials are the most flexible and will adapt readily to new environments. Gen Xers, for whatever reason, are more stubborn and rooted in their ways.

One of the biggest challenges we have is how to engage our employees at all of these levels, including our volunteers. Most of our volunteers are traditionalists, along with a couple baby boomers. It's a challenge communicating with our employees across generations. Again, the millennials are flexible; they use social media and think outside the box. Other generations are more rooted in their ways. So we have to be creative in how to engage them and get them more on board with where we're going.

SMITH: Even in our organization, we have a pretty aggressive mentoring program with limited success among the Generation Xers. We have outstanding success with the millennials, a very enjoyable relationship. It doesn't feel forced. They look forward to meeting and discussing issues. The millennials love working with the baby boomers, and vice verse.

SCANLAN: I think the millennials are wise and are constantly learning. They want help and realize they can benefit from working closely with others above them. And they share their learnings — often through social media — with their peers. Everybody pulls along with them. It's very different.

MULLINS: We're trying a team-based approach and trying to align people with shared interests. We want to ensure there's a cross section from each workforce sector as we go forth. We're getting some pretty good results.

MODERATOR: How do you recruit and retain the baby boomers? What's the best approach?

DOMANICO: As I stated earlier, baby boomers make up the largest segment of our employee population. And most job applicants are baby boomers. I've been trying to find younger managers to bring in because we don't want to age out due to retirements. In California, it's tough to find younger employees because of the real estate situation. The real estate boom is forcing many people to stay put. In Northern California, we competed against the high-tech world from a workforce perspective. Gen Xers had a lot of options. Health care, in comparison, comes across as a traditional workforce setting. We don't have large campuses with all kinds of recreational activities. That's been a challenge for us.

SCANLAN: I'm curious as to whether any of you have noticed a marked difference in the patient-clinician interaction based on generations? What does it mean for the quality of the care? In Lancaster, we're seeing a real commitment to quality across all age groups. We're in a very diverse community, and it's a younger community. We're trying to cultivate a pipeline of talent across all age groups for succession purposes. One of the things we do is to hold open some slots for new nursing grads each year.

MALANEY: That's a great question. I don't want to overstate this, but we have definitely received feedback from some of our patients and residents in nursing homes and hospitals who are bothered by piercings and tattoos. That's led to a fairly massive effort in our organization to define what is acceptable, and it's caused some big changes. We remind our staff that they are in the service field. We respect everyone's right to express themselves, but this may not be the right field for some people, depending on their willingness to subjugate their needs versus the people they're going to serve. We've had some really direct discussions about that and it's changed our approach to recruiting. We're a rural organization, kind of in the middle of a cornfield in northwest Ohio. We've started to recruit among families. If we find a hard worker, there's a pretty good chance that they're going to be around some other hard workers. They also seem to understand this notion of service to others, so it's great.

MULLINS: We do this as well. We have also recognized the benefits of hiring among families. It's a good fit.

SMITH: Considering the quality of nursing care by generations, we have to remember that nursing is very physical work. There's life to the baby boomers who are still working at the bedside. It will be interesting to see if that becomes a patient safety issue after a while. A 12-hour shift for a baby boomer is a long shift. We're getting close to a place where we're going to have to start looking at that, I believe.

MODERATOR: Do you see technology getting in the way between Generation X or the millennials in terms their interaction with patients?

MULLINS: Well, it's not just a generational issue, it's a technology issue that must be addressed by organizational policy. The same goes for issues relating to personal appearance. It all has to be driven by the policies of the organization. It's important to have a clear, consistent policy. If we don't speak to those things, then we have undesirable outcomes.

SMITH: As a leader, I love working with the millennials. But the biggest hurdle for me was the fact that they're texting while we're talking to them, or they will come to a meeting and they will set up their computers. It took me a while to get past that. At first, I was insulted.

MALANEY: I think you still should be.

SMITH: I don't believe it's a reflection of how important they think the meeting is; it's just their world.

MULLINS: It goes back to the expectations that we create. If we're the leaders in the organization, we can say, "We don't text in meetings." If that's OK with you, then say that it's okay. If it's not OK, you say that it's not respectful. Some of this stuff is basic blocking and tackling. We need to articulate our thoughts, establish policies and follow up on them. These generational issues will go by the wayside once everybody understands what rules we are playing by.

MODERATOR: Let's dig into that a little deeper. If you prohibit texting, and that's the primary form of communication for millennials, does that impact workplace satisfaction or recruitment? A corollary to that question is: As our workforce is changing, so is our patient population. What's the implication of that?

RICE: What really matters more than the policies are values. As we onboard new people, we need to focus on values and what we're here to achieve. Over time, if we stick to the values and people really operate from that platform, some of these things may not seem quite as important down the road. Looking forward 10 years or so, our community will be vastly different. What might have been offensive 10 years ago or in the present won't be so important in the future because it won't really relate to how you care for a patient and our institution's core values. We need to have flexibility. That's what makes working with so many different generations so interesting. The baby boomers in leadership positions, need to determine if limiting texting in meetings is really that important.

