In Promedica Toledo Hospital's coronary unit, a bulletin board carefully decorated with personal photographs and captions written in flowery handwriting hangs in a hallway. It's called the "Getting to Know You" board. Every month, one nurse in the unit has the whole board to herself. She can fill it up with family photos, pictures of her hobbies, or images of herself cuddling with her dog or on a ski vacation with her friends.

The bulletin board is just one of the little morale boosters Deb Piatkowski, nursing manager of the Ohio hospital's Heart and Vascular Institute, has come up with to help keep her younger employees happy. "To an older nurse, a pat on the back and a 'Good job,' is probably all that they want," Piatkowski says. The younger nurses, on the other hand, expect to be recognized for their accomplishments and rewarded for their extra efforts. For instance, if asked to come in on short notice, they want to know what they'll get in return — a day off, perhaps, or bonus money.

So the budget-challenged Piatkowski and staff nurse Mary McVey constantly brainstorm new ways to make the under-30 set feel special: a "come in late or leave early" incentive for the nurse who collected the most money for the hospital's Heart Walk (Piatkowski worked the hours that the winner took off) or a "no-float pass," for nurses who expeditiously trained co-workers on a new vascular line pull procedure.

"When we're busy, we get pizza," Piatkowski says. "We write a lot of thank-you notes. We don't have a lot of monetary things we can give."

Baby boomer Piatkowski admits that she doesn't always get where the younger nurses are coming from. "And then I have to stop and step back and say, 'Oh, I know why I'm not getting it. Because they're not thinking like I am.'"

Side by side

For the first time, four generations are working together in hospitals. There are the pre-baby boomers who didn't live through the Great Depression but may remember World War II rationing. Then come the baby boomers, born between 1946 and 1964, who tended to grow up in large families fed by postwar consumerism and the new medium of television. The Generation Xers, born between 1965 and 1985, saw the collapse of the U.S. manufacturing economy and were the first kids to use computers in any meaningful way at home and at school. The Gen Yers (sometimes called Millennials), born after 1985, were the first to relate their whole life through technology, connecting with the world through the Internet, social media, texting and smart phones.

Each generation brings different expectations for their careers and their personal lives. Each has its own work habits, life goals and attitudes shaped largely by the social and historical eras in which they came of age. Understanding their differences is critical for hospitals to recruit and retain the best talent and to ensure that tensions that are bound to arise do not interfere with the smooth running of the organization.

As pre-boomers and baby boomers retire, and more competition for good new employees heats up, generational differences can't be brushed aside.

"Typically, when I look at generational diversity, I position it as a necessity, not a nicety," says Christine Ricci, a vice president at health care recruiting firm B.E. Smith. "Before, we used to talk and think about it. Now, we have to do something about it."

Thomas Dolan, president and chief executive of the American College of Healthcare Executives, sees a definite advantage in cultivating a multigenerational workforce. "Most hospitals are going to have multigenerational patients," he says. "People like to see individuals like themselves in an organization. That's a real benefit, that we mirror the people we serve."

ABOUT THE SERIES: H&HN's bimonthly "Generations in the Workplace" series focuses on the challenges of four generations of employees working side by side in the hospital. Over the course of 2013, we will examine their different expectations and work habits, and what it takes to maintain a spirit of good will and cooperation. The next installment, in March, will look at how generational differences play out in hospitals' physician and nursing staffs.

But Dolan worries leaders might overthink generational trends. "People like me in our 60s forget what we were like in our 20s," he says. "And we say, 'Oh, those people in their 20s think they know it all.' But that isn't a generational difference — that's just a difference in age."

Nevertheless, hospitals that don't plan ahead to recruit and retain younger employees may have to do some serious scrambling to fill vacancies. Around 15 to 18 percent of hospital CEOs typically retire every year, but that number is expected to spike as boomers hit their mid- to late 60s. A 2008 study of chief nursing officer retention conducted by researchers at the University of North Carolina reported more than 25 percent of nurse executives surveyed planned to retire within five years, and 62 percent expected to make a job change.

Defining the generations

When Ricci gives talks on generational diversity to health care groups, she uses three prototypical people to illustrate the differences among workers of various generations. Her baby boomer prototype is a hospital CEO who's very loyal, probably having worked for only three organizations during her career. She's at the office from 6 in the morning until 7 at night. She values her benefits: health insurance, life insurance, long-term care and vacation.

The prototypical Gen Xer works in the office from 8 to 5. But "that loyalty like the boomer [demonstrates] isn't necessarily there," Ricci says. "They've seen what their parents have gone through, and they don't like it." Gen Xers also respond well to 15 to 20 percent management incentives and small tokens of appreciation.

The Millennial is even more flexible when it comes to organizational loyalty. He's OK with changing jobs every one to three years, and he wants his job to accommodate his personal life. If he needs to leave work midmorning to drive his mother to the airport, he expects to be allowed to do that.