MULLINS: Setting the expectation is important. I don't see texting as a problem, in general. It's a matter of when you are texting. Clinicians should not enter a patient's room and begin entering data without engaging the patient. And it's not appropriate to text in meetings where it's important to be engaged in the dialogue. We've all seen instances where groups of people sit at a table at a restaurant and no one is talking to each other. Instead, everyone is looking down at their phones.

MALANEY: Our governance set some very high standards for us around service excellence scores, clinical excellence and safety. In terms of service excellence, we let feedback from the people we serve guide us. It really doesn't matter what I think; it matters what the patient thinks. That is where governance is important. And using patient feedback to guide our policy is something that's easy for our clinicians to appreciate and understand.

SHEETS: We struggle a bit with patient engagement across generations. Baby boomers respond to loyalty and consistency. For Gen Xers, it's lifestyle issues such as paid time off. And millennials want a voice. They want to participate and they want opportunities. So, the sooner we understand the currency for the generations, the better able we'll be to engage them. If they are not getting the type of feedback and currency they want from the organization, they will not be aligned with your organization's policies and standards on how you want to deliver care.

MALANEY: We've gotten better at telling people our expectations. We have adopted the Disney model in some respects. Disney sets expectations for behavior and personal appearance up front. They are unabashed. If this fits you, great. If not, let's not waste time. We've become more like that, for the better.

SCANLAN: Scott, you brought up the issue of governance. It's interesting to note that boards are generally not multigenerational. So the conversations between boards and management and other workers might also be a place where communication needs to be reassessed. Board composition may need to reflect the generationally diverse workforce and community.

CALDWELL: We talk about the call to action to eliminate disparities in health care, and one of those calls to action is making sure we begin to diversify our boards and our senior leadership. Many of our boards are no longer a true reflection of our communities. They tend to be mostly male baby boomers. One question I have deals with the closeness of the generations. The younger baby boomers and the older Gen Xers are close in age so there is some competitiveness between those groups. They view each other as competition and that's why some Gen Xers may get stuck in middle management. But there's a significant gap between the baby boomers and the millennials, and that's one reason why there is little friction between those groups.

MULLINS: I would like to go back to something we talked about earlier. As leaders, we need to be careful not to unnecessarily segment the generations. If the organization sets the expectations and the values, we'll draw people to the organization from all generations that relate to those values and those expectations. It truly doesn't matter what generation someone is from; if they don't buy into our values, they most likely never will. It's important that we articulate our mission as best we can. It's not so much a generational issue, as it is about personal values.

SCANLAN: Self-selection plays a role, particularly in health care. People select health care careers because they have a desire to help people. We're fortunate that we have self-selection already.

SHEETS: That's certainly the case for clinicians, but not necessarily for some of our ancillary positions like housekeeping and food service. It's sometimes more difficult to get people in these roles to understand how their roles align with the organization's mission and values. But their roles are important. Proper housekeeping is critical for infection prevention, and food service is a big part of patient satisfaction and engagement.

MODERATOR: I talk to a lot of boards about the importance of aligning medical staff and finding the right person who is committed to organizational values. Too often, it seems that boards are distracted by the physician shortage and feel they don't have a choice. How do you balance that? How do you create the vision and select people who are going to be supportive of that vision regardless of their generation?

DOMANICO: I have to go back to what Larry said earlier. You can't dice it too much. We already expect a great deal of our middle managers in terms of performance reviews and feedback. Many of our managers have 50 or 60 direct reports so we can't expect them to have different expectations based on an employee's age group. It won't happen. In my organization, I don't feel we are anywhere near that level of sophistication from a human resources perspective to even support the managers in trying to manage four generations a different way. There are commonalities among generations. Everyone wants to be treated with respect and they want recognition.

SMITH: You are right. We're probably overthinking it on many occasions. It would be a difficult undertaking for many organizations.

MULLINS: John, this speaks to your point about the rush to recruitment. We have erred in that respect. We need to take our time and find the right fit for the position. One good hire will mitigate many unsuccessful hires. Establishing a recruitment process that aligns with the organization's values is as important as any of the other credentialing activity.

MODERATOR: Let's switch gears now and talk about leadership and leadership development. Are there different approaches to leadership development based on the different generations? Let's skip the baby boomers, assuming that most of them are in leadership roles now. But if you look at Generation X and the millennials, what are the strengths that you want to build on and what are the areas that you think you need to develop?

CALDWELL: I've been fortunate to mentor a number of individuals and I'm happy to see that two of them are now chief operating officers. I spent a lot of time with them teaching humility and respect. And I found exactly what Lee said. Everyone wants respect and everyone wants to be heard. As I mentor young people, I try to teach them that they must be respectful of others, regardless of what they do within the organization. That's important.

SHEETS: That's where we do see some difference between generations. There is a sense of entitlement that has a great deal to do with how they were raised. Generation Xers didn't go through the Great Depression or World War II. As leaders, we must work with them and help them realize they need to put in the hard work and earn their stripes. They need to invest in themselves and be open to feedback, especially criticism, to become leaders themselves. That's how they will become solid, empathetic leaders.

MALANEY: Is anyone familiar with Bruce Tulgan? He wrote "Managing Generation X," and has conducted scores of interviews with individuals across generations. According to his perspective, Generation X was shaped by their parents' experiences in the workplace. Many saw their parents lose their jobs. They saw their parents' loyalty to their workplace go unrewarded. In his interviews with Generation X, he often finds reluctance to make long-term career plans. They don't want to take the risk.

This generation responds to straight talk. They don't want promises of big careers that you may not be able to keep. That's where humility comes into play. Another thing they respond well to is the development of usable skills that may carry over into new positions. It makes sense to me, and I think that's good advice for dealing with Gen Xers.

MULLINS: Again, it goes back to treating every individual with respect. But Scott brought up the importance of building trust. Employees must feel that you mean what you say. And they want to be associated with an organization that they feel is doing good things.
So, from a leadership perspective, if we as leaders move in this direction, that's going to help us better recruit the people cross-generationally. You will attract people who have those same sets of values. We'll always have generational issues in the workforce, but this builds a foundation to which they can all relate. Who can predict what the workforce will be like 20 years from now? If we recruit people who have shared values, cultures and traditions, we can overcome a lot of the barriers among the generations.

SMITH: That's true. As mentioned before, baby boomers respond to loyalty and consistency. They have tenure in their positions, while Gen Xers have a bit less. When I started out, it did not reflect well on individuals if they switched jobs more than twice in five years. That matters less now. Millennials are willing to change jobs every three years. How do you develop someone like that? How do you provide leadership development when you may have them for a mere 18 months?

MALANEY: You've got to teach fast, right?

SMITH: I think what you do is teach them and give them the skills they need and hope they come back.

CALDWELL: It does require some level of patience. My daughter is a chemical engineer. She worked for Anheuser-Busch for a year and a half. She wanted to be a manager. As a typical baby boomer, I told her she had not been there long enough to reach that level. I told her to wait. But she didn't want to wait and she sent out her resumé and now she's a manager for Coca-Cola. So, I guess she was right.

But if you look at it from the organization's perspective, perhaps there was something they could have done to manage her expectations. Could Anheuser-Busch have done something that would have strengthened the relationship? What can we do to ensure that our high-potential employees don't move on to other organizations? We're looking at early retention strategies to help us with that.

MULLINS: We are going to have to come up with some creative retention models to make sure we don't lose out on top performers. I believe our traditional model doesn't get us there, and we will have to craft something that doesn't exist. We're going to have to be fairly smart.

MODERATOR: Are all of you facing this issue? Are you concerned that the talent you have may not stay?

RICE:We're willing to take a risk and work to develop our talent and invest in our potential leaders. We want people to see they have a career path. If we don't make any investment and they stay, that's an even worse position for us. It's kind of a trade-off.

We do see people leave and come back. I don't believe that's necessarily a bad thing either. We don't discourage that. We have an administrative program and one of our fellows this year decided to leave us and go to work for a startup. I think that's brilliant because younger people are at a point in their careers where they can take that risk. Hopefully, they will gain a different skill set that can be useful to us should they come back.

You can't be too risk-averse or you'll miss some opportunities.

DOMANICO: We talk about people not staying as long as they used to and, in some ways, our benefit plans encourage that. We've moved away from traditional pension plans to matching plans where they take the money with them. It makes us more mobile as professionals. So, it's kind of interesting. We wish that people would have a longer view of the world, but our benefits in some ways contribute to turnover.

SCANLAN: The Affordable Care Act will exacerbate that even further. Some people have been afraid of movement because of fears they may not be covered for pre-existing conditions. Now they will not be held back. This next year will change the thought process of employees, regardless of where they are in their careers and there are going to be some radical changes. As employers, we have to be aware of that and think about that going forward.

MALANEY: Our organization is in a town of about 50,000 people. It's a little unusual because we have two Fortune 500 companies headquartered there. We've been concerned about our ability to recruit physicians to the area, as most small communities are. But we've done fairly well in recent years. We are hearing from physicians that they don't want to go to a big city. They see the vitality of the community. They see a thriving downtown. And it looks like a nice, interesting place to live. We're seeing that with other health care workers, too.

On another note, it's unclear what impact health care reform will have on the health care workforce. But it's safe to say that many organizations may have to make significant cuts to survive due to declining reimbursements. It will be challenging. But if that is true, we're going to have the ability to be pretty picky in terms of whom we want to bring into our organizations.

MODERATOR: It will be challenging for organizations. It can't be a matter of first hired, last fired. It would require a good evaluation system and one that's flexible, because the values of these groups are very different.