The shorter office hours aren't necessarily bad, Ricci says. "The Yers who come in at 9 and leave at 4:30 may be so connected, there is great speed behind their work activities," she says. "They may still be as productive as the boomers — it's just how they do their work that's different. They're very savvy at the computer, the phone, GPS, tablets. They know how to leverage technology to increase productivity. As long as they have access to that technology, they can be very productive."

Of her prototypical Gen Yer, Ricci says, "In her work hours, she's got the phone in hand, the iPad in her briefcase, she's typing on her handheld phone and, at the same time, she's got the earbud on. Wireless technology lets her do three different things all at once. That's quite different from how the boomer may operate."

Dolan believes that each age group can share valuable experiences with the others. Millennials may not, across the board, want to work long hours, but even baby boomers now strive for work-life balance. "We didn't think about work-life balance as much,” he says of earlier generations. "But over time we have, and I think we've actually learned from the younger generations — who learned about it when they saw their parents working so many hours — how important work-life balance is.”

Stephanie Drake, executive director of the American Society for Healthcare Human Resources, says that good managers are aware of broad differences across the generations, but they try to figure out what an employee's individual strengths are and make the most of those. "It's easy to group employees by generational differences, but we all have different personalities, and different competency levels,” she says. "So it's important to help those employees work with each other, learn from each other, and be able to leverage each other's innate skills."

Lauren Hill, director of diversity and staff development at Beaumont (Mich.) Hospitals, has found that employees are eager to learn about generational differences if it helps them better understand their co-workers and their patients. Each year, Beaumont hosts a diversity conference with a different theme. The 2009 conference, which focused on generational diversity, "was the best-attended and most well-received conference we've had,” Hill says.

Following up on that success, Hill and her staff encourage managers to discuss generational diversity in their staff meetings, providing them with presentation materials and a video they can access on the hospital website. "One of the things that we encourage is to understand that taking the time on the front end as a supervisor can certainly benefit you and the employees because you're helping them to gain confidence, to feel comfortable, to be independent and make decisions," Hill says.

Beaumont also offers a course called Generation Sensation, in which employees of different ages and rank can get together "in a safe environment for open dialogue” and talk about generational differences, real or perceived.
Hill received enthusiastic feedback from one young staffer. "He came back and said how people were honest about some of the stereotypes they had,” she says, "and that it was interesting listening to some of the stereotypes boomers had for Millennials; he also was able to talk about himself and debunk some of the myths."

Inviting friction?

Gen Yers' tendency to multitask can offend older people when it gets in the way of face-to-face communication.
Neeraj Kanwal, M.D., Promedica's vice president for medical affairs, says that faculty members were taken aback when they first saw students checking their phones during lectures or while on rounds. "They'll be looking up the reference, a study, a question right on the spot."

Kanwal tries to make the best of it. "While the fact that they're not paying attention can be off-putting for the faculty, what they're trying to do is to assimilate in a different way."

Rather than steering students back to the textbook or a traditional lecture, the hospital's faculty has changed its curriculum to focus more on teaching students how to find the information they need — what are legitimate sources of information, how to use real-time information, and how to search effectively.

Kanwal also noticed that when the medical residents are at work, they're completely engaged. But when they're off, "they're off and they don't want to come back in.” So the residency program has to be specific about what they call FFOs — Forced Family Outings. "If they have to come back for an evening program or are expected to participate in something, the program directors and faculty have to make it mandatory,” says Kanwal. "So they understand that this is part of the work, and not an optional activity. They tend to separate their work time and their home time so much more discretely than previous generations, so everything has to be explained: 'This is official and this is not official.'"

Scheduling is another area in which generational differences can make things especially fractious. A few years ago, Toledo Hospital's respiratory therapy department switched from offering 8- and 12-hour shifts to just 12-hour shifts. The complaints haven't stopped rolling in.

"A lot of our older staff have come and said, 'These 12-hour shifts are killing me. I can't do it anymore,'" says Alison Avendt, Promedica's vice president, professional and support services. "And the younger staff are saying, 'Don't ever take away those 12-hour shifts.'"

The shift difference, says Avendt, is "something that we in the health care industry need to look at, because I'm sure we're not unique to the idea that to our aging workforce, those 12-hour shifts are getting harder. And what are the safety impacts for our patients? But yet, we have a younger workforce that sometimes does a better job of balancing work life than some of us do. They really want that balance: 'When I'm at work, I'm working, and then I want my time off to do the things I want to do.'"

Respiratory therapist Sandy Martin, a Gen Yer who's the youngest on the day shift in adult critical care at Toledo, prefers the longer shifts because she has "so many days off in between to do the rest of the things I need to do." She also prefers working part-time per diem than "being forced" to work full time. That way, she can work days (she'd be on nights if she worked full time) and pick up full-time hours on the weeks that she wants to.

But Marie Weatherford, a pediatric respiratory therapist who's been working nights at Toledo for 15 years, would switch to the shorter shifts if she could. "The older I get, the more my body's saying it would rather do five 8-hour shifts and feel nice and refreshed mentally and physically."

Bringing in fresh recruits

Hospital leaders often find themselves between a rock and a hard place. They want to keep the knowledgeable, dedicated people they have, but they need to recruit and retain younger workers — workers who may not want to stay in one place too long — to fill the huge gaps in their workforce that are coming as the baby boomers retire.

The methods employers used to attract and keep workers in the past may not work for a new generation. A 2012 survey by health care recruiting firm Bernard Hodes Group found that 47 percent of Millennials put a high value on workplace environment and culture, compared with only 23 percent of boomers. The values were reversed for job benefits. Forty percent of boomers said a good benefits package made them stay with an employer, while only 22 percent of Millennials shared that view.

At Toledo Hospital, people like Luke Barnard, manager of workforce planning for Promedica, are trying to figure out the best way to prepare for a slew of imminent retirements in departments like nursing and medical technology. They're also dealing with an annual turnover rate that's traditionally been more than 30 percent, much higher than the industry average of just above 20 percent.

"A third of the people we hire every year turn over," says Barnard, a self-described data junkie who is just four years out of college. "You think about that in just recruitment dollars spent, time spent. A third of what they're doing in that department is just turning over the same people."

His department posts job listings on Facebook and LinkedIn, but it's also wrestling with an antiquated job application system that's about 10 years behind the industry standard and lacks meaningful tracking.

So like Piatkowski, other hospital leaders have had to come up with creative yet budget-friendly ways to attract a younger generation of workers as well as build on the strengths of the people they already have.

In January 2012, the nursing department established a six- to nine-month residency program for new hires that pairs them with senior nurses and gives them experience at each of the hospital intensive care units. Since the residency program started, the hospital's overall turnover rate has dipped to 25 percent, which Barnard attributes partly to the new program, partly to people holding onto their jobs longer in a bad economy.

In 2011, department leaders met with higher-ups at the University of Toledo, to see if they could work out a tuition deal for hospital employees. "They came back and essentially offered us free tuition," Barnard says. Full-time employees receive tuition waivers for up to eight credit hours. It's been a hugely popular program since it started in August 2011.

Piatkowski has learned to accept that her younger employees might leave after a few years of training. A bulletin board alone isn't going to keep them. But if they have a good experience, she hopes they'll either leave for another hospital in the system or find their way back to Toledo Hospital with even more training. "Ten years ago, when I was first in leadership, you didn't grow your people to get them to leave and take other positions," she says. "You wanted to keep your staff. You didn't want anyone to steal them. But I think we've changed that outlook. We have lots of people who have gone and come back and been very successful and very welcome and make a huge impact."

Laura Putre is a freelance writer in Cleveland.

Generational Generalities

Every hospital executive, clinician and staff person is unique, with different needs, different expectations and different career and life goals. At the same time, it is useful to understand certain characteristics that are typically, if not universally, found among leaders and employees of different generations.

Work Hours

Baby boomers | 6 a.m. to 7 p.m.
Gen Xers | 8 a.m. to 5 p.m.
Gen Yers | Prefer flexible schedules

Defining Characteristics

Baby boomers | Loyal, experienced, like face-to-face communication rather than texting and emailing. Good at following rules and less flexible at innovation. Willing to come in on short notice. Too much praise embarrasses them.

Gen Yers | Change jobs every one to three years. Want their jobs to accommodate their personal lives. Multitask when they're at work. Question rules and ask for rewards in exchange for extra work. Comfortable with social media; use smart phones and tablets like an extension of themselves. Tend to be more informal in their appearance.


Baby boomers | Struggle to keep pace with new technology. They're getting ready to retire and there aren't enough younger leaders to replace them.

Gen Yers | Their informality — including tattoos, piercings, and in one case at Toledo Hospital, a sweatsuit worn to an interview — might need to be reined in so they don't scare off the older patients. Have trouble ungluing themselves from their devices in meetings.


Start a leadership program just for recent graduates.

Lauren Hill, director of diversity and staff development, Beaumont Health System: Every year, the president of the system's largest hospital selects a graduate student for a yearlong fellowship program in hospital leadership. "It's an opportunity to get young people who are interested in health care working with our executive leadership team on significant projects," Hill says. Three of the fellows have gone on to work in health care leadership.

Try a little reverse mentoring.

Barb Tassel, administrative nursing director at Toledo Hospital: For training in electronic health records, some of Toledo's younger staff are designated as "superusers." They float around the training room in orange vests, answering questions of staffers, including older physicians, and helping out as needed. "They literally swamp the place with resources," Tassel says.

Change policies to fit the times.

Gayle Capozzalo, executive vice president, strategy and system development, Yale New Haven Health System: Yale New Haven's leadership development program, which among other things trains executives to better understand generational differences among employees, has contributed to many human resources policy changes. To reduce the multitude of HR issues around overly informal dress the hospital implemented a uniform policy for clinicians and other workers. Employees wear scrubs color-coded to their profession, making it easy for patients to identify, say, a nurse vs. a doctor or a medical assistant.